“The opposite of depression is not happiness, but vitality.”
This quote from writer Andrew Solomon contains some important wisdom about the nature of the beast we call depression. It is normal to experience sadness, to have days of feeling grumpy or down. We all have days like this, sometimes a few in row. It is normal to feel sad in response to distressing life events – these are the bumps in the road of life, and for most of us, we navigate over the bumps and get on with the life we recognize as ours. However, when the obstacle is not the normal vicissitudes of daily life, but rather a run-in with depression, this can be altogether a different story. Life becomes a foreign and exhausting experience, where it feels like there is no respite and no hope for a more engaged tomorrow. Here are some things to look for if you aren’t sure whether or not you might benefit from help for depression. If you have found that, for more than two weeks or so:
1. Everything is exhausting: the tasks of daily living – getting the mail, taking out the trash, doing the dishes, talking to friends or family – are overwhelming and extraordinarily demanding. If it feels like doing the little things of everyday life is just too much to face, you may be dealing with depression.
2. Everything is annoying: for many people, and this can be especially true for men, who in our culture our discouraged from acknowledging that they feel down or sad, depression shows up as extreme irritability. If you find that you are responding to the other people and events of your life with intractable bouts of extreme irritability not in proportion to the events in question, you may be dealing with depression.
3. Everything is overwhelming: you used to find that life was a pretty comfortable place for you, but now find that even minimal levels of stimulation are overwhelming for you. People in your life talk too much or talk too loud, bright colors are intrusive, any change in plans or routine is unbearable, even music, books or movies you used to enjoy demand too much energy – if this sounds familiar, you may be dealing with depression.
4. Everything is un-interesting: you used to enjoy your hobbies, had activities or events in your life that predictably brought you pleasure, but now, nothing is pleasurable or enjoyable. If food tastes bland, jokes are never funny, you don’t look forward to things you used to, you can’t seem to care what’s going on around you, you may be dealing with depression.
5. Anything could provoke tears: if you find that you cry frequently, sometimes for reasons you don’t understand, or for no reason at all, you may be dealing with depression.
6. Nothing provides relief: if you have come to a place where you feel no hope that things will change or improve, and/or you feel helpless to gain traction and return to a place where life held some pleasures, if a sense of defeat and purposelessness has invaded your daily routine, you may be dealing with depression.
It’s important to note that, if several or all of these things ring true for you, you do not have to just suffer through it. There are effective tools for managing and resolving depression, most notably, therapy and medications. Statistically speaking, the best outcomes in terms of recovery happen when we use both of these approaches together; you will have to find the specific remedy that best suits your particular needs. What’s most important is that you know that you don’t have to keep struggling and you certainly don’t have to accept that this is just the way things are. Depression is an awful monster that can take over people’s lives, whisper horrible things in their ears, and prove a relentless and formidable burden. While you may not know what to do to get rid of this monster if it has invaded your life, you don’t have to do it alone. A skilled therapist can help you move back to a place of vitality and engagement in life. Please – if this describes you or a loved one – know that we as a community of experienced therapists would like to help you begin the work of taking back your life from this monster. There is hope, and there is help. Finding the right therapist can be a great first step.
“The opposite of depression is not happiness, but vitality.”
Q: Some parents I know seem in a rush to have their children go on medication for things like depression and hyperactivity. What should parents do before making the jump to medication?
A: For psychological disorders, a thoughtful and accurate diagnosis is key to developing an effective treatment plan. What elementary child does not have occasional concentration problems in class? Does this mean that he/she has Attention Deficit Hyperactivity Disorder (ADHD)? Similarly what adolescent isn’t moody from time to time? Do we diagnosis him/her with Bipolar Disorder? Many mental health professionals would agree that these two disorders are highly over diagnosed in children and adolescents. This is a significant concern because both ADHD and Bipolar Disorder are typically treated with strong psychoactive drugs. Once diagnosed, patients may be on these drugs for the rest of their lives.
The accuracy of a diagnosis is a function of gathering information from multiple sources and thoughtfully ruling out other variables that may better explain the symptoms. For example poor concentration is also a symptom of depression. Some would argue that mood swings are a normal function of hormonal changes in adolescence. While it can be costly, considering formal testing by a trained psychologist can dramatically increase our objective data and thus increase the accuracy of our diagnosis. There are specific psychometric tests that can assess attention impairment (e.g. the TOVA), mood disorders (the MMPI), and other psychological conditions. A comprehensive psychological evaluation would include a battery of tests; an analysis of the child’s medical, family, educational, and social history; as well as surveying parents, teachers and children, in order to get a convergence of multiple data points as to the source(s) of the presenting problem. In the end the cost of a thorough psychological evaluation may be far less than the impact of an incorrect diagnosis.
When accurately diagnosed and treated, medications can prove to be a great blessing in treating conditions like ADHD and Bipolar Disorder. We just want to do everything we can to be sure of the root cause, which allows us a much better chance of developing a treatment plan to address it.
By Dr. Jan Hittelman
Q: How do I get my unwilling teenager to talk to someone, such as a therapist?
Sign me, Concerned Mom
A: The pivotal challenge in creating getting your teen to meet with a counselor is getting them to willingly attend the initial session. Who wouldn’t be uncomfortable with the prospect of sharing personal information with a complete stranger? Particularly when you know you’re “not crazy,” don’t particularly like the idea and are other-referred (aka, dragged in by your parent). Luckily, there are steps that you can take that will greatly increase your chances of success:
Do your homework. A common mistake is to pick a random therapist, have it not work out, and have your teen more resistant than ever to see “another shrink.” Make sure that the therapist you go to is licensed and experienced. You can check a psychotherapist’s license status online at: www.doradls.state.co.us/alison.php. Next, try to make sure that he/she has experience working successfully with adolescents. You can accomplish this by getting recommendations from friends, coworkers or community professionals (your pediatrician, school personnel-guidance counselors, school interventionists, etc.). In addition, don’t be reluctant to first interview the therapist over the phone or in person. Ask about their experience working with adolescents and how they would approach treating someone with symptoms like your child is exhibiting. Does this seem like someone your teen could relate to?
Empower your teen. It is important to give your teen a voice in the decision making whenever possible. After explaining why you feel that talking to someone is important, consider sharing the decision making with him or her. For example, say: “While you need to go to this initial appointment, we can talk together afterward to decide together if continuing would be a good idea.” Any effort to respect his voice in the decision-making process will increase his investment and eventual benefit.
Provide him with an out. One reason that teens (and others) resist the idea of counseling is that there is a concern that it may go on forever. During the initial meeting, I suggest to parents that they make an agreement with their teen to attend four to six additional sessions. If he doesn’t feel that it’s worth his time and (his parents’) money, he can rethink it at that point. That doesn’t necessarily mean stop altogether, but reevaluate it.
Reinforce his efforts. Along the way, make sure to let your teen know that you’re proud of his efforts. This would ideally start with that initial session and continue throughout treatment.
By Jan Hittelman
Attention Deficit Hyperactivity Disorder (ADHD) is estimated to affect 3-7% of school-age children. For many, these challenges continue into adulthood. There are three types of ADHD; “Predominantly Inattentive”, “Predominantly Hyperactive-Impulsive”, and a combination of the two (“Combined Type”).
Over the years there have been valid concerns that many children are inaccurately diagnosed as having ADHD. This is problematic in part because medication is often prescribed to treat the disorder. It has been shown that some children, who were initially diagnosed as ADHD, were actually in the early stages of having Bipolar disorder and the ADHD symptoms were a function of the manic component. In these cases, prescribing stimulant medication can actually trigger manic episodes. There have also been instances where children were initially diagnosed with ADHD and it later was determined that their concentration problems were actually a symptom of depression. Finally, there are large numbers of children that were simply misdiagnosed and did not need to be put on medication at all.
To accurately diagnose ADHD there need to be several indicators that together confirm the diagnosis. These would include: feedback from parents, teachers and children themselves; objective evidence based on standardized psychometric tests constructed to assess for ADHD; and meeting the specific criteria developed by the American Psychiatric Association. Too often these critical steps are skipped and medication is prescribed.
As a parent it is important to work with mental health professionals who have expertise in diagnosing and treating children with ADHD. Too often ADHD medication is administered by a primary care physician instead of a psychiatrist, who has specialized training in administering and monitoring psychotropic drugs. While psychological testing can be time-consuming and expensive, it is a critical component in reaching an accurate diagnosis. In addition, tests that specifically measure ADHD can be used to monitor and adjust dosage levels to ensure maximum effectiveness.
In my experience, when a child is accurately diagnosed with ADHD and put on the proper medication regimen, the results can be dramatic in terms of their newfound ability to focus in school and reduce their impulsive behaviors. In addition, behavioral strategies to help strengthen the child’s social, coping, and problem solving skills are often an important component of an overall effective treatment plan.
By Jan Hittelman
Last month’s column on teen depression highlighted the importance of a good initial assessment. Several readers questioned exactly what an assessment is, let alone a good one.
You may be surprised to know that even within the mental health field there are a range of definitions regarding a psychological assessment. It is even more surprising that many mental health professionals are not extensively trained in conducting an initial assessment. The purpose of the assessment is to clarify the nature of the treatment issues to be addressed.
What is a psychological assessment? First of all it is different than a formal “psychological evaluation”, where standardized psychometric tests are administered (i.e. intelligence, academic, personality, and perceptual tests). Depending on the results of the assessment, a more in-depth psychological evaluation may be recommended. A psychological assessment typically includes several components:
• A detailed history (often from the parent if the client is a minor) that usually includes information on birth, educational, social, familial, and emotional experiences of the referred client.
• A one-on-one interview between the therapist and the client where additional detailed information is collected. This is sometimes referred to as a “Clinical Interview.”
• An opportunity to build a relationship with and empower the client, allowing him or her to be a partner in developing the treatment plan.
• An additional discussion with family members, which may include the client.
• Providing specific diagnoses and recommendations to the client (and/or parent) as a result of the information obtained.
Why is a psychological assessment so important? The assessment is a critical component in helping to develop a thoughtful treatment plan for the client that addresses their underlying social/emotional/behavioral issues. This is of particular importance when the client is a child or adolescent, because, unlike an adult, it may be unclear what the underlying issues really are. An example of why an assessment is critical is teen depression, as it is often misdiagnosed because it can look like anger or irritability. Another common misstep for a client that is a child or adolescent, which can be avoided through an assessment, is providing individual therapy when in fact family therapy may be what is needed. As you can imagine, there are many other examples of issues that are missed without a thorough initial assessment. The goal of the assessment is to better understand the initial concerns before investing a lot of time and money in treating the symptoms rather than the underlying problem(s). While there may be an additional cost in obtaining the initial assessment, it is well worth the investment and may reduce the overall costs by addressing the correct underlying issue.
What are the Right Questions to Ask? When considering psychological counseling, there are several questions that should be asked: Are you licensed? Do you have extensive experience working with someone this age and who presents these kinds of concerns? And perhaps of equal importance; what is your assessment process and what does it include? Doing a good job as a consumer will increase the odds that therapists will successfully do theirs.
By Jan Hittelman
All licensed mental health professionals are trained in making psychiatric diagnoses. The diagnostic system is standardized, meaning that everyone uses the same criteria. The “Diagnostic and Statistical Manual of Mental Disorders” or “DSM” is the accepted standard and is published and periodically revised by the American Psychiatric Association. Everything from disorders first diagnosed in infancy or childhood to psychological issues due to a medical condition are included. Each diagnosis has its own numeric code. These codes are often required by insurance companies in order for clients to get reimbursed for mental health services.
There has always been some degree of controversy regarding psychiatric diagnoses. One can argue that diagnosing clients amounts to pigeonholing, because if it were truly accurate we would each have our own unique diagnosis. While some clients’ symptoms neatly fit into certain diagnostic categories, many do not. Consequently, many view diagnosis as the application of a label in order to provide the insurance company with required information. On the other hand, the process of carefully assessing the client and determining an accurate diagnosis can have a significant impact on the subsequent treatment they receive.
A diagnosis like Bipolar Disorder or Attention Deficit Hyperactivity Disorder, for example, often results in recommendations for psychotropic medication. Consequently, it is very important that the diagnostic work is thoughtful and accurate as it is certainly not beneficial to put clients on unwarranted medications.
Similarly if we do not have a clear understanding of the disorder, then our treatment plan may miss important underlying issues that are fueling the symptoms that we see. A common challenge with children and adolescents, for example, is accurately diagnosing depression. Unique to children and adolescents, irritability can be a sign of depression. If an adolescent is brought in because of anger issues, which is quite common, it is important to rule out underlying depression. Otherwise simply treating the anger outbursts will be ineffective and put the child at risk for increased depressive symptoms.
As a client, it is a good idea to discuss your diagnosis with your mental health professional. Ask them to share the specific symptoms or criteria used to make the diagnosis and be sure that you’re in agreement. At the very least you should know what information is being submitted to your insurance company. Many clients are uncomfortable with this information “being on record” with the insurance company or elsewhere. There are concerns of being permanently labeled and this information being shared with others. This is not a real concern, however, as client records are strictly confidential by law and an insurance company or mental health provider is not allowed to share this information without your written consent. If you question the accuracy of your diagnosis, speak to your provider about it. You can always get a second opinion as well. Psychotherapy can be expensive and time-consuming. It is to your advantage to make sure that your treatment is based on a sound diagnosis from the start.