How to Evaluate Your Psychiatrist or Other Therapist If You Have (Or Possibly Have) a Depressive Disorder by John R. Lipsey, M.D., Assistant Professor of Psychiatry at the Johns Hopkins University School of Medicine.

1) It is impossible to get good treatment for depression if your therapist does not fully understand the differential diagnosis of depression. That is, some patients have symptoms of depression as a reaction to life circumstances; others, as a manifestation of an underlying major depressive disorder. The latter disorder is a medical illness strongly influenced by genetic factors, and it appears as a more or less stereotyped syndrome. In major depression, the patient has a profound and sustained lowering of mood and of mental and physical energy, often accompanied by self-doubt, self-criticism, and self-blame. Patients usually have changes in their sleep and appetite (in either direction). They may be irritable, their pleasure in usual activities is greatly diminished, and their hope for the future darkens. Suicidal ideas are not uncommon. Clearly, patients with this illness may find that their symptoms are worsened by environmental stressors, and at times these stressors may even provoke an episode of the illness in a predisposed person. However, environmental factors are not the major cause, and for these patients the most effective intervention is pharmacological treatment with antidepressants.

On the other hand, some patients have symptoms of depression that are fully understandable as an emotional reaction to difficult life circumstances. These depressive reactions are usually transient; respond well to positive changes in the environment; and occur most frequently in vulnerable individuals who find themselves in situations where their intentions, wishes, and desires for the future are thwarted in some way, or who have been severely disappointed or grief-stricken by some sort of loss. In general, these patients do not need pharmacological treatment, do not have strong family histories of mood disorder, and are best approached with appropriate psychotherapy.

The important issue, however, is that patients in the second category, who are demoralized, are not necessarily less depressed than patients with major depressive disorders. You simply cannot tell from the degree of a person's sadness or depression whether the person is demoralized or whether he or she has a major depression. If your therapist doesn't know this, and treats all depression as an illness, with antidepressants, or treats all depression as a response of life difficulties, with psychotherapy, you don't have a good therapist. Put another way, if your therapist only knows about one type of depression, you'd better be sure it's the one you have, or you may be hit with a hammer when you aren't a nail.

2) A good therapist will always take a detailed story of both the patient's various symptoms of mood disorder (especially, suicidal ideas) and the patient's current life circumstances. If a therapist does only one or the other, it is difficult to see how he or she will be able to reach an appropriate diagnosis and treatment.

3) A good therapist should always take a detailed family history of psychiatric disorders, because the evidence is overwhelming that major depressive disorders are strongly genetically influenced.

4) A good therapist should take a thorough medical history, looking for potential medical causes of depression. For example, several neurological disorders, endocrine disorders, and a variety of medications can cause depression, so the medical history is extremely important in planning appropriate treatment.

5) Any good therapist should be willing to speak to family members in order to get another view of the patient's symptoms and history.

6) If antidepressants are used to treat major depression, the prescribing physician should initiate thorough trials of such medication and try different antidepressants if the first ones are not successful. Approximately 80 percent of patients with major depression should respond to one of the first three antidepressants prescribed, if these medications are given in adequate doses for about eight weeks each. Blood tests to measure levels of antidepressants are useful to assess the adequacy of the dosage.

7) Depression, from whatever cause, is usually a treatable condition. A good therapist is one who does not give up early.

There is little sense in seeing a therapist who doesn't basically believe what you say. Similarly, it makes little sense for the patient not to tell the truth. If the truth is not being regularly told and believed, there is obviously a mismatch between the therapist and the patient.

9) Any good therapist should be flexible in approach to diagnosis and treatment. That is, he or she should always be willing to at least consider different diagnoses and treatment approaches, and he or she should always be willing to discuss the reasons for making a particular diagnosis and proposing a particular treatment. A good therapist also is always willing to consider having the patient obtain a second opinion, especially if diagnosis is in doubt or if treatment is not progressing successfully.

You need to find a doctor
you trust and with whom you feel comfortable,
who is knowledgeable about various
treatments, and is open-minded to
new approaches. Note: This topic is frequently brought up by patients and prospective patients. In this article, I have outlined briefly some general rules that I believe patients might use when evaluating their own treatment. Of course, these rules are really my personal opinions, and different mental health professionals might have different views; but the above thoughts may be helpful to patients as they seek and enter treatment.

John R. Lipsey, M.D.

A FAMILY MEMBER'S PERSPECTIVE — WENDY F. BAYNARD, a report on a presentation 1 by Wendy F. Baynard, M.S.W., Smooth Sailing, Spring 1995

Although Wendy Baynard's talk (at the symposium) focused on her husband's bipolar disorder and its effect on their family, it also poignantly illustrated the apparent genetic basis of the disorder (highlighted by other speakers): she noted that two of their children have mood disorders (one depression, the other manic depression). Their 12-year old daughter started treatment at age eight and has taken lithium.

Ms. Baynard outlined her 50-year-old husband's 20-year history of mood changes, which for many years was "explained" as a drinking problem. Sixteen years ago, after the birth of their first child, he went to Alcoholics Anonymous and stayed sober for 13 years—but was never "really happy." Her husband's career—he was at times a Reagan administration appointee, a law partner in a prestigious firm, and an attorney in a solo practice that did not take off—seemed to be a reflection of the highs and lows of his personal life.

Early in her talk, Ms. Baynard described life with her husband as "never dull"; later she noted that "the hardest part of living with him was the unpredictability of his moods." Medication for depression enabled him to get out of bed to go to work, but it did not help him avoid having inappropriate reactions which ravaged his personal and professional life. Those reactions ranged from frustration at trying to understand the new phone system his company installed, to believing he could do anything (including choreograph his daughter's sixth-grade dance program), to having irrational outbursts of temper.

To be able to sustain financial stability, Ms. Baynard got a master's degree in social work, and for her own well-being, she promoted friendships for support. She described her anger and frustration at seeing her husband's potential "thrown away." For the children's sake, she maintained an atmosphere of calmness and never maligned her husband before their children. She also discovered DRADA in 1993, took the training program for support-group leaders and started a support group for family members.

Apparently, only after a drinking relapse, detoxifica-tion, and inpatient psychiatric treatment was her husband properly diagnosed with bipolar disorder. He had to learn to accept that diagnosis and the words that go with it, such as mentally ill and manic depression.

The attitude of acceptance appears to have been trans-mitted from father to son. Ms. Baynard concluded by recalling a conversation she had with her younger son, who had read a poem about Vincent van Gogh and was surprised to learn that van Gogh had committed suicide. Mother explained to son that had van Gogh lived today, he probably would not have died, given modern treatment and medica-tion. Her son's response: "I didn't know I was that lucky."

1 Presented at a DRADA/Johns Hopkins symposium, Baltimore, Maryland, April, 1995

by Marion Ehlrich
Smooth Sailing: Spring 1995

BENEFITS OF MEMBERSHIP

Individuals, organizations and corporations are welcome to join DRADA.

Become a DRADA member today and you will:

Receive DRADA's newsletter, Smooth Sailing, featuring articles by mental health professionals, descriptions of personal experiences with depression or manic-depressive illness, and reviews of books about the illness.

Receive a discount on registration for the annual mood disorders research/education symposium which is of interest to both health professionals and laypersons.

Feel connected to a community of people who are living with depression and bipolar illness; a community that seeks to eliminate the stigma associated with depression and bipolar illness.

Be informed and up-to-date with accurate news concerning mood disorders, treatments, research, and other related issues.

Understand depression and bipolar illness better and feel secure in your knowledge about mood disorders.

Have the opportunity to express yourself freely and openly about issues concerning depression and bipolar illness, as well as have the opportunity to listen to others.

Click here to go to the membership and donation form. (Requires Adobe® Acrobat® Reader®)

DRADA also depends on financial contributions from its members, organizations, corporations and individuals of the general public. Click here to learn about the benefits of a donation.

RESEARCH LAB

Research Studies

Current Johns Hopkins Research Studies

1. CLINICAL TRIAL ON BIPOLAR DEPRESSION:
Dr. Jennifer Payne is conducting a research study to examine the effectiveness of Riluzole in treating the depression phase of bipolar disorder. This outpatient study of medication or placebo will last 9 to 12 weeks. Participants should be between the ages of 18 and 75, have a diagnosis of Bipolar I or Bipolar II, be depressed, and be in current treatment with an outpatient psychiatrist. The study includes medical and psychiatric evaluations as well as time-limited medication treatment at no cost. If you are interested in participating, please contact Annie Chewning at 410-502-2334.

2. CONNECTIONS OF MOOD AND ANXIETY DISORDERS:
Dr. Sean F. MacKinnon is conducting a research study to discover a possible cause of both anxiety and mood symptoms. Anyone who has been part of a Johns Hopkins Genetic study of bipolar disorder is eligible. The study involves a on-time visit to Johns Hopkins Hospital for a session lasting approximately two hours. Study participants will have their breathing and blood pressure measured while they breathe regular air and air mixed with a small amount of carbon dioxide over a period of 15 minutes each (carbon dioxide is a natural byproduct of breathing, and is the gas that makes up soda bubbles). The patterns of response to these tests will be used to look for genes for bipolar and anxiety disorders. If you are interested in participating, or have questions, please call Brandie Craighead at 410-955-3616.

3. EMPLOYMENT AND WORK DISABILITY IN BIPOLAR DISORDER:
Dr. David Schretlen is conducting a study of factors that are associated with work disability and employment in individuals with bipolar disorder. Study participants will be interviewed about their work history and current mood symptoms, and they will take some pencil-and-paper tests of attention, memory, and problem-solving. All reasonably healthy persons with bipolar disorder are welcome to participate, regardless of whether or not they are employed. The assessment will take about 2 and 1/2 hours, and participants will be paid for their time. If you are interested in this study, please call Patricia Gregory at 410-614-4476.

--------------------------------------------------------------------------------

Sheppard Pratt Research Study:

Sheppard Pratt is seeking volunteers for a clinical research study to evaluate the safety and effectiveness of an approved medicine under investigation for the treatment of depression due to bipolar disorder. To qualify for participation you must:

†Be at least 18 years old
• Have been diagnosed with Bipolar Disorder
• Be experiencing symptoms of depression

As a qualified participant you will receive, at no cost:
• Monitoring of depression and bipolar symptoms
• Study-related examinations
• Study-related medication

If you are experiencing depression due to bipolar disorder please call 410-938-3139 to learn more about becoming a participant in this research study.

American Academy of Child and Adolescent Psychiatry (AACAP)

American Medical Association Publishing Home Page

Dana Foundation

|||*|&k=MentalHealthZoneFR408.html" add_date="868299061" last_visit="868299005" last_modified="868299005" onClick="MM_openBrWindow('http://www.intelihealth.com/IH/ihtIH?t=8271&p=r,IHW|||*|&k=MentalHealthZoneFR408','intellihealth','toolbar=yes,location=yes,status=yes,menubar=yes,scrollbars=yes,resizable=yes,width=600,height=600')">InteliHealth (Mental Health Basics)

Internet Mental Health

JHMI-InfoNet: Patient Advocacy Groups

Johns Hopkins Psychiatry Home Page

MEDLINEplus page on Bipolar Disorder

National Alliance for the Mentally Ill (NAMI)

National Alliance for Research on Schizophrenia and Depression (NARSAD)

National Depressive and Manic-Depressive Association (NDMDA)

National Institute of Mental Health (NIMH)

Pendulum's Bipolar Disorder / Manic-Depression Pages

Science Online

Scientific Journals

Young People's Program

Annual Symposium

DRADA, in cooperation with Johns Hopkins Medicine, hosts an annual mood disorders symposium. This event is held at Johns Hopkins Medical Campus every year in early spring. Ticket prices are discounted for Adobe® Acrobat® Reader® - click here for free download). The purpose of the symposium is to inform interested persons about the latest research findings concerning depression and bipolar illness. The program seeks to answer questions concerning diagnosis, treatment, and new findings in basic and clinical research on mood disorders. This program is valuable to mental health professionals, patients, family members of people living with these illnesses, as well as the general public. Every year, there are speakers who present their own stories of how depression and bipolar illness have affected them. Symposium speakers have included:

Dick Cavett

Drew Carey

Art Buchwald

Greg Montgomery

Click If you would like to read some Smooth Sailing summaries of symposium speakers please click here.

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Newsletter

Smooth Sailing is DRADA's quarterly newsletter to members. Included in the newsletter are articles about new medical advances, book reviews, and personal experiences from those who are affected by the illness. DRADA members find our newsletters to be very helpful and informative.

Additional benefits of the newsletter include:

Access to up-to-date medical information from psychiatrists at the top hospital in the U.S. (U.S. News and World Reports).

Feel connected to a larger community that cares about mood disorders and those affected by them.

Share in others' personal experiences and possibly write something about your own.

Click here to read a piece from a previous Smooth Sailing.

To become a member or find out more about member benefits click here.

Young People's Outreach Program

DRADA's most notable educational program is the Young People's Outreach Program, which seeks to:

Raise awareness about depression and bipolar illness in adolescents.

Decrease stigma attached to mood disorders in adolescents.

Facilitate open discussion about this often dangerous illnesses in teenagers.

Increase knowledge of how to get help.

Mental health professionals from DRADA or involved with DRADA visit high schools to talk about depression to students, parents, and teachers. This program continues to expand and already is well recognized for its effectiveness in teaching teens about the signs and symptoms of depression as well as where to seek help. These visits include presentations of "Day for Night-Recognizing Teenage Depression", DRADA's award winning video.

Books and Videos

DRADA sells a variety of books and videos, which can be used for personal use or to teach others about depression and bipolar illness. These books and videos have been reviewed by a team of Hopkins doctors, nurses, and DRADA board members and are recommended because of the outstanding quality of information they provide. Click on the "DRADA Store" button on the side navigation bar to learn more about the books and videos or to order.

Frequently Asked Questions (FAQs)
About Peer Support

"How is Peer Support different than DRADA's support groups?"

DRADA's support groups meet in person at a designated time and place on a regular basis. All the members in the group provide mutual support. In Peer Support, mutual support is also provided, but on a one-to-one basis with your partner. You can call or email your partner when you need support, as they can do with you. There is no need to wait for the next meeting. This program is great for persons who are unable to attend support groups or for those that already attend groups and would like additional support.

"How do I make the most of my Peer Support relationship?"

The most important recommendation I can give is to give it time. Giving it time means that you do not let differences in each other turn you away from the match. A different person's viewpoint on experiences with the illness can be very helpful to hear. You may not be able to tell from the first conversation whether or not the two of you will make good support partners. The first couple of conversations can feel awkward and stilted. Keep trying and you will feel much more comfortable as details of each others lives and sharing feelings about depression and bipolar illness come up. Establish a regular time with each other that you will talk and agree on who's turn it is to call. Also, let it be okay for either of you to call the other at any time in between in case you need support right away. Make sure that you respect the other person's need for support as well as receiving support from him or her. Ask about how they have been feeling lately. Also, respect their needs and responsibilities away from the Peer Support relationship. Most people have families and commitments, which may mean that they are not always available to talk. This does not mean that they do not want to talk with you. Ask when is a better time to call back. All relationships take work to develop, including Peer Support. And if, after giving it some time to work out, you do not feel that it is a good match for you, please call to give it another try with someone else.

What do I do if I do not think that my peer support partner is a good match for me?

Please call the coordinator to talk about your particular situation. We can either help you work it out or look for a new match for you. Sometimes it takes a couple of tries before you find a match that works well for you. The coordinator wants to help you find the support you’re looking for, no matter how long it takes. Let us help you to keep trying. Peer support can be an important adjunct to medical treatment. Other mechanisms include a support group, one or more peer support partners, spiritual support systems, as well as family and friends. It is best to receive support from a variety of sources.

“If I sign up for Peer Support, does that mean that I can stop seeing my therapist?”

A Peer Support partner can be a great addition to the treatment that you receive from your therapist. We encourage you to continue seeing your therapist because Peer Support is not professional treatment. It is a form of self-help, enabling you to form friendships with other people with mood disorders. You and your partner will give each other encouragement and someone to share experiences with. So, please continue to see your therapist and physician and continue with any treatment plan that is in place and enjoy the extra support that Peer Support can give you and that you can give to your partner as well.

Please check back periodically for new FAQs about Peer Support!

Contact DRADA’s peer support coordinator, Chantal Abukutsa at 410-616-2820 or DRADAPeerSupport@jhmi.edu for more information.

Undercurrents: A Life Beneath the Surface, Martha Manning, San Francisco: HarperCollins, 1995. (Hardback, 197 pages, $20.00)

In Undercurrents, psychotherapist Martha Manning, Ph.D., uses revealing excerpts from a personal journal to tell the story of her own experience with a severe and medication-resistant depression. Dr. Manning's writing is sparked by her candor, sharp wit, and uninhibited sense of humor. Fascinating and sometimes surprisingly intimate scenes from her daily life propel the narrative. Also included are musings about her work as a professor of psychology and clinical psychologist; her religious and spiritual life; and her relationships with family members, colleagues, and friends. A forthright description of electroconvulsive therapy (ECT), the only treatment that relieved Dr. Manning's near-suicidal depression, demystifies this much-maligned technique. Undercurrents has something to say to everyone whose life has been touched by depression—not only patients, but also family members, friends, and mental health professionals. Patients will find much to identify with, for Dr. Manning captures the experience of depression with a vividness reminiscent of William Styron in his book Darkness Visible.

The emptiness of the depression turns to grief, then to numbness and back again. My world is filled with underwater voices, people, lists of things to do. They gurgle and dart in and out of my vision and reach. But they are so fast and slippery that I can never keep up. . . . All escapes are illusory—distractions, sleep, drugs, doctors, answers, hope. . . . (p. 99)

Family and friends of someone who has had a severe and lengthy depression will recognize her husband's frustration and despair over his wife's condition.

"No, Martha . . . I don't think you know what it's like to have to manage everything alone. Keara [their 12-year old daughter], the house, the families, the friends. I dread calling you. I dread coming home to you because I don't know how you'll be. You are receding every day. I'm living with a ghost. And I don't know how much longer I can take this." (p. 92)

Months passed. As Dr. Manning's depression deepened, she consoled herself with thoughts of death. First her therapist and then her psychiatrist suggested that her best hope for recovery might be ECT. This suggestion was not well received. After another month of deterioration, a still dubious but desperate Dr. Manning checked into a local hospital for ECT. After only two treatments, two days apart, Dr. Manning's sleep improved. That seemingly slight change marked the beginning of her halting climb out of depression. Treatments and improvement continued. Although ECT, like other treatments, is less than perfect, Dr. Manning readily affirms its effectiveness. "I will never be the ECT postergirl. I am the first to admit the downside—confusion and memory loss. But damn it, it worked." (p. 166) Other mental-health professionals may be surprised at Dr. Manning's reaction to life on an inpatient psychiatric unit.

Being shepherded from one stupid group to the next is my punishment for all those times my patients bitched about life on inpatient units and I told them [to] "cooperate" and "get as much as you can out of it." We in mental health . . . have positive intentions, . . . but benign tyranny is no less oppressive than malevolent tyranny. (p. 133, 134)

Her insight about a therapist's role, however, is a tribute to all "care professionals" worthy of that name.

[My] memories of my own doctors remind me that the process of just walking the road with someone is so important. The communication of hope, the administration of gentleness, and the sharing of some part of self can make a long lonely journey, in all its circuitousness, almost bearable. (p. 151)

As Undercurrents draws to a close, Dr. Manning movingly describes the joys and fears of returning to a full life. It will never be the one she had before, but she treasures its blessings in a new way. Readers will long remember Dr. Manning's story—told in her own marvelous voice—and wish her well.

by Anne Heasty, M.S.
DRADA Book Committee
Smooth Sailing: Spring 1995

Click here to order the book Undercurrents: A Therapist's Reckoning with Her Own Depression, by Martha Manning

BIPOLAR ILLNESS: WHAT IS DIFFERENT ABOUT YOUNG PEOPLE - A report on a presentation1 by Gabrielle A. Carlson, M.D.,2 Smooth Sailing, Spring 1998

Dr. Gabrielle A. Carlson stated that children and adolescents with bipolar disorder warrant special attention, since 20 to 30 percent of bipolar patients experience the onset of their illness before the age of 25. Also, she cautioned that diagnosing adolescents can be particularly challenging because 1) they often have had no prior episodes, and 2) their symptoms of mania or hypomania [relatively mild mania] are clearly associated with other psychopathology, such as ADHD/ODD [attention deficit hyperactivity disorder/oppositional defiant disorder]. Symptoms shared by mania and ADHD/ODD include hyperactivity, impulsivity, distractibility, and emotional lability. Adolescents who have externalizing disorders [conduct/behavioral disorders] or who are substance abusers are particularly vulnerable to bipolar illness, and substance-abusing patients with bipolar illness have four times the usual rate of conduct disorders. In the adolescent population, uncomplicated bipolar illnesses are rare.

Studies suggest that rates of mixed mania [symptoms of mania and depression appearing simultaneously] and comorbid mania [mania coexisting with another disorder] are higher in young people than in the adult population. In about 80 percent of the adolescent/young adult group, the illness first occurs as depression, with mania following as long as three to four years later. A psychotic depression often indicates that a bipolar illness will follow, and there is often a family history of mood disorders.

Not surprisingly, Dr. Carlson observed, outcomes are worse in adolescents than in patients first diagnosed with bipolar illness after age 30. Adolescents with comorbid disorders fare worse than adults in terms of their ability to get along in the work environment, even though they can return to their former level of functioning. Not only do these early-onset patients have more persistent substance abuse, but they also have more recurrence of mood episodes.

There are several important considerations in treating this population of adolescent bipolar patients who have comorbid externalizing disorders and substance abuse. These patients need comprehensive treatment planning and special education. Medication alone is unlikely to eliminate the patient's psychopathology, since the mood disorder and the externalizing disorders and the substance abuse need to be treated. Not surprisingly, medications for mood disorders are also used to treat aggression. The medications, then, are likely to be needed all the time, not just during a mood disorder episode. Since bipolar illness runs in families, it may also be necessary to treat the parents.

In summary, adolescents with bipolar illness deserve special attention because they truly have special needs.

1Presented at a DRADA/Johns Hopkins symposium, Baltimore, MD, April 30, 1998.

2Professor of Psychiatry and Pediatrics, Director of Child and Adolescent Psychiatry, State University of New York at Stonybrook.

by Ann M. Bain, Ed.D.
Smooth Sailing: Spring 1998

When diagnosing a mood disorder, adolescents can be at a disadvantage. The symptoms of depression and bipolar disorder (manic-depressive illness) in young people can differ from adults. Symptoms can be missed if you don't know what to look for.

Well meaning parents or teachers may think that a young person is unhappy or moody because it's a natural part of being young. This is especially true for adolescents, who are expected to be "hormonal" and rebellious. Persistent unhappiness or moodiness is not normal for anyone.

One way to overcome this problem is to educate teenagers themselves. This is why DRADA created the pamphlet:

I wish I was never born. I really hate myself.

Hey! You don't have to feel this way!

Teenagers, if you or someone you know often has feelings like these, read this pamphlet. You can also read the answers to Free single copies of our pamphlet are available. If you would like to receive one by regular mail, or if you would like to order this pamphlet in bulk quantities, you can e-mail Paula at paula.drada@erols.com or call her at 410-987-7447. Please include your name and post office mailing address.

You can find additional information on depression and teenagers below.

ADDITIONAL INFORMATION

Helpful Resources For Young People

Let's Talk About Depression.
From the National Institute of Health (NIH).

What to do When a Friend is Depressed: Guide for Students.
From the National Institute of Health (NIH).

A Helpful Resource For Parents

A highly recommended book for parents is Lonely, Sad and Angry: A Parent's Guide to Depression in Children and Adolescents, by Barbara D. Ingersoll, Ph.D. and Sam Goldstein, Ph.D. The authors provide a readable overview of symptoms, diagnosis, and treatment of depression in the young. Read a complete review of the book.

A Helpful Resource For Everyone

Day for Night: Recognizing Teenage Depression
A video produced by DRADA.

Teenagers relate their own experiences with depression and/or bipolar disorder (manic-depressive illness), their treatments and recovery, and encourage other teens to seek help. Also, professional explanations and tips about recognizing and treating these illnesses are provided by Paramjit Joshi, M.D., Chairman, Department of Psychiatry and Behavioral Sciences, Children's National Medical Center and formerly associate professor of Child and Adolescent Psychiatry at the Johns Hopkins University School of Medicine.

For more detailed information on depression and bipolar disorder (manic-depressive illness), be sure to visit our Reference Shelf. Supplemental information can be found in our First Person Experiences, Books, and Videos sections.

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