The Grey Dog

I was once a moody child; I’m still a moody child… sorry, adult. Anyway, I’m also a bit sensitive about the topic. It’s as if being moody means being naughty, or maybe contrary. Not quite right in the head, or something -not well adjusted, at any rate. I take exception to that. I mean, just because I often have trouble mixing with people at parties who only want to make small talk -usually about other people- and then walk away shouldn’t disqualify me from church or anything… Okay, I don’t go to church, but you see what I’m driving at, I hope. Moods are kind of baroque frames around my happiness. They make even run-of-the-mill joy look like ecstasy.

I’m not advocating ignoring the more severe and persistent forms of mood -they may in fact herald something very important. I am saying that not all of us who are occasionally disgruntled, frustrated, or unhappy have some underlying pathology. And to label those occasions as bouts of depression is to dilute the word, mistake the condition, assume everything is the black dog.

I was therefore relieved to find someone who relates to that view:  https://theconversation.com/is-my-child-depressed-being-moody-isnt-a-mental-illness-92789

The author, Dr. Stanley Kutcher, Sun Life Financial Chair in Adolescent Mental Health, at Dalhousie University, Begins by noting that, ‘[…] if the media coverage is to be believed, we are drowning in a sea of mental illness that threatens to overwhelm post-secondary Institutions. […] The prevalence of mental illnesses (defined using clear diagnostic criteria) is not rising in this cohort.

‘Youth self-reports of negative emotions are increasing. But the self-report scales used in studies documenting this have not been calibrated for generational changes in language use. Nor have the results been validated using clear, clinically valid, diagnostic criteria applied by expert clinicians.

‘[…] The above noted self-reports do identify the ups and downs of everyday emotions, but these are not criteria for diagnosis of mental illness. So we can say that youth on campus may report feeling more negative emotions than previously, but this is not the same thing as saying that young people have more mental disorders than previously.’

He cites an interesting example of the lack of application of basic critical thinking and analysis: ‘In late 2017, the study “Mental ill-health among children of the new century: Trends across childhood with the focus on age 14” was published by the National Children’s Bureau in the United Kingdom.

‘This showed that self-reported negative emotions were present in about one quarter of this surveyed group, but this was interpreted as 25 percent of 14-year-old girls in the UK suffer from depression! The fact that parental reports identified about five per cent of this cohort as having significant mood problems was ignored by almost all commentators. This latter number is much more in keeping with known rates of depression in the population.’

I wonder if our expectations of normalcy are to blame. As Dr. Kutcher explains, ‘These concerns are not the result of substantial epidemic increases in the rates of mental illness. They arise, in some part, from poor mental health literacy and unrealistic expectations of the normal emotional states that life challenges elicit.’

He makes some interesting and important points, I think. ‘[…] First, the increased public perception that being well means only having positive feelings is taking over the social discourse on mental health. When the measure of health is simply feeling good, negative emotions become a marker of being unwell. […] Without addressing the life challenges and opportunities that negative emotions signal to us, we can’t develop resilience. Mental health is not a static concept wearing a big smile. There are good days and bad days, good weeks and bad weeks. We still have mental health even if we are having negative emotions.’

‘Second, the use of words originally developed to identify mental illnesses to describe normal negative emotional states has burgeoned. […] Further, the use of terms denoting illness, such as depression, to mean all negative emotions is even more confusing. Now, words like sadness, disappointment, disgruntlement, demoralization and unhappiness are all lumped together as depression.’

He feels that the continued and almost obsessive use of technologies like smart phones for communication-especially by the young- may limit their ability to express complex messages and ideas and hence increase the sense of isolation, of being misunderstood -or perhaps, of even being mislabelled. And since it is adults, by and large, in charge of the classifications, it’s almost a case of two solitudes, two Magisteria, staring at each other -neither the wiser. Neither the winner…

Interestingly, I think I caught a whiff of this while waiting for a bus the other day. Two quite young teenage girls were sitting on the only bench in the little shelter, both clutching their mobile phones like purses. Because the rest of the bench was filled with their back-packs and some school binders, I merely stood outside and leaned against the wooden frame.

“But what did he say, Kitty? Is he, like, mad at you or something?” This from a petite little girl with long, straight dark hair and a big red coat with only a pair of blue boots sticking out from the bottom.

Kitty shook her head and leaned back on the wall of advertising behind her. She also had dark hair, but short and messy. It fit rather well with a large, thick and ragged blue sweater, torn on at least one sleeve to show a thin arm underneath. Her jeans were also fashionably torn, but looking as new as her pink running shoes. “No… Not mad… Just, like, upset. He says I’m moody -and all because I don’t want to, like, talk with him and Mom at the dinner table. I mean, nobody, talks anyway.” She shrugged theatrically and leaned forward on the bench again.

Her friend sighed sympathetically. “Yeah, my mom keeps wanting me to… you know, like communicate with her, too. But I mean, ever since dad left, she’s always either on her phone, or has the TV on.”

Kitty, nodded. “Yeah well, like, my parents think I should see a counsellor at school… They think I’m depressed, eh?” Her friend’s expression tightened, but she stayed silent. “But my dad always has his phone on the table and, like, keeps glancing at the news on his apps or, like, he’s waiting for an important Email, or whatever. And my mom’s a realtor, remember, so she does the same.” Kitty glanced around the wall and saw a bus was coming. “That’s all they talk about, anyway, Jen.”

Jen was staring intently at the ground in front of her. “Well, I think my mom’s depressed, you know, but she won’t go see anybody about it.” She took a little stertorous breath. “She thinks she’s coping… But I think, like, she’s just escaping online and stuff…”

The bus pulled up, and Jen seemed on the verge of tears, so Kitty reached over and hugged her. “We have to be strong for them, you know, Jen…”

That’s all I heard before they quickly gathered their things and walked over to the bus, arm in arm. Kitty must have whispered something else to her, because they both started to giggle before they got on.

I don’t know if it’s the technology, but it did make me wonder whether we really have a handle on mental health yet.

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The Grief that does not Speak

How weary, stale, flat, and unprofitable seem to me all the uses of this world!

Like Hamlet, we all recognize this mood: the black dog lying in the noonday sun, the cloud that even hides the moon. It is the tear that defeats the wavering smile –and yet… And yet, there is often something more behind the grief, something that is hidden beneath the first impression. Shakespeare, again, understood this over four hundred years ago: ‘Give sorrow words. The grief that does not speak whispers the o’erfraught heart and bids it break.’

I suppose we all impose our own reality; we all see the world through our own experience. But, sometimes we see through that glass darkly. Things are not always what they seem.

Alethea looked calm and happy as she sat in my waiting room. In fact, she was smiling and talking with a little child who’d toddled over to her in his diapers with a toy. She was bending over in her seat, her long black hair almost reaching the little boy, as she tried to make him laugh. Her full-length black, cotton skirt and her blue silk blouse contrasted sharply with his bulky white diapers –a chiaroscuro worthy of a picture, but he waddled off to another woman as quickly as he’d arrived. The waiting room is like that here: a work in progress; an evanescent scene of fleeting beauty.

Alethea smiled again when I greeted her, and examined me with friendly eyes. I had anticipated avoidance, or at least timidity from a woman referred to me with recalcitrant depression. A woman, according to a rather extensive explanatory note, who seemed refractory to multiple attempts at treatment. But I’m a gynaecologist, and although we’re sometimes involved on the edges of depressive illnesses, most of us lay no claim to the territory. We’re adjuncts –often last-minute guests- invited to the therapy just in case; we’re seldom primaries.

But in my office, she seemed less at ease, her eyes flitting from the plants in their pots to the eclectic pictures hanging on the walls. They spent some time inspecting a terra cotta sculpture of a woman begging with a bowl that I’d positioned on a little oak table.

“You certainly have wide-ranging tastes, doctor.” I don’t think she meant it as a criticism, so I took it as the long missing compliment I have yet to hear from my staff.

I smiled, and opened up the computer.

“I’m afraid my GP wrote a rather long note justifying the referral to you; she seems quite worried –or maybe frustrated with me.” Alethea rested her eyes on me for a few seconds. “I asked to see you rather than a psychiatrist.” And then she chuckled. “She was not happy about that, I’m afraid.”

I pushed the computer to one side and sat back in my chair. “Do you mind if I hear your version, first?” I asked.

“Thought you’d never ask,” she said as she made herself more comfortable in the sturdy, old wooden captain’s chair that I insisted on keeping across from my desk, her eyes twinkling with amusement at my suggestion, but still cautious.

“Well,” she started, obviously trying to place the events in their proper order, “A few months ago, I went to see my GP because of some problems I was having –you know, coping stuff,” she added when I wrinkled my forehead. “Anyway, I was in tears when I sat down in her office and had trouble even talking to her without crying.

“She got very clinical and I could tell she was trying to remain an objective observer.” Alethea rolled her eyes and sighed. “She does that sometimes when all I need is a hug or something.” She risked a quick glance at my expression. “But I realize that’s not what doctors are supposed to do…

“Anyway, she asked me all the usual questions about my work, and my home life…” Alethea blinked and looked away. “I think she felt a bit uncomfortable with that part because my partner also used to go to her.” Suddenly she stared at me and I could feel the anger in her eyes. “I really don’t know why that would matter…”

She quickly snatched a tissue from my desk and wiped her eyes. “I’m sorry, doctor, I guess my GP is not the only one who gets frustrated.” She took a long, deep breath and exhaled it slowly. “She said she’d never seen me like that before, and that whatever might be going on, I was seeing it through the lens of depression.” She glared at the begging lady statue for a moment. “She actually said ‘lens of depression’ for god’s sake! Like no matter what I said, or experienced, it was somehow misinterpreted through that bloody lens, or whatever.”

Alethea seemed uncomfortable and kept readjusting her body on the hard chair so I pointed to a more comfortable one nearby. That got her smiling again, but I could tell she was still angry.

“She insisted I go on one of those new antidepressant medications –you know, the ones that aren’t supposed to make you tired. The ‘no side-effects pill’ she called it. ‘Just try It for a few weeks and let me know if it helps,’ she said and escorted me to the door, all buddy-buddy.”

She brought the comfortable chair close to the desk and helped herself to a handful of tissues. “But it only made things… worse.”

I leaned forward on my chair, detecting something she was implying in the way she said that word. “How do you mean, Alethea?”

A tear rolled down her cheek and she dabbed it with the tissue. “I didn’t feel at all like sex, when I was taking it and…” She hesitated for a moment. “And that really made her mad.”

I was confused. “Made who mad?”

She was staring at her lap, but her eyes wandered up to my face for a brief look before she called them back. “My partner.” She sighed again. “So I decided to go off the antidepressants after a while and went back to the GP. She seemed upset that I had only given them a month, and said I was still acting depressed. At that point she said I needed to see a psychiatrist, but I refused. ‘You have a chemical imbalance,’ she almost screamed at me, and implied that if I didn’t get help soon, there might be dire consequences.” Alethea glanced at me again. “I suppose she thought I might try to off myself or something.” She giggled at the thought and when I looked puzzled, she smiled and continued. “Maybe it’s your birth control pill, Alethea. I don’t know why you insist on taking them anyway.’” Alethea’s face turned mischievous and her eyes twinkled like when she first came in. “Because I’m Bi, you stupid woman!” she said and laughed. “Well, I didn’t actually say that to her, but I felt like it…

“Anyway, I convinced my GP to send me to you.”

I squirmed a little uncomfortably in my own, soft chair. “Why me?”

A playful smile emerged. “My aunt and cousin see you… They said maybe you’d listen.”

I think I blushed. “And what about your partner? Did she think you were… depressed?” I hesitated before using that word. “Did she listen?”

Alethea’s face suddenly tensed. “She was abusive,” she said between gritted teeth, and sent her eyes to scout my face again. “She used to scream at me and throw things around. I hated going home after work.”

“Did you tell that to your GP?”

She shrugged. “I told you, she felt uncomfortable about it. And anyway, she had a diagnosis –and a treatment,” she added, with a wry smile. “That’s what medicine is about nowadays, isn’t it?” The smile disappeared, to be replaced by a sweet grin. “And once you have a treatment, it’s… Next!” she said, rolling her eyes, and we both laughed.

“And so what’s happening now? Are you still with your partner?”

Her face beamed and her eyes sparkled. “Now, I’m back with my old boyfriend -it takes a long time to get in to see you,” she explained with a chuckle. “We’re even planning to have a child soon, maybe.” Her eyes hovered under the ceiling for a second or two. “I guess I wasted your time, doctor, but my aunt was right -it does help to talk about it… And I thought I should meet you anyway,” she added, and decided to make eye contact again. “You delivered my cousin last year…” The twinkle returned. “Care to see me again –in a while?”

I think my smile told her I’d love to see her again.

And as she left, I couldn’t help but think of that wonderful metaphor of Khalil Gibran: ‘Sadness’, he said, ‘is but a wall between two gardens.’

It certainly is.

Depression and Inflammation

The practice of obstetrics and gynaecology is normally a kaleidoscope of colours –from the pale red blush of an embarrassed face, the bright green flash of twinkling eyes, to the panoply of skin colours proudly arrayed like just-washed clothes in the waiting room. There is no rank to the colours, no special prize for the one most displayed, no arbitrary preference, but I am wary of grey…

You don’t have to be a psychiatrist to spot the clouds, nor possess a doctorate in psychology to feel the angst. Depression is a fog whose periphery shades and obtunds everything and everyone nearby. Its boundary is indistinct and to approach is to be enveloped. Obscured. Affected. It has the strange property of contagion.

Not to pretend an exact analogy, but I have often wondered about the resemblance of depression to how many of us react to an acute illness like, say, a ‘cold’ or even a headache –so-called ‘sickness behaviour’: fatigue, apathy, loss of focus, withdrawl… All of these are vaguely reminiscent of the psychological behaviour in depression, although I suspect most of us have not really thought about it in those terms. Admittedly, the resemblance is tenuous and terribly non specific, and yet I find the correspondence intriguing –not least because the symptoms are caused by some physical malfunction and seem almost designed to isolate and rest the body to allow healing.

So I was excited to read about the work being done investigating the link between depression and inflammation. One of the more informative evidence based reviews I have found was published in the June 2013 edition of Current Psychiatry and the author was Dr. Maria Almond from the University of Michigan:  http://www.currentpsychiatry.com/home/article/depression-and-inflammation-examining-the-link/b436332438ceca4baabe8be08701d6dc.html

The concept of inflammation having a role in what has always been considered a mental maladjustment reminds me of the story of stomach ulcers. Remember, it was not so long ago that ulcers were attributed to stress. It seemed intuitively obvious that it would –and should- be so. And then Helicobacter pylori was discovered in a large percentage of these patients and when treated, seemed to alleviate the symptoms. Mind you, not everone with Helicobacter was symptomatic, but its undisputed role in the disease process changed our thinking about psychosomatic illnesses –opened our minds… Or at least should have.

And then there is the oft refuted contention that cardiovascular diseases may have their origin in infectious –or at least inflammatory- processes. The arterial plaques that can narrow or block important blood vessels and lead to strokes or heart attacks have been commonly attributed to cholesterol levels –too much ‘bad’ cholesterol (LDL) will form these plaques and impede blood flow past them. Observational science at its finest; but seeing them and recognizing their significance, still does not answer the question of why they formed in the first place. There have been attempts to attribute the reason for their formation to inflammation and underlying damage to the arterial wall. But it is a chicken-and-egg observation: did the damage result from inflammation –ie some infectious, or other agent- or did some other cause for damage engender inflammation and attract the cholesterol to form the plaque in an ongoing attempt to heal it?

But as a gynaecologist I admit that I am straying into uncomfortable territory here, so I will merely leave it as a sort of illustration of the There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy type assertion.

The article on depression is exciting because it opens up entirely new ways of thinking of mental illness. It proves nothing, to be sure, and there are no doubt many ways of refuting the evidence it provides –including the fact that the causes of depression are likely as multifactorial as are, say, headaches or abdominal pain. One interpretation is unlikely to explain them all, I agree, but I am still beguiled by the way the observations seem to hint at commonalities. As the article points out:

In our progression toward understanding depression’s pathophysiology, we see factors that point to a relationship between depression and inflammation:

  • depression frequently is comorbid with many inflammatory illnesses
  • increased inflammatory biomarkers are associated with major depressive disorder (MDD) 
  • exposure to immunomodulating agents may increase the risk of developing depression 
  • stress can activate proinflammatory pathways
  • antidepressants can decrease inflammatory response
  • inhibition of inflammatory pathways can improve mood.

I’m not sure how this would explain the increased risk of antepartum –and especially postpartum– depression. Would the ever-changing level of hormones in pregnancy play some role in facilitating an inflammatory process? Or would the physiologic stresses engendered by the increasing needs of the developing foetus play a role? As another observation pointed out in the paper explains:

Acute and chronic stress is associated with increased availability of proinflammatory cytokines and decreases in anti-inflammatory cytokines.3,24 One theory looks to glucocorticoid response to stress as an explanation. Miller et al25 found glucocorticoid sensitivity decreased among depressed women after exposure to a mock job interview stressor and increased among nondepressed controls. Because glucocorticoids normally stop the inflammatory cascade, this finding suggests depressed individuals may not be able to control inflammation during stress.26 At the level of genetic expression, there is increased transcription of proinflammatory genes in response to stress  […]

Heuristic, to be sure, and certainly thought-provoking, but still a long way from convincing. But in Medicine, as in Science, it pays to have an open mind; to look around as you wander along long the well-trodden path. We haven’t seen everything yet; sometimes we have not even left the trail. There is something written by Lao Tzu that I have always remembered from my youthful philosophical journeys: If you do not change direction, you may end up where you are heading. Perish the thought.

Another Advantage of Breast Feeding?

As Mark Twain observed: What a good thing Adam had- when he said a good thing, he knew nobody had said it before. I don’t know about you, but I am getting tired of the media reporting on studies that contain nothing new and passing them off as fresh and enlightening. Even more upsetting is the fact that we often don’t even notice -or care… Studies that say nothing fresh or merely recycle what we already know, do not contain information so much as noise.

Time, then, to ask a more searching question: why is it important that we study this? And this is not to denigrate pure science, nor to suggest that investigations that are not directly goal-oriented are worthless. There is much value in answering the question by asserting that we were simply curious how it worked. Or why. Or under what circumstances -all of which are adding to our understanding of the world. Curiosity, after all, is merely a yet-unaswered question. A piece of the knowledge jigsaw puzzle. And its answer may well be worthy of reportage…

But to investigate the wheel and then conclude that it likely works by rolling, does nothing to inform. Indeed, publication of the results does little even to entertain, let alone educate… Or perhaps it does entertain -like those endless cat videos on Youtube, maybe there is value to a mindless occupation of the time that stretches between otherwise meaningful events. But the whole endeavour smacks more of playing cards until someone turns out the lights…

What is it that has me so vexed? So frustrated at banality uncleverly disguised as news? Well, I happened upon an article in the BBC ‘News’ about breast feeding and how it decreased the risk of depression.  http://www.bbc.com/news/health-28851441   It seemed a reasonable hypothesis; almost 14,000 mothers were studied and the results published in the online journal Maternal and Child Health (Aug. 21/14).

It’s a rather complicated statistical paper, but in summary it suggests that the risk of depression after delivery decreases considerably  if the mother was healthy to start with, intended to breast feed and found that she could. Okay, I could have predicted that. But, if she had been healthy, intended to breast feed, but found she couldn’t for some reason, her risk of depression more than doubled. Oh yes, and they found that  “the beneficial effects of breast feeding were strongest at 8 weeks after birth and that the association was weaker at  8 months and onwards.”  Uhmm… am I missing something here? Has something hitherto unsuspected slipped past me? Something, at least, that would change attitudes to breast feeding, or management plans for pregnancy?

Post partum depression is a serious problem in our society, with up to 10% (or more) of women at risk. That’s why we screen women during early and mid pregnancy to anticipate that risk and attempt to set up support systems for those who we judge are on that path. Anything that might ameliorate the danger is therefore a valuable addition to our management strategies. I’m not sure this study has even re-invented the wheel, however. It seems to demonstrate that if a mother’s plans work out, she is happy, if they don’t, she isn’t… Is it helpful to know this? Perhaps -but does it change anything? I suspect we will all continue to encourage mothers to breast feed and regard the oxytocin it engenders -the bonding hormone- a plus. But not an unanticipated one. Nothing has changed…

But then again, maybe constant reiteration –permananent recycling- is what we want. What we deserve…Maybe a society that tolerates laugh-tracks on comedy programs to help them to know what is funny, and that thinks apparently spontaneous applause in a talk show demonstrates the merit of the discussion, needs to be apprised of the obvious.

Am I being too cynical? Too arrogant? Well, perhaps. And yet…

It was early Thursday evening, and I was sitting in the OR lounge waiting to do an emergency operation. A surgeon and her resident were sitting nearby, their faces glued to the ever-changing TV images in front of them. I thought at first it was a talk show but they were staring at the screen as if it were a parental avatar, their expressions religious, their attention rapt.

I had been too preoccupied until that point to notice, but they seemed so intense I suspected something of profound significance was being discussed so I turned to watch. It was actually a cooking show and some celebrity that I didn’t recognize was being shown the basics of barbecuing a hamburger. “First, you want to get the grill good and hot,” the serious looking man in the chef’s hat was saying, pointing at the thermometer on the hood. “Then, you carefully place the patty on the grill –use a spatula with a long handle so you don’t burn yourself- and sear one side just enough to keep the juices sealed in…” He said this in a hushed and reverent tone as if it were one of the Ten Commandments. The studio audience clapped in delight at this little pearl of wisdom, and I noticed the surgeon restraining herself from doing the same. Her resident, ever mindful of imitative protocol, actually did manage a clap after glancing furtively at her mentor.

The surgeon suddenly became aware of my presence in the room and smiled with an expression I used to see in church after a sermon. She seemed surprised at my composure in the face of the Revelation. Or maybe annoyed that I hadn’t understood. Actually, I was disappointed; I felt as if I’d just been told the earth was round.

And it wasn’t even the vapidity of the program that made me remember the incident –maybe some people don’t know how to barbecue hamburgers, so maybe the show deserved prime time. Maybe the information it contained truly was important and not just another example of mildly entertaining celebrity fluff. Not having watched what went before, perhaps it was just an inter regnum… But no, it was more the reaction to it. The surgeon and her acolyte seemed overly awed by its significance -as if they wouldn’t have been at all surprised if it were the subject of a research paper in a prestigious journal.

I suppose the depressing reality is that it is me who is so far off-kilter that I cannot appreciate something of value. That I mistake the important for the banal. Knowledge for noise. But I can’t help wondering who decided that a celebrity learning how to cook a hamburger should occupy prime time. Or wondering why a study showing that people may get depressed if things don’t work out as they planned surprises anyone.

We all need a time out, for sure: a time when we just unbutton the brain and let it sit on the couch beside us eating popcorn. But surely we also need a time in. I’m with Shakespeare on this: We know what we are, but know not what we may be.