Now Available as a Paperback

From Therese Borchard, author of Beyond Blue:

I kept saying to myself, "Did he just write that?" "Did he really just write that?" until I got to the third chapter and expected the pages ahead to be full of the same playful, entertaining .... um .... original prose that preceded it.

Anyone can jot down the bizarre thought patterns that are floating between their brain lobes. I guess what makes McManamy different is that he has taken a tour of Dante's Inferno and, while there, jotted down some funny notes that people who had been to Dante's Purgatory--or maybe even the first layer of hell--might appreciate, read in the bathroom, or digest like their favorite comics because the stories simply make them feel better. They are written by an intelligent man who has suffered and has been able to translate that suffering into hysterical laughter.

Funny is good. And this man's outrageous stories make me laugh. Sometimes they even make me forget about my day's trauma. Now that's a miracle.

Purchase paperback edition ($9.95)

Or download directly to your Kindle or Kindle app ($4.99):

In Appreciation: Mike Wallace 1918-2012

I will be very brief. He was one of us. In 1997 he disclosed his bouts with depression. As much as anything else, his going public brought out into the open a topic that had been considered taboo. He was a hero, one who lived by his ideal to comfort the afflicted and to afflict the comforted. He was a role model, working into his late eighties, going-going-going. And he remains a legend, long to be remembered.

Rerun - Presidents Day Special: Lincoln and His Depressions

I originally published this as a newsletter piece in 2005 and soon after on mcmanweb. Enjoy ...

The year is 1860. In a makeshift meeting hall, the Illinois delegation to the approaching Republican Convention is meeting to consider which of their own to back as a favorite son for the Presidential nomination. There is no clear-cut favorite. Moreover, it’s widely acknowledged the choice will be an empty gesture. The nomination is virtually a done deal. William Seward of New York, the party’s leading light, has nearly all the delegates he needs for a first ballot victory.

But then something completely unexpected happens. Abraham Lincoln is introduced. A distant relation enters carrying two split log rails. From them hangs a banner:

Abraham Lincoln
The Rail Candidate

The crowd goes wild. The hall shakes so much that the canvass roof flies off the building. The image of a humble rail-splitter is all this group of delegates needs to give Lincoln its enthusiastic backing. The dynamics of the nomination has completely changed. Illinois’ freshly-minted favorite son is on his way to becoming a serious contender.

The meeting breaks up the next day. In the nearly empty hall, a man sits alone, elbows bent, hands pressed to his face. He confides to someone who approaches him, "I’m not feeling too well." The man is Abraham Lincoln. He is battling a crushing depression.

The event is recounted in Joshua Shenk’s outstanding 2005 book, "Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness." Writes Mr Shenk:

Lincoln’s look at that moment – the classic image of gloom – was familiar to everyone who knew him well. … He often wept in public and cited maudlin poetry. He told jokes and stories at odd times – he needed the laughs, he said, for his survival. As a young man he talked of suicide, and as he grew older, he said he saw the world as hard and grim, made that way by fates and forces of God. ‘No element of Mr Lincoln’s character,’ declared his colleague Henry Whitney, ‘was so marked, obvious and ingrained as his mysterious and profound melancholy.’ His law partner, William Herndon said, ‘His melancholy dripped from him as he walked.’

Mr Shenk relates that depression was a constant throughout Lincoln’s adult life. He never overcame it. He never rose above it. His life was one long unceasing litany of sorrow. At times, he completely gave in to his condition. He would fail to get out of bed. He would behave very strangely. He would alarm his friends and associates.

"I am now the most miserable man living," the 31-year-old Lincoln confessed. "Whether I shall ever be better I can not tell; I awfully forebode I shall not; To remain as I am is impossible; I must die or be better."

But other forces were also at work, Mr Shenk contends. Depression turned him into a hard-headed realist, untainted by the pitfalls of misguided optimism. His uncanny melancholic third eye allowed him to think like a visionary. And even though he was a religious skeptic, his tribulations would imbue him with a higher wisdom and deeper humanity, so much so that he occupies a unique place in history as an American saint.

It is easy to fall into the trap of romanticizing Lincoln, but the facts speak for themselves. As his life unfolds, one cannot help but have the impression of being in a higher presence. It’s almost a religious experience. Mr Shenk makes the experience all the more moving by allowing us to view the great man through the eyes of our illness. The result is both inspirational and heartbreaking. To begin ….

The Early Years

Abraham Lincoln was different from day one. A voracious reader, intellectually curious, and a sensitive individual in a rural environment that only saw merit in physical labor, the young Lincoln was regarded as lazy and in need of discipline.

There was much cause for sadness in Lincoln’s life. His only brother died in infancy. His mother and aunt and uncle succumbed to an epidemic when he was age nine. Ten years later his sister died giving birth to a still-born infant. His father and mother were disposed to melancholy, and one side of the family "was thick with mental disease."

Despite this, young Lincoln made it into adulthood showing few signs of depression. His first major episode coincided with the death of Anne Rutledge in 1835 when he was 26. Lincoln had long since left the family farm to seek his fortune in the one-horse town of New Salem, Illinois. Many historians contend that there must have been a love interest between Rutledge and Lincoln, but Mr Shenk says there is no evidence.

Depression is not as simple as cause and effect, Mr Shenk reminds us, citing a number of psychiatric sources, especially in someone predisposed to the illness. Any number of apparently innocuous occurrences can set off an episode, including several converging at once. According to one account, Lincoln bore up to Anne’s death fairly well. Then came heavy rains that seemed to unnerve him. He took to walking the woods alone with a gun and talking of suicide. Everyone in the village became aware of his strange behavior, and one concerned couple took him in for a week or two.

Finding His Way in the World

By Lincoln’s late twenties, friends and colleagues regarded him as "melancholic." The condition was virtually indistinguishable from the modern conception of depression, but did not carry the same stigma. Back in those days, despite an individual feeling "unmanned" by his affliction, there was considerable leeway for males to express their feelings in public, especially with the Romantic movement entering full flower.

In Lincoln’s case, his sorrowful demeanor induced people to come to his aid.

Nowhere was this more apparent than when the young man turned up to practice law in Springfield, Illinois with all his worldly possessions in two saddlebags. A store proprietor, Joshua Speed, urged his forlorn customer to take the bags upstairs to his room and the two became fast friends.

In an age when contact with the opposite sex was severely circumscribed, young men were encouraged "to pair off and form a special bond" as part of their grooming for greater responsibilities. Lincoln and Speed even shared the same bed for four years, but this was fairly common practice not to be mistaken for homosexuality. Nevertheless, gender roles were defined quite differently. It was acceptable for young men to display their affection for one another. This kind of intimacy encouraged the expression of one’s innermost thoughts and feelings, including depression.

Mr Shenk points to a number of forces at work when Lincoln was coming of age. On one hand, it was an age of hope. The new economy for the first time gave ambitious young white men like Lincoln the opportunity to realize the dreams of the Founding Fathers. Steam power and the telegraph effectively shrunk the world and created a whole new mobile labor force. Advances in medical science instilled the belief that God was not punishing an individual, which effectively destigmatized illness. This spawned a whole new movement in self-improvement.

At the same time, thanks to a new religious revival, a loving redemptive God replaced the harsh vengeful God of John Calvin. Rather than predestination to hellfire and brimstone, men and women had the power to make moral choices and find their way to God’s favor.

For the first time in history, the individual did not have to subsume his needs to the needs of the tribe or community. But with this new freedom came new fears and anxieties. Gone was the communal security blanket. Ever present was the specter of failure, with full responsibility borne by the exposed individual. America, the land of opportunity, led the world in mental illness.

It was in this heady atmosphere of hope and insecurity that young Lincoln, now a hotshot lawyer and rising star in the state legislature, was to become badly unhinged.

Lincoln's Breakdown

Many historians attribute Lincoln’s depressive episode of the winter of 1840-41 to his breaking off his engagement with Mary Todd. But much more was happening in Lincoln’s life, Mr Shenk points out.
In the legislature, Lincoln had hitched his political wagon to ambitious public works projects designed to open up the hinterlands to economic development. This included an elaborate network of rails, canals, and roads.

Then came the economic depression of 1837. Revenues dried up and the debt exploded. Lincoln used up all his political capital urging the legislature to stay the course, which proved a disaster. By the end of 1840, the state was teetering on the brink of bankruptcy, forcing the abandonment of Lincoln’s beloved projects. The rival Democrats rode into power on the aftermath of the debacle, and Lincoln was cast as one of the scapegoats. He barely held onto his seat in the legislature, his political career virtually finished.

At the same time, he was laboring under a heavy workload as a lawyer, with nine cases before the state supreme court.

As for Mary Todd, the exact time of the break-up is unknown, obviating a simple cause and effect. Another woman had turned him down, and he may have had an interest in yet another. On top of this, his dear friend Joshua Speed was making plans to move back to Kentucky. Then the weather turned bitterly cold.

In January 1841, Lincoln was confined to his bed, and his condition was the talk of the town. He put himself in the care of a physician, which likely made him much worse. Standard medical treatment involved purging the body by aggressively drawing blood, ingesting mercury and other poisons, inducing vomiting, starving the patient, and plunging him in cold water.

A concerned Joshua Speed told Lincoln that if he did not rally he would die. Lincoln replied he was not afraid to die. Yet, ironically, his perceived failures may have stoked his will to live. He confessed to his friend an "irrepressible desire" to accomplish something before he died that would "redound to the interest of his fellow man."

Some 20 years later, Lincoln would remind his friend of that conversation.

Finding Himself

In late 1842, Lincoln bit the bullet and married Mary Todd. His way of dealing with his depression was by throwing himself into his family and his work, but it wasn’t until he reached his mid-forties that he found a cause that animated him. The Missouri Compromise of 1820 had regulated the extension of slavery in the western territories. In practice, it operated as a containment policy that implicitly recognized slavery’s wrong. Lincoln foresaw slavery’s eventual end, but it was not a process, he believed, that could be speeded up.

That all changed in 1854 with the passage of the Kansas-Nebraska Act. Suddenly the northern territories were in play. Three years later, the Supreme Court’s infamous Dred Scott decision held out the prospect of legalized slavery in the northern states, as well. Slavery was no longer a wrong. It was about to become a universally recognized right. Passions on both sides were awakened, but the situation clearly favored the south.

Lincoln’s melancholia allowed him to see events with preternatural second sight. Southerners with a vested interest in the outcome stood a clear chance of having their way over largely indifferent northerners. It was the thin edge of the wedge that could put an end to free labor markets everywhere and dash the dreams of the Founding Fathers. The clock was being rewound back to the Dark Ages, and Lincoln was not confident of his ability to put a stop to it. Nevertheless, he felt compelled to speak out against the madness, even at the risk of his career.

Paradoxically, his political career took off, though true to melancholic form he saw every slight setback as a major failure. The new political reality spelled the end of Lincoln’s Whig party. In its place stood the newly-formed Republican party. In 1858, Lincoln found himself in the national spotlight in his series of debates with the author of the Kansas-Nebraska Act, Stephen Douglas. Both were contesting the same Senate seat.

The Senate was Lincoln’s lifelong dream. In an era of lackluster Presidents, this was the forum of his heroes such as Daniel Webster and Henry Clay. But Lincoln was prepared to sacrifice his ambitions for the cause. His antislavery position ran ahead of public opinion, but he strongly felt the greater interest was better served by enlightening the voters.

Lincoln also saw ahead to 1860, when Douglas was likely to be the Democratic standard-bearer in the Presidential election. In the debates, he forced his rival to expose himself as too moderate for his southern backers. The next Republican candidate for President, he knew – certainly not he – would benefit.

Lest we mistake Lincoln as morally flawless, he neither viewed African-Americans as biologically equal to whites nor did he envision the two races living together in harmony. The world was a stupid place back then, arguably only slightly more stupid than it is today.

In early 1860, Lincoln traveled to New York to deliver an address to the Cooper Institute. He brilliantly succeeded in linking the dreams of the Founding Fathers to the anti-slavery position, and threw down the gauntlet on right versus wrong. He brought down the house, and achieved rave notices everywhere. No one was quite ready to seriously consider him as Presidential timber. Yet …

Improbably, on the strength of his new-found image as the rail-splitter, Lincoln won his party’s nomination on the third ballot. The election was a shoo-in. Thanks in part to the Lincoln-Douglas debates from two years before, an irreparable schism had formed in the pro-slavery ranks. The Democratic party splintered three ways, allowing Lincoln to win with just 40 percent of the popular vote.

Even more improbable, Lincoln’s well-known melancholia was not seen as a character flaw. Today, the immensity of a Lincoln-sized depression would disqualify a candidate from virtually any elected office save dog-catcher. Back in Lincoln’s time, living successfully with a mental illness was viewed as a character virtue. Maybe they weren’t all that stupid back then, after all.

The Presidency

By the time Lincoln was sworn in, seven southern states had bolted from the Union. Facing the Republic’s gravest crisis, he assumed office with no executive experience, forced to govern from an untenable position. One slight overstep and the border states would join the South, ending all hope of reunification. When hostilities broke out, the North lost far more battles than it won, forcing all and sundry to second-guess his leadership. As the terrible carnage mounted, much of the population lost its resolve, leaving Lincoln with a very weak bargaining hand. When he pressed his position harder, rebellion threatened to erupt on the home front. Few believed there would be a successful conclusion to the war. No one thought he could be reelected.

Of all things, a lifetime of living with depression admirably prepared him for the task. He possessed both the intestinal fortitude and the moral will. And the insights he had acquired from a lifetime of sorrow seemed to connect him to a higher power. As Joshua Shenk explains, over the course of his adulthood, Lincoln passed from fear to engagement to transcendence.

In other words, having decided that he WOULD live, he then decided HOW to live. When faced with the challenge of a lifetime, he proved more than ready.

But first came more personal tragedy. During his term of office, His favorite son, Willie, died. Of his four sons, only one would live to adulthood. On learning of the death of Willie, he wept convulsively.

In 1862, Lincoln deviated from a previously-held position by proposing to his cabinet the emancipation of slaves from all union-held southern territory. The move risked alienating the border states, but would serve to give the war a higher moral purpose. Nevertheless, Lincoln entertained no delusions about whose side God was on. Death had visited far too many northern households for him to believe that the Almighty was playing favorites. "My greatest concern is to be on God's side," he advised a colleague.

The Emancipation Proclamation would be the first step toward universal freedom and enfranchisement. Soon after, Joshua Speed would pay a visit, and Lincoln would remind him of their conversation some twenty years earlier, when only his desire to accomplish something great gave him the will to live.

"I believe in this measure my fondest hopes will be realized," he confided to his friend.

Sainthood

On assuming his second term of office, Lincoln spoke the finest words ever uttered in the English tongue:

With malice toward none, with charity for all, with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds.

He had six weeks to live, his last days filled with a transcendent lightness of being. It was as if, his mission on earth accomplished, he were ready to be taken up into heaven. On April 14, 1865, a man with a gun obliged. Now he belonged to the ages.

Final Words

In Lincoln’s depressions, we see the illness in its full destructive horror, one that nearly succeeded in cutting short the life of a promising young man and made the rest of his existence miserable. This is the side of depression with which we can all unfortunately identify. But we also see an aspect to his depressions that equally resonates with us – how our suffering can strengthen us, ennoble us, and embolden us, often to achieve the impossible.

Our sense of achievement need not be the same as Lincoln’s, nor for that matter what our families may expect of us. It is simply enough that we survive from day to day with the kind of grace that is used to define courage. Believe me, if Lincoln were to visit you right now, he might admonish you to make your bed, but he would do it in the way of a funny story. And he would let you know how proud is of you - no doubt about it. Take heart. Lincoln lives in us all. Walk tall.

Is Bereavement Part of Depression? And What the Hell is Depression, Anyway?

Willa Goodfellow’s latest Prozac Monologues piece raises the very important discussion about how bereavement fits (or not) into depression. Ronald Pies, one of the two principal figures behind the proposed DSM-5 “bereavement exclusion” to the depression diagnosis, has left a comment.

The discussion is framed in such a way that the nominal topic - bereavement - unlocks the key to the real issue, namely can any two people actually agree on what depression is all about? What about depression-like behavior?

Some background: The DSM-IV expressly rules out the depression diagnosis if the symptoms are attributable to bereavement for a period of two months or less. The DSM-5, due out in 2013, would drop this exclusion. This has created the mistaken notion that the DSM-5 is proposing to turn bereavement into a psychiatric illness. Allen Frances, who oversaw the DSM-IV, recently told the NY Times that “the revisions will medicalize normality.”

Let’s turn to what the DSM-5 is actually proposing. In the updated depression diagnosis, the symptom checklist would stay the same. In the fine print below, this gets the axe:

“The symptoms are not better accounted for by Bereavement ...”

Willa’s post sees this as the last piece in restoring the complete depression diagnosis. She points out that the DSMs I and II attempted to separate out depressions they saw as situational (exogenous) from those they saw as biological (endogenous). The DSM-III abolished this distinction, essentially viewing depression as a depression, but left in bereavement as an exception. The DSM-IV continued with this.

Willa asks us to view depression as something that happens when life throws too much at us, a point of view backed by some very impressive brain science. Some of us may be genetically resilient, but others (namely, us) prove highly vulnerable, owing to a hyperactive stress response. Says Willa:

What difference does it make whether the one damn thing too many is loss of a job or loss of a loved one?  It's still one damn thing too many.  And doctors need to take time to figure out what is going on with the person sitting in the office on her last nerve, not say, “There, there. You'll feel better in a couple months.”

As Dr Pies’ says in his comment:

[If] it looks like a duck, walks like a duck, and quacks like a duck, it's likely to be a duck, until proved otherwise. That is: if a patient shows up in the doctor's office meeting the full symptom and duration criteria for Major Depressive Disorder(MDD); but happens to have lost a loved one within the past two months, we should not withhold the diagnosis of MDD, simply because it occurs in the context of bereavement.

Are we clear on this? Good. Now let’s muddy it up. In an article on my website, Placing Depression in Context, I too observe the old clinical vs situational distinction, with reference to the DSMs I and II, and like Willa I view the distinction as naive and unscientific. But, nevertheless, I also see merit in bringing back some of the old reasoning. As I put it:

The endogenous-exogenous distinction does encourage us to examine where our depression might be coming from. If your marriage is falling apart, for instance, or your situation at work is going badly, it is obviously worth exploring this association. Sort of like investigating whether a person with a pulmonary disorder is working in an asbestos mine. For some crazy reason, the "modern" DSM-III of 1980 and its successors didn't think this was important.

I also looked at normal vs abnormal. In other words, are some of our depressions a normal reaction to an abnormal situation? Aren’t we supposed to feel depressed when we have lost a loved one? Moreover, if life is getting to be too much for us, our depressions may be telling us that we may need to make an immediate course correction. From my article:

This is straight out of evolutionary psychology. Depression has been called the end of denial. The rose-colored glasses come off. Reality takes over. Maybe instead of banging your head against the same wall - again and again and again - you need to cut loose destructive friends, bail out of a bad relationship, rethink that toxic work environment.

Listen to your depression. It may be an unwelcome guest in your brain, but it is definitely telling you something.

But my article also describes a situational depression I found myself in back in 2004, one that very easily could have led to a clinical depression. I simply did not have the luxury of leaving things to chance, not with my vulnerable brain. I immediately changed my routines and found a new project to work on.

In other words, I was feeling depressed. I needed to act right now.

This is precisely Willa’s point. Prior to reading her piece, I was on the side of not changing the bereavement exclusion. Now I’m teetering the other way. But this is because Willa’s piece challenged me to rethink depression, not bereavement. Depression is never what we think we think it is. Something to think about ....

Illustrating Depression and Bipolar

As most of you who follow this blog know, at the beginning of this year I essentially blew up mcmanweb and started over. The site was in serious need of an updating, plus a facelift. My first phase involved a complete redesign, together with rewrites and reorganization of a lot of old articles. This consumed most of my time well into spring.

Throughout the rest of the year, I made incremental changes and additions.

I began mcmanweb around this time in 2000, with a small collection of articles on depression and bipolar. My goal was to create a comprehensive resource exploring mood disorders from every conceivable angle. Over time, I built up a collection of more than 300 artlcles (later pruned down to about 250), most written by myself, but with some personal accounts from contributors.

As the years went on, I essentially turned over just about all my content, save the pieces on famous people and personal stories. But by this time last year, it was clear to me that I had fallen way behind. I’ll just mention one of the matters I had to deal with, which involves design and the organization of my content.

The key to a successful website is making it easy for visitors to find what they are looking for, fast, and to facilitate their going deeper and wider. My basic navigation since the beginning has been successful -with content organized under categories such as Mood, Treatment, Science, Stories, and so on - and I stuck with what worked.

Thus, from my home page - as well as every page on the site - you can click on a category, which will take you to a landing page with the articles containing the information you are looking for.

But how do you bind a site together? At the same time, how do you differentiate between categories? How, in essence, do you lend coherence to the reader’s experience?

This time, I decided that a collection of old (and a couple of new) master’s paintings would define the look and feel to mcmanweb. A different old master would illustrate each category. Moreover, I carried forward these same old masters into every article. Thus, a Rembrandt for all my DSM articles, a Vermeer for my Treatment articles, and so on.

So here I am - today - nearly a year after I started the project when it occurred to me that I never explained my choice of illustrations to my readers. I just remedied that a few minutes ago, with short explanations on all my landing pages, which I have reproduced here. So without further ado ...

The pic to illustrate Mood is a close-up of La Tour’s “Magdalen at Night.” The woman seems to question her very existence. We have all been there.

The pic to illustrate Behavior is a close-up of Holbein’s “Henry VIII.” The monarch’s defying the Pope and killing off half his serial wives takes care of the seriously disturbed side of the personality equation. His sixteenth century rock star status - he was an accomplished lutenist, singer, organist, and composer, and a generous patron of the arts - captures the creative and positive side. Mind you, Henry’s way of resolving personal domestic quarrels can also be regarded as creative.

The pic to illustrate The DSM-5 is a close-up of Rembrandt’s “Moses.” Was there any other choice?

The pic to illustrate Treatment is a close-up of Vermeer’s “Cavalier with Young Woman.” I also use Vermeer to illustrate “Recovery.” The Treatment pic has two people in it, suggesting the wisdom of seeking expert help. The Recovery pic has a solitary woman actively engaged in a pursuit, reinforcing the notion that we are in charge.

The pic to illustrate Recovery is Vermeer’s “The Lacemaker.” Same explanation as above.

The pic to illustrate Science is a close-up of Dali’s “Exploding Raphaelist Head.” Dali was equally fascinated with Freud and the quantum building blocks of existence. This painting says it all.

The pic to illustrate Issues is a close-up of Raphael’s “The School of Athens.” Here we see Socrates engaging in a dialogue with a student. Socrates always challenged our cherished beliefs, strongly suggesting that anyone who claims to know the answers is a fraud. Indeed, if there is an absolute truth, there is no way of knowing it, much less knowing we know it.

The pic to illustrate Famous is a section from one of Warhol’s “Marilyn” prints. Marilyn’s iconic status made her a no-brainer to lead the parade of notables chronicled here. Warhol’s recasting of the same image in different shades suggests that what you see is not necessarily what you get.

The pic to illustrate Stories is Fragonard’s “A Young Girl Reading.” We all have stories in us. What the woman in the illustration does after reading one of them is up to her. Who knows, once she gets out of that chair.

The pic to illustrate Populations is a close-up of Bruegel’s “The Wedding Dance.” We may be one, but each one of us is also unique.

The pic to illustrate Relationships is a close-up of Klimt’s “The Kiss.” Ah, the possibilities. Alas, the ambiguities.

***

I cordially invite you to check out mcmanweb.

Rerun: This Veteran's Day

I run this every Veteran's Day and Memorial Day:

This Veterans Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Veterans Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Veterans Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Veterans Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Veterans Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Veterans Day:

It's our turn now.

***

From Therese Borchard's Beyond Blue:

• Almost one in three veterans returning from Afghanistan and Iraq confront mental health problems.
• On an average day in this country, suicide claims another 18 veterans.
• Approximately 30 percent of veterans treated in the veterans health system suffer from depressive symptoms, two to three times the rate of the general population.
• More Vietnam veterans have now died from suicide than were killed directly during the war.
• Approximately 40 percent of homeless veterans have mental illnesses.

The Stress-Emotions Connnection

Yet another totally reworked article in my never-ending mcmanweb blow-everything-up-and-start-over project, edited for your reading pleasure ...

Stress is to mood what that iceberg was to the Titanic, with therapies increasingly geared toward neutralizing its vast destructive powers.  In a 2002 NIMH study, healthy subjects with a certain short variation (allele) to the serotonin transporter gene viewed images of scary faces as their brains were being scanned. The part of the brain which governs fear and arousal - the amygdala - lit up like a Christmas tree.

A year later, a study on a New Zealand population found that those with this very same short allele were far more at risk of depression after being exposed to four or more lifetime stressful events (including employment, finances, housing, health, and relationships) than their long-allele counterparts.

Vulnerability vs Resilience

Is mental illness a "vulnerability" disease? Are the lucky ones, in effect, genetically "resilient" to what life happens to throw their way? Or does life have a way of turning even resilient brains vulnerable?
At the 2002 American Psychiatric Association's annual meeting, Charles Nemeroff MD, PhD of Emory University asked his audience: "Is the biology of depression the biology of early trauma?"

In an experiment designed to startle lab rats by blowing an air puff in their faces, Dr Nemeroff and his colleagues found those who had been separated from their mothers as pups showed a greater stress response, with tissue samples revealing higher concentrations of the hormone CRF (corticotropin-releasing factor).

Women abused in childhood, Dr Nemeroff explained, end up with a sensitized brain system, where CRF receptors are to be found in abundance. Depressed patients have high concentrations of CRF in their cerebrospinal fluid.

A 2000 study that he co-authored with Christine Hein PhD found that women with a history of childhood abuse exhibited increased pituitary and autonomic responses to stress when given math tests and made to speak in public compared with the controls. This was especially true for the women with current depression and anxiety.

Stress Pathways

The stress response - fight or flight - kept our distant ancestors alert and alive long enough to pass on their genes, which certainly comes in handy in modern life, especially when a zeppelin is chasing you.

As Kurt Vonnegut describes it in his 1973 novel, "Breakfast of Champions":

My mind sent a message to my hypothalamus, told it to release the hormone CRF into the short vessels connecting my hypothalamus and my pituitary gland.
 
The CRF inspired my pituitary gland to dump the hormone ACTH into my bloodstream. My body had been making and storing ACTH for such an occasion. And nearer and nearer the zeppelin came.
 
And some of the ACTH in my bloodstream reached the outer shell of my adrenal gland, which had been making and storing glucocorticoids for such emergencies.
 
My adrenal gland added the glucocorticoids to my bloodstream. They went all over my body, changing glycogen into glucose. Glucose was a muscle food. It would help me fight like a wildcat or run like a deer.
 
And nearer and nearer the zeppelin came.
 
My adrenal gland gave me a shot of adrenaline, too. I turned purple as my blood pressure skyrocketed. The adrenaline made my heart go like a burglar alarm. It also stood my hair on end. It also caused coagulants to pour into my bloodstream, so, in case I was wounded, my vital juices wouldn't drain away.

Vonnegut is describing a neuro-endocrine loop known as the hypothalymus-pituitary-adrenal (HPA) axis as it is supposed to act in dangerous situations. But what about when there are no zeppelins in sight, when we simply need to be on our toes? The abused and depressed women in the Heim-Nemeroff study exhibited a six-fold greater ACTH increase over the controls. In effect, these women - who only needed to be sufficiently alert to do math tests and speak in public - were being primed to flee attacking zeppelins.

Throw in an over-reactive amygdala and a picture begins to emerge of the human psyche on the breaking point. As Robert Sapolsky of Stanford describes it in a Sept 2003 article in Scientific American: "When we erroneously believe a stressor is about to happen we have entered the realm of neurosis, anxiety, and paranoia."

All those glucocorticoids Vonnegut was talking about don't simply evaporate. Stress has been linked to just about every physical illness imaginable, whether as a risk factor, a cause, or the triggering event.

In the brain, the neural synapses are flooded, setting the scene for excess glutamate to overstimulate brain cells, leading to neuronal loss and atrophy. In this sense, according to Husseini Manji MD, formerly of the NIMH, mood disorders may be regarded as fundamentally atrophic (ie stemming from brain cells in physical distress) rather than symptomatic.

Back to Freud, of All Things

Of all things, the Freudian-inspired DSM-I of 1952 and the DSM-II of 1968 - the ones that everyone ridicules as pre-modern and unscientific - may have gotten it right. Those early DSMs may have wrongly attributed serious mental illness to neurotic or psychotic-reactions, but they very correctly attributed the stresses of dealing with life as the driving force to these reactions.

The "modern" DSMs III and IV, with their exclusive focus on symptom check-lists, threw us off the scent.

Maybe stress can't account for everything going wrong with our brains, but it always needs to be the first place to look. Modern brain science, in effect, has simply relocated the stress dynamic from the metaphysical construct of the mind to the decidedly more prosaic meat housed inside our skulls.

But not just any old meat. We're talking highly specialized, intricately connected meat - live meat - as sensitive to present and past experience as photosensitive paper is to light. When our environment acts, our brain reacts.

But not blindly. Our stressful reactions are telling us something. That maybe, for instance, we need to get out of our denial and recognize that things at work or in our personal relationships are not okay. That maybe, while we have a chance, we have to change ourselves or change the situation around us. Because, if we don't, our depression or anxiety or mania is going to tell us the same thing, only in a much louder voice, with far fewer choices.

Our environment molds our brains, our brains mold our environment. Round and round it goes, a constant cycle of reaction and adjustment. We the vulnerable tend to have a harder time adapting and adopting, but this very insight also tends to be our best motivator.

Be hopeful, take the initiative, live well ...

Full stress article on mcmanweb

When Substance Use Butts Heads with Mood

As you probably know by now, I have been replacing a lot of the old articles on mcmanweb with brand new ones. More recently, my focus has been on disorders that overlap with mood, including schizoaffective and anxiety. This time around, it's alcohol and substance use. Following is an edited extract ...

Walk into any AA or NA meeting, and you will hear people talking about their cravings. Walk into a DBSA group and you will find some of these very same people talking about "self-medicating." Two different problems altogether or two faces of the same problem? It's hard to tell.

Fifty percent of those with lifetime mental illness also have a lifetime history of at least one substance use disorder. Six in ten of those with bipolar have experienced a substance use disorder some time during their life, more than five times the rate of the general population.

Perhaps you can see where I am going with this. If all alcohol and substance abuse is strictly genetic, then why would these genes be so unevenly distributed? Why would they so heavily cluster in the mood disorders population? That can't possibly be right, can it? So what else can be going on?

A Desperate Need for Release?

In the initial going at least, individuals tend to indulge in alcohol and drugs to feel better than they are currently feeling right now. Some may continue this way, but for many the situation has changed. The crying need is for the chemical fix, not the feel-good state (which the brain may have built up a tolerance to).

With a mood disorder (not to mention vulnerability to stress) this is turned around. The overwhelming compulsion is for release from the psychic pain, be it depression or runaway mania or anxiety. A bit of feel-good (or feel less-bad) may be involved, but one is left with the sense of an individual putting out a fire or fleeing a burning building.

But life is complicated. Addicts may claim they are self-medicating. Those who started off self-medicating may not recognize they have have turned into addicts.

Messed Up vs Clear Head

Some over-zealous participants in AA and NA caution that taking psychiatric meds is another form of chemical dependency.

But people take psychiatric meds for entirely different reasons than those talking alcohol or recreational drugs. For the most part, there is no feel-good effect from a psychiatric med. Whereas an addict may start with an initially clear head for the purpose of getting it messed up, a person with a mental illness tends to be coming from the opposite direction.

Of all things, when researchers began investigating the inordinately high rates of cigarette smoking in those with schizophrenia, they discovered that nicotine had the momentary effect of restoring lost cognitive function. Think about it - for the first time in years or decades your brain is suddenly coming in loud and clear. To these individuals, the medically horrendous side effects are well worth the few precious seconds of mental clarity.

If nicotine came in a pill prescribed by doctors, with similar results, would you dare accuse these individuals of having a chemical addiction or dependency? (Nicotine agonists are in development.)

The Craving and Self-Medicating Factors

The inhibitory neurotransmitter GABA quiets down activity in the neuron, which is vital for keeping the brain in healthy stable state (homeostasis). Its tag team partner glutamate achieves a similar end through ramping up neural activity. Inevitably, when things go wrong, the two neurotransmitters are complicit in a range of mental illnesses and conditions, from anxiety to schizophrenia, with depression and mania thrown in for good measure.

When alcohol molecules bind to the neuron's GABA receptors, GABA transmission is increased. Because GABA is active throughout the brain, effects can range from euphoria to sluggish thinking to loss of muscle control. Over time, the neuron structurally changes to accommodate increased GABA supply, setting up the conditions for a craving.

Next neurotransmitter ...

Dopamine is central to pleasure and reward, motivation, alertness, executive function, and muscular control. Dopamine dysregulation (too much or too little) has been implicated in depression, bipolar, ADHD, OCD, aggression, novelty-seeking, schizophrenia, and Parkinson's.

Dopamine surges account for the highs from street drugs such as cocaine and crystal meth and prescription drugs of abuse such as methamphetamines, but these effects tend to wear off as the neuron structurally changes to compensate, again setting up the conditions for a craving.

Then there are brain systems involving serotonin (LSD and ecstasy work on this neurotransmitter), THC (cannabis), and stress regulation.

Since all these systems are intricately interconnected and interdependent, an addiction to one substance may involve an addiction to other substances. Likewise, mental illness and addictions share many of the same pathways. Serotonin has received most of the attention regarding depression, and it is no coincidence that ecstasy provides instant relief. Likewise, for vegetative depressions, a methamphetamine may offer a quick dopamine jump start.

Self-medication, then, is a clumsy and ultimately self-defeating attempt to bring the various brain systems into alignment. Think of alcohol, for instance, as an anti-anxiety med with an outrageous side effects profile. Ultimately, the short-term neurotransmitter surge sets up the conditions for the long-term depletion. Self-medication and craving become one.

When Anxiety Butts Heads With Mood

I just finished rewriting my old mcmanweb article on anxiety and mood, which I expanded into two articles: Anxiety in Depression and Bipolar, and The Mood and Anxiety Connection. Below are three snippets from the two articles, thoughtfully stitched together for your reading pleasure ...

Emil Kraepelin in his classic 1921 "Manic-Depressive Insanity" had this to say about what he called "excited depression":

It is here a case of patients who display, on the one hand, extraordinary poverty of thought but, on the other hand, great restlessness. ... Mood is anxious, despondent, lachrymose, irritable, occasionally mixed with a certain self-irony. ...

And here he is expounding on "depressive or anxious mania":

A morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything ...

Unbelievably, the DSM-IV is silent on both anxious depression and anxious mania. The DSM-5, due out in 2013, would change this somewhat, with the new diagnosis of "mixed/anxiety depression," but nearly a century after Kraepelin, the people who should know better can't bring themselves to acknowledge the obvious in mania.

Mixed Depression/Anxiety

Filed under "Depressive Disorders" is the proposed DSM-5 diagnosis of "mixed depression/anxiety." This involves "three or four of the symptoms of major depression" (a straight depression diagnosis requires at least five symptoms). One of the symptoms must include depressed mood or loss of pleasure. The depressive symptoms must be accompanied by "anxious distress."

The draft DSM-5 defines anxious distress as "having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen."

In essence, the DSM-5 is part-way to acknowledging that anxiety can be both an illness and a symptom of another illness. Depression, psychosis, sleep, and eating and other conditions already share this dual status. Indeed, in this particular area, the DSM-5 harkens back to the pre-modern DSM-I of 1952 and DSM-II of 1968, which viewed much of mental illness as the result of an underlying emotional disturbance called "neurosis." (More serious was "psychosis.")

According to the DSM-II, "anxiety is the chief characteristic of the neuroses." In a manner of speaking, anxiety both drove neurosis and could be one of its main symptoms, along with depression. Back in those days, symptoms were viewed as maladaptive responses to one's surroundings.

In other words, anxiety and depression and mania and even schizophrenia were seen as failures in our ability to cope. As naive as this may appear today, there is considerable merit in the old view that anxiety is inevitably to be found at the scene of the crime in almost any mental illness, whether as the principal or the accessory. Mix despair with anxiety and we're immobilized, unable to pick up the phone. Change it to a racing mind and we're yelling into that same phone, freaked out over some slight disturbance.

In one sense, the world is way too close and immediate, on the other too far and disconnected. One day we're treading water surrounded by thrashing ravenous crocodiles. The next we're Major Toms, a million miles from nowhere, cut off from humanity.

Mixed Mania/Anxiety

The DSM-IV does not recognize this state, and neither would the DSM-5. From a clinical level, mixed mania/anxiety would probably be impossible to diagnose, so why bother? But on a personal level, we need to acknowledge reality. It's easy, really. Simply imagine a state of irrational worry combined with failure to control one's impulses. Thus, you may find yourself fretting about your situation at work. Fairly normal. What's not normal is storming into the boss' office and quitting your job, with no other job lined up. This happened to me. It wrecked my life, but I'm grateful I ONLY quit my job. In the frame of mind I was in, I could have done something much worse.

An additional twist: Walk into any support group, and you will hear participants discussing their "mood triggers." Excessive worry, for instance, may cause you to lose sleep, which makes you a sitting duck for mania. Or it may set off depression, which later sets up mania. Keep in mind, depression and mania never operate in isolation. We are talking about a constant two-step, in this case with an additional dance partner.

My Driver’s Test Mood-Anxiety Hell

From a blog I did on HealthCentral ...

My anxiety levels are through the roof. I have just met a wonderful woman who lives [40 miles away] in San Diego. I NEED to pass this test. The inspector asks me to turn on my left signal. I turn on my right signal. It's all downhill from there. FAIL! I feel lower than a snake's belly. I'm a loser, an idiot. The woman I just met is going to dump me for sure. We work it out. She will help me. I book another appointment for August.

Two weeks later, I call her in a panic. I have just discovered DMV videos on YouTube. More than a hundred of them. Ten top reasons drivers fail the test. Something about forgetting that Burma is now called Myanmar. Automatic fail.



I’m never going to pass this test!



Yesterday. I’ve willed my heart down to merely 300 beats a minute. Turn left, the inspector instructs.

What did he mean by that? I wonder.

He's scribbling in his clipboard. One turn and already I've given him something to write about! I'm doomed! The test ends. The inspector tells me I have a tendency to overthink and panic. Duh! He tells me I've passed. I passed! I refrain from hugging the inspector.

Presidents Day Special: Lincoln and His Depressions

I originally published this as a newsletter piece in 2005 and soon after on mcmanweb. Enjoy ...

The year is 1860. In a makeshift meeting hall, the Illinois delegation to the approaching Republican Convention is meeting to consider which of their own to back as a favorite son for the Presidential nomination. There is no clear-cut favorite. Moreover, it’s widely acknowledged the choice will be an empty gesture. The nomination is virtually a done deal. William Seward of New York, the party’s leading light, has nearly all the delegates he needs for a first ballot victory.

But then something completely unexpected happens. Abraham Lincoln is introduced. A distant relation enters carrying two split log rails. From them hangs a banner:

Abraham Lincoln
The Rail Candidate

The crowd goes wild. The hall shakes so much that the canvass roof flies off the building. The image of a humble rail-splitter is all this group of delegates needs to give Lincoln its enthusiastic backing. The dynamics of the nomination has completely changed. Illinois’ freshly-minted favorite son is on his way to becoming a serious contender.

The meeting breaks up the next day. In the nearly empty hall, a man sits alone, elbows bent, hands pressed to his face. He confides to someone who approaches him, "I’m not feeling too well." The man is Abraham Lincoln. He is battling a crushing depression.

The event is recounted in Joshua Shenk’s outstanding 2005 book, "Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness." Writes Mr Shenk:

Lincoln’s look at that moment – the classic image of gloom – was familiar to everyone who knew him well. … He often wept in public and cited maudlin poetry. He told jokes and stories at odd times – he needed the laughs, he said, for his survival. As a young man he talked of suicide, and as he grew older, he said he saw the world as hard and grim, made that way by fates and forces of God. ‘No element of Mr Lincoln’s character,’ declared his colleague Henry Whitney, ‘was so marked, obvious and ingrained as his mysterious and profound melancholy.’ His law partner, William Herndon said, ‘His melancholy dripped from him as he walked.’

Mr Shenk relates that depression was a constant throughout Lincoln’s adult life. He never overcame it. He never rose above it. His life was one long unceasing litany of sorrow. At times, he completely gave in to his condition. He would fail to get out of bed. He would behave very strangely. He would alarm his friends and associates.

"I am now the most miserable man living," the 31-year-old Lincoln confessed. "Whether I shall ever be better I can not tell; I awfully forebode I shall not; To remain as I am is impossible; I must die or be better."

But other forces were also at work, Mr Shenk contends. Depression turned him into a hard-headed realist, untainted by the pitfalls of misguided optimism. His uncanny melancholic third eye allowed him to think like a visionary. And even though he was a religious skeptic, his tribulations would imbue him with a higher wisdom and deeper humanity, so much so that he occupies a unique place in history as an American saint.

It is easy to fall into the trap of romanticizing Lincoln, but the facts speak for themselves. As his life unfolds, one cannot help but have the impression of being in a higher presence. It’s almost a religious experience. Mr Shenk makes the experience all the more moving by allowing us to view the great man through the eyes of our illness. The result is both inspirational and heartbreaking. To begin ….

The Early Years

Abraham Lincoln was different from day one. A voracious reader, intellectually curious, and a sensitive individual in a rural environment that only saw merit in physical labor, the young Lincoln was regarded as lazy and in need of discipline.

There was much cause for sadness in Lincoln’s life. His only brother died in infancy. His mother and aunt and uncle succumbed to an epidemic when he was age nine. Ten years later his sister died giving birth to a still-born infant. His father and mother were disposed to melancholy, and one side of the family "was thick with mental disease."

Despite this, young Lincoln made it into adulthood showing few signs of depression. His first major episode coincided with the death of Anne Rutledge in 1835 when he was 26. Lincoln had long since left the family farm to seek his fortune in the one-horse town of New Salem, Illinois. Many historians contend that there must have been a love interest between Rutledge and Lincoln, but Mr Shenk says there is no evidence.

Depression is not as simple as cause and effect, Mr Shenk reminds us, citing a number of psychiatric sources, especially in someone predisposed to the illness. Any number of apparently innocuous occurrences can set off an episode, including several converging at once. According to one account, Lincoln bore up to Anne’s death fairly well. Then came heavy rains that seemed to unnerve him. He took to walking the woods alone with a gun and talking of suicide. Everyone in the village became aware of his strange behavior, and one concerned couple took him in for a week or two.

Finding His Way in the World

By Lincoln’s late twenties, friends and colleagues regarded him as "melancholic." The condition was virtually indistinguishable from the modern conception of depression, but did not carry the same stigma. Back in those days, despite an individual feeling "unmanned" by his affliction, there was considerable leeway for males to express their feelings in public, especially with the Romantic movement entering full flower.

In Lincoln’s case, his sorrowful demeanor induced people to come to his aid.

Nowhere was this more apparent than when the young man turned up to practice law in Springfield, Illinois with all his worldly possessions in two saddlebags. A store proprietor, Joshua Speed, urged his forlorn customer to take the bags upstairs to his room and the two became fast friends.

In an age when contact with the opposite sex was severely circumscribed, young men were encouraged "to pair off and form a special bond" as part of their grooming for greater responsibilities. Lincoln and Speed even shared the same bed for four years, but this was fairly common practice not to be mistaken for homosexuality. Nevertheless, gender roles were defined quite differently. It was acceptable for young men to display their affection for one another. This kind of intimacy encouraged the expression of one’s innermost thoughts and feelings, including depression.

Mr Shenk points to a number of forces at work when Lincoln was coming of age. On one hand, it was an age of hope. The new economy for the first time gave ambitious young white men like Lincoln the opportunity to realize the dreams of the Founding Fathers. Steam power and the telegraph effectively shrunk the world and created a whole new mobile labor force. Advances in medical science instilled the belief that God was not punishing an individual, which effectively destigmatized illness. This spawned a whole new movement in self-improvement.

At the same time, thanks to a new religious revival, a loving redemptive God replaced the harsh vengeful God of John Calvin. Rather than predestination to hellfire and brimstone, men and women had the power to make moral choices and find their way to God’s favor.

For the first time in history, the individual did not have to subsume his needs to the needs of the tribe or community. But with this new freedom came new fears and anxieties. Gone was the communal security blanket. Ever present was the specter of failure, with full responsibility borne by the exposed individual. America, the land of opportunity, led the world in mental illness.

It was in this heady atmosphere of hope and insecurity that young Lincoln, now a hotshot lawyer and rising star in the state legislature, was to become badly unhinged.

Lincoln's Breakdown

Many historians attribute Lincoln’s depressive episode of the winter of 1840-41 to his breaking off his engagement with Mary Todd. But much more was happening in Lincoln’s life, Mr Shenk points out.
In the legislature, Lincoln had hitched his political wagon to ambitious public works projects designed to open up the hinterlands to economic development. This included an elaborate network of rails, canals, and roads.

Then came the economic depression of 1837. Revenues dried up and the debt exploded. Lincoln used up all his political capital urging the legislature to stay the course, which proved a disaster. By the end of 1840, the state was teetering on the brink of bankruptcy, forcing the abandonment of Lincoln’s beloved projects. The rival Democrats rode into power on the aftermath of the debacle, and Lincoln was cast as one of the scapegoats. He barely held onto his seat in the legislature, his political career virtually finished.

At the same time, he was laboring under a heavy workload as a lawyer, with nine cases before the state supreme court.

As for Mary Todd, the exact time of the break-up is unknown, obviating a simple cause and effect. Another woman had turned him down, and he may have had an interest in yet another. On top of this, his dear friend Joshua Speed was making plans to move back to Kentucky. Then the weather turned bitterly cold.

In January 1841, Lincoln was confined to his bed, and his condition was the talk of the town. He put himself in the care of a physician, which likely made him much worse. Standard medical treatment involved purging the body by aggressively drawing blood, ingesting mercury and other poisons, inducing vomiting, starving the patient, and plunging him in cold water.

A concerned Joshua Speed told Lincoln that if he did not rally he would die. Lincoln replied he was not afraid to die. Yet, ironically, his perceived failures may have stoked his will to live. He confessed to his friend an "irrepressible desire" to accomplish something before he died that would "redound to the interest of his fellow man."

Some 20 years later, Lincoln would remind his friend of that conversation.

Finding Himself

In late 1842, Lincoln bit the bullet and married Mary Todd. His way of dealing with his depression was by throwing himself into his family and his work, but it wasn’t until he reached his mid-forties that he found a cause that animated him. The Missouri Compromise of 1820 had regulated the extension of slavery in the western territories. In practice, it operated as a containment policy that implicitly recognized slavery’s wrong. Lincoln foresaw slavery’s eventual end, but it was not a process, he believed, that could be speeded up.

That all changed in 1854 with the passage of the Kansas-Nebraska Act. Suddenly the northern territories were in play. Three years later, the Supreme Court’s infamous Dred Scott decision held out the prospect of legalized slavery in the northern states, as well. Slavery was no longer a wrong. It was about to become a universally recognized right. Passions on both sides were awakened, but the situation clearly favored the south.

Lincoln’s melancholia allowed him to see events with preternatural second sight. Southerners with a vested interest in the outcome stood a clear chance of having their way over largely indifferent northerners. It was the thin edge of the wedge that could put an end to free labor markets everywhere and dash the dreams of the Founding Fathers. The clock was being rewound back to the Dark Ages, and Lincoln was not confident of his ability to put a stop to it. Nevertheless, he felt compelled to speak out against the madness, even at the risk of his career.

Paradoxically, his political career took off, though true to melancholic form he saw every slight setback as a major failure. The new political reality spelled the end of Lincoln’s Whig party. In its place stood the newly-formed Republican party. In 1858, Lincoln found himself in the national spotlight in his series of debates with the author of the Kansas-Nebraska Act, Stephen Douglas. Both were contesting the same Senate seat.

The Senate was Lincoln’s lifelong dream. In an era of lackluster Presidents, this was the forum of his heroes such as Daniel Webster and Henry Clay. But Lincoln was prepared to sacrifice his ambitions for the cause. His antislavery position ran ahead of public opinion, but he strongly felt the greater interest was better served by enlightening the voters.

Lincoln also saw ahead to 1860, when Douglas was likely to be the Democratic standard-bearer in the Presidential election. In the debates, he forced his rival to expose himself as too moderate for his southern backers. The next Republican candidate for President, he knew – certainly not he – would benefit.

Lest we mistake Lincoln as morally flawless, he neither viewed African-Americans as biologically equal to whites nor did he envision the two races living together in harmony. The world was a stupid place back then, arguably only slightly more stupid than it is today.

In early 1860, Lincoln traveled to New York to deliver an address to the Cooper Institute. He brilliantly succeeded in linking the dreams of the Founding Fathers to the anti-slavery position, and threw down the gauntlet on right versus wrong. He brought down the house, and achieved rave notices everywhere. No one was quite ready to seriously consider him as Presidential timber. Yet …

Improbably, on the strength of his new-found image as the rail-splitter, Lincoln won his party’s nomination on the third ballot. The election was a shoo-in. Thanks in part to the Lincoln-Douglas debates from two years before, an irreparable schism had formed in the pro-slavery ranks. The Democratic party splintered three ways, allowing Lincoln to win with just 40 percent of the popular vote.

Even more improbable, Lincoln’s well-known melancholia was not seen as a character flaw. Today, the immensity of a Lincoln-sized depression would disqualify a candidate from virtually any elected office save dog-catcher. Back in Lincoln’s time, living successfully with a mental illness was viewed as a character virtue. Maybe they weren’t all that stupid back then, after all.

The Presidency

By the time Lincoln was sworn in, seven southern states had bolted from the Union. Facing the Republic’s gravest crisis, he assumed office with no executive experience, forced to govern from an untenable position. One slight overstep and the border states would join the South, ending all hope of reunification. When hostilities broke out, the North lost far more battles than it won, forcing all and sundry to second-guess his leadership. As the terrible carnage mounted, much of the population lost its resolve, leaving Lincoln with a very weak bargaining hand. When he pressed his position harder, rebellion threatened to erupt on the home front. Few believed there would be a successful conclusion to the war. No one thought he could be reelected.

Of all things, a lifetime of living with depression admirably prepared him for the task. He possessed both the intestinal fortitude and the moral will. And the insights he had acquired from a lifetime of sorrow seemed to connect him to a higher power. As Joshua Shenk explains, over the course of his adulthood, Lincoln passed from fear to engagement to transcendence.

In other words, having decided that he WOULD live, he then decided HOW to live. When faced with the challenge of a lifetime, he proved more than ready.

But first came more personal tragedy. During his term of office, His favorite son, Willie, died. Of his four sons, only one would live to adulthood. On learning of the death of Willie, he wept convulsively.

In 1862, Lincoln deviated from a previously-held position by proposing to his cabinet the emancipation of slaves from all union-held southern territory. The move risked alienating the border states, but would serve to give the war a higher moral purpose. Nevertheless, Lincoln entertained no delusions about whose side God was on. Death had visited far too many northern households for him to believe that the Almighty was playing favorites. "My greatest concern is to be on God's side," he advised a colleague.

The Emancipation Proclamation would be the first step toward universal freedom and enfranchisement. Soon after, Joshua Speed would pay a visit, and Lincoln would remind him of their conversation some twenty years earlier, when only his desire to accomplish something great gave him the will to live.

"I believe in this measure my fondest hopes will be realized," he confided to his friend.

Sainthood

On assuming his second term of office, Lincoln spoke the finest words ever uttered in the English tongue:

With malice toward none, with charity for all, with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds.

He had six weeks to live, his last days filled with a transcendent lightness of being. It was as if, his mission on earth accomplished, he were ready to be taken up into heaven. On April 14, 1865, a man with a gun obliged. Now he belonged to the ages.

Final Words

In Lincoln’s depressions, we see the illness in its full destructive horror, one that nearly succeeded in cutting short the life of a promising young man and made the rest of his existence miserable. This is the side of depression with which we can all unfortunately identify. But we also see an aspect to his depressions that equally resonates with us – how our suffering can strengthen us, ennoble us, and embolden us, often to achieve the impossible.

Our sense of achievement need not be the same as Lincoln’s, nor for that matter what our families may expect of us. It is simply enough that we survive from day to day with the kind of grace that is used to define courage. Believe me, if Lincoln were to visit you right now, he might admonish you to make your bed, but he would do it in the way of a funny story. And he would let you know how proud is of you - no doubt about it. Take heart. Lincoln lives in us all. Walk tall.

Grading Depression

I recently posted a five-part (and counting) series, Are Antidepressants Bad for You? For a good many, the answer is yes. A lot of it has to do with our antiquated diagnostic criteria for depression, which treats virtually all depressions as the same. This encourages one-size-fits all treatments that turn out to fit very few and harm a good many.

In Feb, the American Psychiatric Association released a draft of an updated DSM, which would perpetrate the mistakes of the past. In light of my most recent series, it's appropriate here to re-run three of my critiques in this one post. Without further ado ...

Grading Depression - Part I

This is the first in a series of report cards that grades the homework turned in last week by the DSM-5 Task Force. Our first assignment: Depression.

First, some background ...

According to statistics cited on the NIMH website, major depression is the leading cause of disability in the US and affects 6.7 percent of Americans in any given year. Plus major depression is a major component to bipolar disorder, affecting another 2.6 percent of the US population each year. In addition, dysthymia (major depression lite) accounts for an additional 1.5 percent.

An illness of this dimension literally comes equipped with its own gravitational field. Thus, few psychiatric diagnoses make sense without some reference to depression, be it anxiety or schizophrenia or borderline personality disorder.

This means that if the people responsible for coming up with a new version of DSM depression get it wrong, then the whole document - together with the whole field of diagnostic psychiatry - is going to be out of alignment.

Fortunately, everyone knows what depression is, right? Um, not exactly. Early versions of the DSM recognized the highly complex nature of the illness at the expense of confusing just about everyone and thus influencing no one. The DSM-III of 1980 and its successors (the DSM-III-R, the DSM-IV, and the DSM-IV-TR) went for simplicity and clarity, which seemed to please just about everyone, except maybe patients.

The major knock on depression as we know it is that it is a catch-all diagnosis for all manner of things going wrong. But this is its major appeal, as well. One one hand, not enough patients are getting better on meds and therapies designed to combat this simultaneously mysterious and obvious entity called depression. On the other hand, just enough are.

At issue for the DSM-5’s Mood Disorders Work Group is how these major contradictions can be reconciled.

Time to start grading ...

The symptom checklist

This was a masterstroke from those who brought us the DSM-III. So much so, that we tend to think of the checklist as something that existed since before the dawn of time and that is based on pure science rather than being pulled out of thin air. Even though the current DSM recognizes several different forms of depression, everything originates from this (five of) nine-item menu.

Critics have identified a number of major problems with the list, namely:

• It is biased toward identifying depression in women rather than men (such as “appears tearful”).
• It fails to identify the patient’s predominant state of mind. For instance, it is possible to check off “feeling depressed,” followed by “significant weight loss,” “insomnia,” “psychomotor agitation,” and “fatigue.” Voila! Major depression, but what does that tell us? Is one vague mental symptom followed by four physical ones truly depression?
• It fails to identify the patient’s predominant state of mind (again). Sad? Agitated? Unmotivated? Feeling hopeless? Overthinking things? Excruciating psychic pain? Yes, we know it’s depression. But what is really going on?

On the other hand, the list has been in service for 30 years. It may not be perfect, but it does give us a reasonable approximation of a condition that so profoundly lays waste to so many. So why change it? This was the approach adopted by the workgroup.

Unfortunately, this was the safe option that gave us nothing to think about, that squelched a conversation that we badly need to be having, and that put the interests of monied stake-holders (such as the insurance industry) over the needs of patients.

Grade: F-minus.
      
Mixed Anxiety Depression

This is a wholly new and separate diagnosis, distinct from major depression. The workgroup recognized that nearly 60 percent of those with major depression also experience anxiety, which adversely affects patient outcomes.

The new diagnosis would acknowledge that one need not experience full-blown major depression or full-blown anxiety to wind up seriously distressed and incapacitated. A little bit of each will do. Thus, Mixed Anxiety Depression calls for just three or four depression symptoms (one which must include either feeling depressed or loss of pleasure), plus “anxious distress” which involves such things as “irrational worry.”

The recognition of anxious-depression is long-overdue, but since it was already listed in the DSM-IV appendix as deserving of future consideration, one cannot give the current workgroup credit for putting the issue on the table. Moreover, there is no mention of how “agitated depression” and other types of “mixed states” may fit into the picture.

Grade: C.

Mixed Episodes

The current DSM only recognizes mixed depression-mania states as occurring in bipolar I, and only in the ridiculously limited context of full-blown mania combined with full-blown depression. The DSM-5 would restore a measure of sanity by acknowledging that mixed states can occur in bipolar II, as well.

How this fits into unipolar depression is unclear. On one hand, the workgroup expressly rules out unipolar depression if the patient had ever experienced a mixed episode. On the other hand,
with no explanation, the workgroup adds the specifier, “with mixed features.” Huh?

There is good evidence that many individuals with unipolar depression experience mania/hypomania symptoms in their depressions, not enough to rate a diagnosis of bipolar, but enough to raise their levels of distress and make their depressions more difficult to treat.

On this very important issue, the DSM-5 workgroup has not handed in its homework.

Grade: Incomplete.

Grading Depression - Part II

Part I began issuing grades on the homework handed in last week by the DSM-5 Task Force concerning its proposed revisions to depression. To recap:

The symptom checklist - “So why change it? This was the approach adopted by the workgroup.” Grade: F-minus.

Mixed anxiety depression -  “The recognition of anxious-depression is long-overdue.” Grade: C.

Mixed depression-mania episodes - “On this very important issue, the DSM-5 workgroup has not handed in its homework.” Grade: Incomplete.

Moving on ...

Chronic and Recurrent Depression

These are two entirely different animals. For the first time, the DSM would fully acknowledge the chronic variety (“chronic depressive disorder” with an episode lasting at least two years). The new diagnosis would subsume dysthymia and change its threshold to include major depression as well as low grade depression.

Gone is the “chronic” specifier to a major depressive episode.

The DSM-IV criteria for recurrent depression would stand, namely two or more major depressive episodes (lasting at least two weeks) at least two months apart. No provision is made, however, for the reality of highly-recurrent depressions that come and go at a faster rate.

Recurrent depression - and the highly-recurrent variety in particular - may have more in common with bipolar depression than unipolar depression, or at least may occupy common ground in dire need of mapping. Somewhere, somehow, on some level, the rather obvious overlap between unipolar and bipolar needs to be recognized and dealt with. On this vital issue, the workgroup looked the other way.

Grade: F.

Severity

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would obviate the rather arbitrary and clumsy distinction the current DSM makes between major depression and dysthymia (which the workgroup proposes eliminating).

It also places less emphasis on the symptom checklist. Thus, someone with all nine depression symptoms who is nevertheless able to hold down a job and keep his or her marriage going is in much better shape than someone with only four symptoms who technically does not meet the threshold for major depression but hasn’t been able to get out of bed in six months.

The Mood Disorders  workgroup is currently investigating a variety of measures.

Grade: Incomplete.

The Specifiers

The current DSM uses these to parse out different types of major depression, thus major depression with: psychotic features, catatonic features, melancholic features, atypical features, postpartum onset.

The DSM-5 would leave this list intact with two exceptions. “Chronic” is removed as a specifier and upgraded to a diagnosis, and “mixed features” is added with no explanation. In addition some changes are added to the psychotic features specifier to account for severity as well as type (“congruent” or “incongruent”).

The problem with specifiers in this context is they are only as good as the symptom checklist they are supposed to be specifying. There must be a better way, for instance, of distinguishing an agitated depression from a vegetative one or a mainly sad state of mind from one characterized by the lack of ability to care.

Think of depression as too much emotion on one hand and not enough on the other. Factor in too much or not enough thinking, and you can see that the experts charged with this brief had their work cut out them. They didn’t put in the work.

Grade: F.

Reactive Depression

The DSM-II of 1968 distinguished between what it saw as biologically-based depression (endogenous) and depression seen as a reaction to stressful events (exogenous). The DSM-III and its successors wisely ditched speculating about cause and effect and stuck to categorizing observable symptoms.

Thirty years later, however, advances in brain science suggest some merit in going back to the future, but with this ironic twist: Although current brain science does not yet support diagnostic descriptions based on underlying biology, one can make a good biological case for supposedly non-biological reactive depression.

Not only that, we already know that managing stress is a key to managing one’s depression. Stress Junction is where Freud, brain science, and common sense meet. The DSM-5 workgroup missed the bus.

Grade: F-minus.

Personality

Can persistent and treatment-resistant depression be looked upon as a personality disorder? Consider this assignment extra credit. Neither the Mood Disorders nor the Personalities Disorders workgroups took up the challenge.

No grade.

Grading Depression - Part III

NOS

Is there a place in your house you dread looking into? The attic? The crawl space? A certain closet? The bottom of your refrigerator? The current DSM contains its own version of the dreaded place. It is called NOS - not otherwise specified - and accompanies 41 listed diagnoses.

The draft DSM-5 would continue the practice. I peeked in and, suffice to say, experienced every traumatic flashback involving attics, crawl spaces, closets, and refrigerators, and then some. Some background:

If you’re a DSM editor and don’t know what to do with a certain type of symptom or behavior, you create an NOS closet (or refrigerator) and stick the weird stuff in and close the door. Maybe you’ll figure out what to do with it later.

It you’re a doctor and don’t know how to diagnose a certain patient, you write up NOS and find the appropriate closet (or refrigerator), shut your eyes, stick it in, and close the door. Maybe you’ll come up with the correct diagnosis later.

The trouble is NOS is a black hole. What, for instance, does “Depression NOS” mean? Imagine “Cardiovascular NOS” and you can see that the practice is unacceptable, whether one is practicing medicine or writing a diagnostic manual. Moreover, the practice is highly abused. A background paper put out by the DSM-5 mood disorders workgroup cited an unpublished study that found that the specialist and nonspecialist clinicians in the sample employed “NOS” in 37-38 percent of their primary diagnoses for depression.

The DSM-5 would change NOS to CNEC (conditions not otherwise classified). I opened the freshly painted closet door to find ...

Subsyndromal depressive CNEC. This would include patients in obvious distress who somehow don’t meet the formal diagnostic criteria for depression. Given the extremely wide view of depression the DSM already employs and its generously low thresholds it’s hard to imagine such a group. Certainly there are those who must put up with residual symptoms once the worst is over, but can’t we find a better way of defining this category? Out in broad daylight?

Major depressive disorder superimposed on a psychotic disorder. What the hell is something this major doing buried away in a closet?

Recurrent brief depressive disorder. So THAT’s where they stuck highly recurrent depression! I was looking all over for it. Nope, not out with recurrent major depressive disorder, where it belongs. Nope, not red-flagged as a type of depression closely related to bipolar. Nope, stuck away in a closet.

PMDD. Are you kidding me? We still hide “women’s problems” in the closet?

The sad thing is the things lurking in the DSM-5 CNEC closet are nearly identical versions of those still gathering dust in the DSM-IV NOS refuse bin.

Grade: F-minus

To Sum Up

Thus concludes my three-part DSM-5 Depression Report Card. Here are the subjects and my grades:

• Symptom Checklist: F-minus
• Mixed Anxiety Depression: C
• Mixed Episodes: Incomplete
• Chronic and Recurrent Depression: F
• Severity: Incomplete
• The Specifiers: F
• Reactive Depression: F-minus
• Personality (extra credit): No grade
• NOS: F-minus

Overall grade: F

Concluding Remarks

One of the ironies in issuing this report card is that I owe much to virtually all of the members of the DSM-5 mood disorders workgroup. I have read their articles. I have heard them speak at conferences. I have asked them questions face-to-face. In some cases, I found myself seated at the same breakfast or luncheon or dinner table.

My dealings with these individuals have been extremely productive and beneficial. To a person, they are as dedicated to their work as they have been gracious to me. Moreover, a good deal of what I know about mood disorders can be attributed to them and their colleagues. Many of my key Aha! moments are a direct result of the wisdom they have shared with me, their professional colleagues, and with patients and family members.

So, what went wrong?

For one, DSM-5 operating parameters were far too restrictive, involving an onerous burden of proof for new inclusions. Too often, the necessary empirical data was lacking. We may “know” for instance that depression is bound up in personality, but can we “prove” it?

Scientists need to “validate” their claims with scientific evidence. But what if the picture they produce is inaccurate and misleading and leads to the kind of absurd results I've brought up this series? No acknowledgment of the obvious relation and overlap between depression and bipolar? C'mon!

My concern is with "credibility," which the DSM-5 sacrificed in its obsessive over-pursuit of "validity." As a result, the DSM-5 is failing in its key mission of aligning psychiatric authority to our clinical reality.

Nevertheless, everyone has a stake in the status quo - Pharma, the insurance companies, the clinical-research establishment, perhaps even patient advocacy groups. Credible or not, the DSM pays the bills. Thus, no one is about to stand up and say the DSM-5 is a piece of shit. Okay, I just did, but who listens to me?

The other main problem is “paradigm freeze,” which I will get to in a future blog piece.  

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet.