4 things to do
A common practice in the treatment of a first major depression is to keep patients who have responded to drugs on them for about a year. Then, because such patients can go a long time before a second depressive episode, they are weaned from the drugs, typically over a period of a week or two. A second depression is usually treated similarly. It is only when someone becomes clinically depressed for a third time that it seems reasonable to keep patients on drugs indefinitely. When I suggest to a patient that it is time to come off these drugs, I make a few recommendations that I think lessen the chance of the depression relapsing immediately. I want to list them here, but there are certain considerations that make me hesitate:
- Although those recommendations are considered carefully, they may be wrong. At best they should be understood by the reader as the opinion of an experienced psychiatrist who tries to keep up with the psychiatric literature. But things change. As I learn more, I sometimes find reason to change my opinion. The advice of an expert—any expert—should not be taken as the last word. Experts are wrong all the time in medicine, and I have written about such mistakes in “Worried Sick?”
- Advice that is sensible for most patients may well be dangerous for a particular few. I mention a few examples below.
- Any proposal for a medical condition, however innocuous, that causes a patient to put off seeing a doctor can cause harm. In such a way, a depressed individual who takes an herbal concoction may put off starting on proper treatment and will suffer, therefore, longer than necessary. I would not want any of the suggestions I make below to be taken as the best treatment for a major depression. They are not.
There is another reason to hesitate to give advice over the internet, according to a child psychiatrist friend of mine. “You can get sued for medical malpractice.” That is not a thought that occurs to me very often. During the many years I have been in practice, no one has ever suggested they might sue me—except for my father, come to think of it. Towards the end of his life he threated to sue me for medical malpractice, and I had to explain to him that he could not, since I had nothing to do with his medical care. In fact, I lived in a different city.
Also, my friend points out, anybody can sue anybody else for any reason at all. If I were to recommend eating healthy salads (and I do), some guy could sue me if he choked on the salad. In fact, if he were hit by a truck after eating a salad, he could sue me for causing him to be distracted. No doubt I would win such a suit, but I would have to pay litigation costs. It is easier never to say anything on the internet, or anywhere else, for that matter. I have to take this admonishment seriously. I have readers, I know, who would like me to suffer a calamity. They root for me to die a painful death and go straight to hell. I know this because they have written to tell me so.
But I write this blog with the purpose of being helpful to people and, it seems to me, I should say what I believe. I am told I can mitigate the danger of litigation by offering up a caveat—what in the business is called a disclaimer.
So, here it comes. Get ready… THE REMARKS I MAKE IN THIS BLOG SHOULD NOT BE TAKEN AS PARTICULAR ADVICE FOR PARTICULAR INDIVIDUALS WHOM I HAVE NOT SEEN. Or THE DEPRESSED INDIVIDUAL, OR THE FORMERLY DEPRESSED INDIVIDUAL, SHOULD CONSULT HIS OR HER PHYSICIAN BEFORE IMPLEMENTING THESE SUGGESTIONS. Or INDIVIDUALS SUFFERING OBSCURE ENDOCRINE PROBLEMS OR SKELETAL ISSUES SUCH AS A RECENT FRACTURE OR ARE TROUBLED BY SUDDEN BLEEDING EPISODES OR KIDNEY STONES SHOULD CONSULT A SPECIALIST WHOM THEY CAN THEN SUE SHOULD ANYTHING GO WRONG. There. That makes me feel better.
Suggestions for Individuals Stopping Anti-depressant Medications. (Also, these recommendations may prove useful in preventing people from getting depressed in the first place.)
- Exercise. There are a number of reports indicating that exercise has a measurable, although minor, anti-depressant effect. Certainly joggers report the “runner’s high,” which puts them in a good mood after jogging a distance. I, myself, have noticed that after jogging I do not worry about whatever I was worrying about before I set out. Being the kind of person I am, I then begin worrying about the possibility that I am not worrying about something I should be worrying about. In any case, exercise is something I can recommend whole-heartedly for other reasons. It cuts down the risk of cardio-vascular diseases and of certain cancers. Most important, it halves the risk of Alzheimer’s disease. (As I note above, patients who have recently fractured a leg should not exercise vigorously.)
- Spend time out of doors in the daylight. There is really good evidence that the absence of light makes some vulnerable people depressed. Spending time in the light can ameliorate that depression. There is much more light outside under an overcast sky then there is in the most brightly lit room. Seasonal Affective Disorder (SAD) is a condition wherein vulnerable individuals get depressed every winter at a time when there is little daylight. Ordinary depression also seems to get worse during winter; and I often have to prescribe higher doses of medication at that time.
There is epidemiological evidence for this effect. There is a geographical gradient in which countries further and further away from the equator have a higher and higher incidence of major depression. I have seen men and women who respond to vacationing in Florida (after a few weeks) and then relapse again about a week after returning to New York. There are “light boxes” sold for the purpose of providing light when there is little light outside.
- Take an appropriate amount of vitamin D. There is some evidence that Vitamin D lessens or prevents depression. (This may partially explain the geographic gradient I report above, since vitamin D is obtained from sunlight.) I take 2000 Units of vitamin D a day even though I spend the summer out of doors without sun block, which blocks about 98% of the rays that produce vitamin D. It is possible to take too much vitamin D since it is a fat-soluble vitamin and can accumulate in the body. The first and last time I saw a case of vitamin D poisoning was in 1958. Some researchers report some minor symptoms, acutely, when taking this vitamin; but I have never seen any. Most people who live in our temperate zone are vitamin D deficient, although there is a controversy about just what level is appropriate. (People who suffer certain kinds of kidney stones, as I hint above, should not take Vitamin D except under a doctor’s supervision.)
- Take an appropriate amount of fish oil. Studies regularly show some anti-depressant effect of fish oil in major depression and in bipolar disease. Also, fish oil has been recommended as a way of preventing cardiac disease and inflammatory responses, such as arthritis. The effect is hard to pin down. Just how much someone should take depends on a number of factors, too numerous to list here. It is possible to take too much. When investigators discovered that Eskimos, who eat almost exclusively meats with high concentrations of fish oil, were largely immune to cardiac disease, they recommended such a diet to others. We have not evolved, here in the Northeast, to subsist exclusively on fish oil, so some of these individuals developed severe bleeding episodes. (See the disclaimer above.)
There you have it. Four reasonable strategies to prevent a relapse of a major depression. They do not actually prevent most serious depressions, but they may have an effect on borderline cases. They not only promote health in general, they promote a proactive attitude toward physical and mental health which serves to counteract the sense of helplessness many depressed people feel.
(c) Fredric Neuman