Author Archives: drhansdreyer

Hansie’s story

To give you some insight into my life, I’ve decided to share ‘snapshots’ of my life with you … those milestone events that essentially make Hans Dreyer, Hans Dreyer. It’s never easy to look back and communicate these things with raw honesty; to peel back those protective layers that hide the pain … but it’s so important. Through this series I hope you’ll somehow be able to better relate to the man behind the advice … to understand that I’ve ‘been there’ and ‘done that’. Above all I hope that my struggles (and my victories) will encourage you to see that Bipolar Disorder can be a blessing if you understand it, and that you can learn how to live a successful, enriching life despite it. You CAN achieve amazing things, and it’s NEVER TOO LATE to embrace this truth! Bipolar Disorder needn’t be the terrible monster that ruins families, promising careers and lives.

Let me start by sharing the single most tragic event in my life … the death of our youngest son, Hansie.

… THEN YOU DID IT

Then you did it… that one thing that we were so afraid you’d do. It was one wintry Wednesday; a day that started like any other day… Paulina still made you tea when you came home from school that day; you weren’t feeling well, you told her. Then she heard you locking our bedroom door. She even heard the safe key ‘click’ as it unlocked. While she stood around, wondering what on earth she should do next, Paulina heard the shot that shattered our hearts into thousands of little pieces.

Panic-stricken, she ran into the street… it was exactly the time that moms picked up their Grade 1 and 2 kids from the Primary School across the road from our house. She ran up to the first mother she saw, hysterically clinging to her and begging her to come and help. They rushed into our house together. By this stage, blood had already begun to seep through the floorboards of the top story.

The telephone call I received, somewhat prepared your mom and I for what was to come. “You need to come home right away. There was a shooting accident. The bedroom door is locked, and there’s blood.”

On the way home, Mom and I prayed that it wouldn’t be serious… that you’d only managed to fire a shot through your arm or shoulder… that you’d still be with us. I dashed up the wooden staircase and kicked our bedroom door down. Mom stayed in the kitchen… her eyes transfixed on the blood seeping through. There was no way someone would still be alive after losing all that blood…

There you lay on the floor, with your pillow and duvet… on the spot that you and Mom still huddled together in front of the heater that morning… did you feel safe here? It was horrific… your face, blue… and the bullet wound in your head. The entry wound was on the right hand side, and Mom felt sick when she remembered a conversation she’d had with you a few weeks earlier. You had asked her professional opinion as a GP, whether it was true that the temporal bone was the thinnest part of the skull, and she’d confirmed that. The exit wound on the left hand side was where damage was clearly evident… where the blood had gushed out.

Mom ran upstairs, fell to her knees and held you… the paramedic said, “You can leave him, Ma’am, he’s already brain-dead.” But when she took your hand in hers, she could clearly feel a pulse… her hands instinctively moved to feel a pulse in the jugular vein… there was a strong pulse there! Our precious, gorgeous 14 year-old curly-haired, blue-eyed boy… Her anxious cry shook the indecisiveness right out of the paramedic. “My child’s heart is still beating… DO SOMETHING!!”

“Oxygen saturation of 60%,” he announced after pegging the meter to your thumb. “Sixty percent is not good enough… bring a respirator, quickly!”

The policeman at the scene had one objective: to get Mom away from you and out of the room, at all costs. I calmly held her and said, “My wife’s a doctor. You’re not going to get her out of the room like this.”

My calmness seemed to help calm Mom down somewhat, and it dawned on her that she was just trying to postpone the inevitable. She knew from that first moment that your brain would have been so damaged, that it would never be able to be reconciled with what we know as ‘life’… it would have been foolish to keep your body alive without any chance of your brain being able to function on its own… and yet, we still decided to have you taken by ambulance to H.F. Verwoerd Hospital (now known as Steve Biko Hospital). Meanwhile, news spread to our nearest and dearest… if I recall, it was your big sister Hanri who had the composure to make that first call.

Funny the things one remembers… I remember grasping at sips of tea through the tears… my mouth felt like cork. Where did everyone come from? They made more tea, they held us, they prayed with us and made more telephone calls… Was it half an hour? Maybe an hour… it felt like time stood still at that stage… we decided to leave to go to the hospital. Your best friends Henno and Christo accompanied us, as did Henriëtte, the girl who stole your heart. Eventually three cars were packed with the friends who used to come home with you after school, and a few of Mom’s and my close friends.

On the way, Mom and I read each other’s minds and hearts… we decided, almost with one breath, that your organs should be donated. It’s funny how, prior to that moment, the very notion of organ donation made me feel claustrophobic… when Hanri had still wanted to purchase a ‘Medic Alert’ bracelet in order to record her organ donor status… it was as if the idea had ripened in our subconscious minds.

A pleasant, upbeat young doctor met us in the Trauma Ward and took us to you. “But Auntie Mariëtte, he’s still breathing – look how his chest is still moving rhythmically!” Henriëtte got this short-lived flash of hope in her eyes. “No my love, it’s the machine that’s doing his breathing for him… he can’t do it on his own anymore,” Mom explained.

We stood there with our hands on your chest … tears crashing down mercilessly … your hand was still warm to the touch, just like that of any patient who was being kept alive against the odds. I think you were already in heaven, my boy… it was your body lying there… the bullet wound didn’t look so horrific any more… it was covered with some gauze and plaster… looked so ordinary.

We surrounded your bed and I prayed… not that you’d carry on living, but that the Lord would give us strength and serenity.

After all of us said our goodbyes, the Head of the Organ Donor Team was standing to the side, waiting to brace the topic. Fortunately, we were prepared for this… the signatures were a mere formality.

At 11 o’clock that night, you were officially declared dead, with the cause of death recorded as ‘heart failure whilst under unaesthetic’. Despite it being a time of intense pain and mourning, we were warmly wrapped in the comfort of those who cared about us.

Your pals lay around on our lawn and spoke, just like they used to, most days after school… except they were gutted … the wind had been knocked right out of them… especially young Dewan… another member of your inner circle, who only found out about the tragedy at Rugby practice that afternoon.

I had always wondered what it would be like to stand at the deathbed of a child… would I cry hysterically? Would I remain in control and try and ‘fix’ the situation? When you and your siblings were small, mom still had such a fear of something happening to one of you. We were a wonderful family… Hanri aged 23, Tom aged 22, 16-year-old Tiaan, and you, my special one, you who were only 14. You had an incredible connection with each other… so much so that people actually remarked on the unique bond.

Back in the early days I prayed and asked God please to protect you children… and even though I ended my prayer with, “Lord, your will be done”, I still had this underlying angst… I used to wonder what if God were to call one of you home early. Until one day. Up to this point I felt as if I was wrestling with God about this… and on that particular day, it was as if the Lord said to me, “My child, if it must happen, I’ll give you the strength and the grace you need, to deal with it.” That peace thankfully stayed with me for years… the realisation that I couldn’t look after each of you, 24/7, eventually set me free. I realised that only God could be with you all, round the clock.

The day after the tragedy, our friend Judith came to us with a scripture… Genesis 15:6: “… and he believed the Lord, and He credited it to him as righteousness…”
This was a huge comfort to me. Although I knew beyond a shudder of a doubt that you had accepted Jesus as your saviour, I asked God if He would please send someone along our path, with a verse, just for us.

Then another friend came with this verse from Job 14:5: “Man’s days are determined; You have decreed the number of his months and have set limits he cannot exceed…”

This was the beginning of a new perspective on your death. God established the days of your life as well. When Mom was pregnant with you, it was almost as if God didn’t want any of her planning in the scheme of things. While her other two pregnancies involved fertility treatment, it hadn’t been so with your conception. Even though we wanted a family with four children, God did it HIS way when it came to you. You were the only little one that Mom was able to breastfeed, and she kept thinking, “Hansie, I’m raising you for myself.” Mom always went on about the other three kids being nuts about me, and that she’d dearly wanted a child who was just crazy about her! (I protested profusely, but we all know how moms can be sensitive about this sort of thing, right?!)

According to mom, this was not to be! You were the one who crept even deeper in my heart, my special boy. Always ready for a hug or a kiss, right up to just before that fateful day. You were the sensitive one, especially when it came to Mom’s and my feelings. You never wanted us to be sad or worried about anything. Is this why you hid your Depression so well? So that we wouldn’t worry more?

I remember when you were in Grade 7 (Standard 5 in those days). You were so depressed and filled with anxiety that winter… you just wanted to hide away… Mom recalls you burying your head under her arm if you’d go to the mall. When spring arrived, you seemed to feel better. Then, in Grade 8, (Standard 6) there was the time that you fired a shot into the ceiling… the barrel of the pistol still seared your cheek…

After three weeks of treatment in the adolescent unit of a psychiatric clinic, everything seemed to go better. Yet now, in retrospect, we sadly recall little things you said, which we didn’t realise at the time were pointing to the fact that that black helplessness called Depression was encroaching on you yet again. You most certainly planned the end, even though there was no note. The safe key was returned to its place; the furniture was repositioned in front of the safe… almost as if you were trying to tell us that this wasn’t an impulsive decision, an accident… it was a deliberate act that you definitely didn’t want to have anyone intercept… and so you locked our bedroom door just to make sure…

Suddenly, so many puzzle pieces fell into place, in respect of the patients we’d counselled for Depression. I suppose I’ve become resigned to the fact that some people, who are in such a dark place where their mood and emotional state are so disturbed, experience a complete annihilation of their survival instinct. In its place, an urge to self-destruct takes over. If one suicide attempt isn’t successful, they try until they get it right.

This is why we know that suicide isn’t that ‘unforgivable sin’… that moment when your death precedes your logistical ability to ask for pardon… Suicide is the most serious symptom of a seriously sick individual. It’s the final symptom in the build-up of a disease… as impossible to prevent in some people as it is to prevent the rupture of an artery, resulting in a stroke, in other people with hypertension.

Mom’s sister-in-law Christine coined it in her note of sympathy after that terrible night: “At the end of the day, Hansie… holding his big-man cigarette, with his taut rugby physique, was just a scared, sick little boy who was standing up against this broken world, and the outrageous demands it makes on our children.”

How low you must have felt… at least, now, you are finally free from that prison of despair, my boy. You’re sitting with your Father in Heaven, never again to be assessed by worldly standards that only caused you pain and disillusionment. How comforting to know that you passed the most important exam on earth, with flying colours… the test of true love. Even your youngest cousin could recall your expressions of affection, and your patience with the little ones!

Never again will anyone complain about your ‘illegible handwriting’ or your hair that’s half a centimetre longer than it should be, according to those school rules!

Cousin Thomas clearly remembered your conversation with him, just a few days before your death, about organ donation. Thomas said there was NO way he’d be an organ donor… that it paints the most horrific mental pictures for him… and yet you returned to this topic several times that day, stressing that ‘It would be cool to donate one’s organs to someone who needs them!’ Do you know how relieved we were when Thomas told us this?

When we heard that you had been declared dead during the anesthesia, we were wondering whether you had died before your organs could be harvested successfully, as you had wished… but later on, a friend told us that a man in her home meeting group had been pushed into theatre at 10 p.m. that very night, with kidney failure. He had undergone dialysis three times a week, and that night, your kidney saved his life, my boy! Your other kidney was donated to a man who had been waiting for a suitable donor, for 16 years.

I believe that, since the time you were born, God planned that you’d be the ‘match’ that would save those two people’s lives. The corneas in those gorgeous blue eyes of yours were donated to a woman who was so short-sighted, she was due to receive a guide dog the following week… thanks to you, she can see today! Even your strong, fit, healthy heart is beating in someone else’s ribcage today.

These realisations left us comforted… even excited, knowing that your death wasn’t in vain… your story made such an impact on certain people that it was the beginning of a whole new adventure with their Heavenly Father for them.

Rest in Peace, my boy… and know that I am at peace, because you are finally at peace, enjoying the sheer glory or heaven alongside your dear Mom who passed away unexpectedly, many years after you. Love you forever, Hansie.

On getting rid of negative thoughts …

A depressed young man sat down next to the grey-haired, stooped figure of his elderly grandfather.

Why are you looking so sad and sorrowful?” the old man asked.

Grandpa, I feel like I can’t find any rest, day or night. I feel utterly useless; that I’m a disappointment to all the people I once loved. I feel like I’ve messed up my whole life. When I’m around other people, I make them feel sad. I doubt if there’s anyone out there that still loves me,” the young man explained. It’s as if my conscience is constantly accusing me of being useless and disappointing my parents and friends.”

The grandpa sat quite still for some time, pondering over his grandson’s dilemma, stroking his grey beard and deeply in thought.

You must learn to correctly identify the voices talking to you and accusing you” the old man gently whispered.

Let me tell you an age-old tale; a story that was carried on from one decade to the next one, as a story told by the wise old men from the tribe, to the children when the nights are cold and they huddle together around a small cooking fire,” he continued …

There was an old man who felt sad and useless; the love of his life could not give him a son for future generations. She remained barren despite the two of them trying everything they knew of, to conceive. They also fervently prayed for a miracle.

In total despair his wife told him, “Please take my slave girl for yourself; take her to bed and let her conceive your child. Her child will be my child, as our ancient customs dictate, under such circumstances.

The slave girl fell pregnant and gave birth to a son. But the she didn’t react subserviently as the custom dictates. She believed she was superior to her barren mistress, and mocked her. The mistress was deeply hurt, and got very angry. She banished the haughty slave girl, sending her into the desert. An Angel appeared to her and urged her to go back and to submit.

Years later the mistress fell pregnant as well; this was nothing short of a miracle. When her young son reached the age of about four, the family had a weaning festival as tradition required.

There were already hard feelings between the banished slave girl who had borne the husband’s first child, and her mistress; and this negative feeling spilled over into the older son’s attitude. He started mocking his younger (half) brother incessantly, and never let up.

Eventually the younger son was ready to explode with frustration. He ran to his mom and said, “My older brother keeps on belittling me in front of all the visitors, he keeps on mocking me, please help me,” he cried. “I can’t take it anymore!”

The old man’s love of his youth ran to him pleading, “Please tell your older son and his mother to leave us! Their attitudes are absolutely uncalled for! They’re turning our son’s life into a misery!”

The old man looked at her with astonishment. “You know I can’t do that! She is my wife by law! You told her I should take her and conceive a child with her! Her son is my own son … in fact, according to tradition he is your son, and I can’t send them away into the desert!”

This explanation did nothing to placate his real wife. She kept nagging and nagging as only a woman could do. “Send them away! Send them away! Tell them to go!”

When he couldn’t stand it any longer, in total despair he relented. “Alright then! If you keep on, and on, and on, pressurising me to send them away, why don’t we go and pray and ask God what we should do. Then you will hear God telling us that I can’t send them away; they are my family according to our tradition, and I have a legal responsibility towards them.”

So they went to a quiet place to seek God’s presence and to pray.

WHAT DO YOU THINK THE OUTCOME WAS?!

It can’t be true, we must be mistaken, listen what God is saying” the old man cried. “God said, ‘Send them away, the son of this slave girl may not inherit anything from all your riches! There is not enough for both of them; only your real wife’s son may inherit.’ “

But Grandpa, what are you trying to tell me through this age old story?” the depressed grandson was confused. What is the connection between this story and my terrible fight with my conscience accusing me?”

THAT WASN’T THE END OF THIS AGE-OLD STORY … ALMOST 2000 YEARS LATER, ITS MEANING IS FINALLY BEING CLARIFIED.

The slave girl and her son represent laws made by men to live by. According to the teachers of that era 2000 years ago, living by certain rules was the only way to attain inner peace and peace with God,” the grandpa goes on to explain.

But these man-made rules are harsh and almost impossible to adhere to. Consequently, it is almost impossible to achieve that sought-after peace of mind, and peace with God.”

The younger son, borne years later by the old man’s first love, symbolises something totally different,” he continues. “The last-born son stands for the fact that we can resist the accusations brought on us by man-made traditions (the older son, whom the slave girl gave birth to). We have the assurance that God allows us … wait, no; he actually orders us, to send that ‘older son’ and his accusations packing! He gives us freedom. He sets us free from all the mockery of the ‘older son’.”

The grandpa turns to his grandson. “You see, this ‘son’ and his mockery of you, is pretending to be your conscience. He wants you to believe that it is your conscience that accuses you of not being good enough; of being a failure. Of being someone you should be ashamed of being. But this is not true. This ancient fable reveals what God wants you to do when you’re faced with all these inner accusations and self-doubt: ‘SEND THEM AWAY! BANISH THEM!’ It’s not your conscience condemning you. It’s man-made rules and traditions that condemn you and bring you down!”

The younger son of the old man’s first love, represents the freedom that God gives us. There is not enough energy in you to listen to both these voices, they will totally and utterly exhaust you. Distinguish which one is the voice of the evil one. The one who pretends to be your conscience. Chase him away tell him to keep quiet! Tell him that God gave you a new direction… to not listen to that voice, to banish him! Turn around. Listen to the other voice, telling you that the accusations are false … telling you that you are free, that you have endless value in God’s eyes, and that is all that really matters.”

Ponder on this, my boy. It’s not your conscience accusing you, it is the evil who pretends to be your conscience. Send him away with the authority that God gives you. Instead listen to the other voice telling you how precious you are to God, and how much he values you, and that is all that matters. There is nothing of any higher value than God’s evaluation of you. Believe that. Keep telling yourself that, and you will be free!”

The young man rose from his grandpa’s porch chair, and straightened up for the first time in a long time. For the first time in many months, he had hope in his eyes. Against all odds, he decided to listen to the wise old man. To shut out the negative accusations. To embrace the freedom that was his; and by God’s grace, to live life seeing God’s worth of him.

***

Author’s note: This article was inspired by Dr Caroline Leaf, author of ‘The Perfect You’. In her book, she explains that the thinking of toxic thoughts can change gene expression in just the same way that exposure to chemicals and pollution does. Our DNA is developed to react to the language of our thoughts and the words following these thoughts. Recent neuro-scientific studies have shown that oxytocin, secreted by the brain, can literally ‘melt away’ negative thought bundles, thereby facilitating the ‘re-wiring’ of new non-toxic pathways. Dopamine works with the oxytocin to achieve this melting down of the negative thought bundles. We know that endorphin release makes us feel good, and also helps to ‘detox’ the brain. When we do good things, and when we reach out to others in love, endorphins are released, making us feel better. Broadly speaking, these findings collectively communicate the fact that our mind influences our brain. I encourage you to read this profound author’s work.

Reference:

Author: Caroline Leaf

Year published: 2017

Book title: The perfect you

Publisher: Grand Rapids Division of Baker Publishing Company

Crisis in treatment of Depression and Bipolar disorder

The increasing rate of Depression in patients is becoming a huge crisis in South Africa and World wide

More than 17 million people in South Africa are dealing with depression, substance abuse, anxiety, bipolar disorder and schizophrenia-illnesses that round out the top five mental health diagnoses, according to the Mental Health Federation of South Africa. Furthermore,

A recent study showed that Depression cost the South African economy more than R232 milliard a year due to lost of productivity. Loss of productivity is caused by absence from work or attending work while unwell. That is 5,7% of the total South African annual economy.

London School of Economic and Political Science. (E-news 10/10/2017 at 19h00)

The incidence of patients with depression is increasing at an alarming rate as the following paragraphs clearly show.

The suicide rate for children aged 10-14 years old has more than doubled over the last fifteen years (3)

According to SADAG (South African Depression and Anxiety Group)

23 people commit suicide every day countrywide and a further 230 attempt to.

That is more suicides than America and the UK. (3)

The country have approximately 8 000 suicides a year. Around one million suicides were recorded each year globally.(3)

According to the WHO (World Health Organization) suicide is the 2nd leading cause of death among 15-29 year olds, with 1 person committing suicide every 40 seconds. For every person that dies by suicide, between 10-20 people attempt it.(3)

  • 1 in 4 SA teens have attempted suicide.

  • 1 in 3 hospital admissions for suicide involve youth.

“Depression and bipolar disorders form part of the top 15 diagnosis codes used, and contribute to some of the highest psychiatric benefits used during the 2013 service period,” (4)

Profmed’s member profiles in 2013, compared with last year, showed a 50% increase in those diagnosed with severe depressive episodes without psychotic symptoms.

There was also a 75% increase in Profmed members suffering from a severe depressive episode with psychotic symptoms for the same period.(4)

————————————–

Bad “Patient compliance” and the alarming effects

75% of people will not get the mental health treatment they need.

Others continue on ineffective doses and medications due to clinical inertia and a lack of appropriate treatment intensification, in patients who are not improving with initial treatments. As a result, as few as 20 – 40 % of patients started on depression treatment in primary care show substantial clinical improvements. (2)

This high percentage of patients not showing substantial clinical improvement, indicates that about 60% of patients do not reach “remission” or “recovery.”

This may be one of the reasons why many people suffering from depression will not go to a clinician for help, because the population out there view treatment for depression as ineffective and a waste of money, since so many of their family and friends have been taking medication for years without any significant improvement.

Therefore adherence cannot be expected per se but needs special efforts on behalf of prescribers and public health initiatives.(1)

This article is based on the result of the research and planing of:

Dr Hans (JGM) Dreyer, Pastoral Counselor in Private practice in Pretoria.

Research Litterature available on request.

Hoe om ‘n Depressiewe pasiënt te ondersteun

HOE OM ‘N DEPRESSIEWE PERSOON TE ONDERSTEUN

Dit is moeilik en verg baie geduld en die regte tegniek

Depressiewe pasiente voel baie maklik verwerp, en sommige beleef dit so erg dat hulle sê  “Ek voel deur God en mens verlate”

Daarom is dit van die uiterste belang dat jy op ‘n baie sagte en simpatieke manier na so ‘n depressiewe persoon luister.

Dit is soms baie moeilik om nie op jou gewone manier te probeer troos nie, want alhoewel jou doel en gesindheid reg is, is jou ou gewone manier dikwels die verkeerde manier.
Ek wil jou ”n ander meer effektiewe manier (tegniek van luister) leer,
genaamd “AKTIEF LUISTER”
maar …
Dit sal alleen werk as jy eers die toestand van jou gesindheid op hierdie oomblik evalueer.

beantwoord eers die onderstaande vraag voor jy verder lees.

Is jou gesindheid op hierdie oomblik:
“Ek is bereid om my ou manier van komunikasie te verander en ‘n nuwe tegniek aan te leer”   
Want dit is gehoorsaamheid aan die woord van God as jy jou manier van kommunikasie so verander soos Efesiers dit hier beskryf. ”
Indien jy nie bereid is om dit so te verander nie, bedroef jy die Heilige Gees, want Efesiers 4:30 sê  na sy raad oor die regte manier van kommunikasie as ons dit nie reg doen nie, bedroef ons die Heilige Gees “Moenie die Heilige Gees bedroef nie”
(Efesiers 4:30)
AS JOU GESINDHEID NOU REG IS NAAMLIK EK WIL DIE REGTE KOMMUNIKASIE MANIER AANLEER …
luister dan mooi watter riglyne word daar vir jou gegee
oor die regte manier van kommunikasie volgens Efesiërs 4:25
Die riglyne oor hoe ons moet komunikeer.  sê onder andere:
Laat daar geen vuil woord uit julle mond uitgaan nie, MAAR NET ‘N WOORD WAT GOED IS VIR DIE NODIGE STIGTING  sodat dit GENADE KAN GEE aan die wat dit hoor.(Afrikaans ou vertaling)

Wat beteken die woorde: MAAR NET ‘N WOORD WAT GOED IS VIR DIE NODIGE STIGTING. Die vertaling hieronder, sal dit dalk duideliker maak.
Die 1983 Afrikaanse vertaling sê “praat net wat goed en opbouend is VOLGENS DIE EIS VAN OMSTANDIGHEDE   (onthou nou hierdie persoon is depressief en sy omstandigheid, die depressie,  bepaal HOE ons met hom moet praat)

‘n Ander vertaling sê weer:
As julle iets sê, moet dit IETS WEES WAT DIE MOEITE WERD IS OM TE SÊ EN VIR ANDER IETS BETEKEN.
Voldoen jou kommunikasie met hierdie depressiewe persoon aan hierdie bybelse riglyne?

AKTIEF LUISTER
Laat ons eers kyk hoe ons gewoonlik ander mense probeer help of probeer troos.

A.  Die “Outomatiese” ou manier:
1.  As so ‘n depressiewe persoon vertel hoe ellendig hy voel en dalk huil, wil jy hom troos.
Baie keer probeer jy hom troos deur te sê: “Toemaar dit is nie so erg nie” of “Jy sal gou weer beter voel”
Maar vir daardie persoon IS DIT SO ERG …
Jou ” GOED BEDOELDE TROOSWOORDE” weerspieël hiermee iets van JOU irritasie teenoor die ander persoon. Dit wys ongelukkig geen begrip vir die ander en geen simpatie of empatie vir hom nie.
Dit laat die ander nog net meer verwerp voel soos… “Niemand verstaan my nie …”
Moet asseblief NOOIT sulke dinge sê nie. Dit bedroef die Heilige Gees (Efesiers 4)
en dit maak die depressiewe persoon baie seer.

2.  Dikwels dink jy dalk dat dit nie so erg is soos die depressiewe persoon dit maak nie, en sê dan: “Ruk jouself tog reg” of “Hou op om net die slegte dinge raak te sien”, of “kyk hoeveel dinge is daar waaroor jy dankbaar kan wees”
onthou asseblief …
Depressie het ABSOLUUT NIKS te doen met die siek persoon se rykdom of met sy gelukkige gesin of goeie werk nie, dis ‘n CHEMIESE WANBALANS (‘n mediese siekte toestand) wat meesal spontaan begin. En onthou asseblief …. die depressie is iets waaraan die depressiewe persoon op geen manier kan verander voordat hy nie eers behoorlik gestabiliseer is nie.

3.  Soms wil ons dadelik raad gee: “Miskien moet jy weer begin oefen, of soms uit die huis uitkom, of vriende oornooi.” Omdat die depressiewe persoon nie enigsins meer RASIONEEL kan funksioneer nie, “hoor” hy nie, of “verstaan” hy nie wat jy sê nie.
Die siekte toestand moet eers deur medikasie tot so ‘n mate gestabiliseer word dat die persoon behoorlik op ‘n rasionele vlak kan funksioneer.
Onthou ook asseblief …Anti-depressante werk nie soos ‘n pynpil na ‘n paar uur nie, maar neem minstens 14-21 dae voor daar enige verbetering is, wees dus baie geduldig met die siek persoon en sy vordering.
MAAR …
As die depressiewe persoon nie dadelik na jou raad luister en doen wat jy gesê het nie, word jy dalk ongeduldig en kwaad omdat hy nooit luister na jou raad nie, of jy voel geiriteerd omdat hy nooit wil toelaat dat iemand hom reghelp nie. Die verhouding tussen julle twee versleg.
                                       NEE …
Onthou asseblief die depressiewe persoon is gladnie instaat om die dinge te doen wat jy vra of die raad te volg wat jy vir hom gegee het nie.  Bid en vra dat die Here vir jou geduld sal gee en jou so  met Sy liefde sal vervul dat Sy liefde deur jou liefdevolle optrede vir die depressiewe persoon sigbaar en voelbaar sal wees.

B.  Uitwerking op die depressiewe persoon
Hierdie soort woorde en optrede,  soos jy dit waarskynlik outomaties en  uit gewoonte doen, laat die depressiewe persoon beleef
“niemand verstaan my nie.”
“Niemand gee regtig om nie”
OF …
“As ek kon sou ek myself regruk of anders dink, maar niemand besef die magteloosheid van hierdie siekte nie.”
Dit vervreem die depressiewe persoon van jou en laat hom nog meer depressief voel. Daarom moet ons na ‘n ander meer effektiwe manier gaan soek.

Hier is een nuwe moontlikheid:

C.  Aktief Luister 
Dit is ‘n spesifieke luister tegniek, en dit beteken dat JY,   JOU ou luister patroon moet wegpak en bereid moet wees om hierdie nuwe luister tegniek aan te leer.
Die nuwe tegniek voel natuurlik vreemd en soms voel dit selfs verkeerd,
maar ek smeek jou …..
verander asseblief terwille van die siek persoon, maar wees ook bereid om te verander, terwille van jouself en jou verhouding met ander mense, en ter wille van jou  gehoorsaamheid aan God.
Jy moet leer om AKTIEF TE LUISTER deur die volgende te doen:

C.1.  Lyftaal
Hou op werk of vroetel waarmee jy besig is.
Draai jou lyf so dat jy reg voor die persoon sit.
Kyk die persoon reg in die oë.
Bepaal jou aandag tenvolle op dit wat die ander persoon sê.

DIT KAN KLINK OF DIT BAIE TYD GAAN NEEM,
   Dit is dalk waar, maar jy gaan ure se tyd en frustrasie spaar deur dit reg te doen. Dit sal ook julle verhouding herstel of sterker maak as die ander persoon uiteindelik besef:  
“JY VERSTAAN MY UITEINDELIK.”

C.2.  Interpreteer woorde (soek na onderliggende emosie)
Die persoon met depressie sal soms ‘n storie vertel, of praat oor ‘n situasie waarin hy verneder is of beledig is. Maar hierdie hele klomp woorde is ‘n poging om die versmorende emosies binne in hom te verwoord en uit te kry.
Die beste wat jy kan doen is om te probeer raai wat is die emosie binne hierdie stukkende persoon, want hy weet self nie wat dit is nie.
Al is die feite verdraai of selfs as dit nie waar is nie, MOENIE met hom daroor stry of die feite regstel nie. Die storie wat hy vertel is sy PERSEPSIE van wat gebeur het. En sy PERSEPSIE is op daardie oomblik vir hom SY WAARHEID.

C.3.  REPEK VIR ANDER SE PERSEPSIE
Jy moet leer om RESPEK te hê vir ander persone se PERSEPSIES, dit beteken dat jy moet aanvaar dat dit regtig vir die ander persoon SY WAARHEID is soos hy dit vertel.
Ons probeer gewoonlik die ander persoon oortuig dat sy PERSEPSIE verkeerd is omdat ek anders daaroor dink. Ek het dus ‘n ander PERSEPSIE as hy.
Onthou terwyl jy ‘n depressiewe persoon wil bystaan moet dit nie ‘n argument word oor wat regtig gebeur het of oor wat die regte feite is nie.
Eers wanneer die depressiewe persoon weer RASIONEEL KAN FUNKSIONEER
(sien volgende paragraaf)
kan daar oor die feite gepraat word, maar alleen as dit ABSOLUUT nodig is. Ons is gewoond om ‘n argument te wil wen, maar soms moet ‘n mens kies,  wat is die belangrikste?
Die SAAK / FEITE
of……
Die VERHOUDING

Dit is soms nodig om die argument oor die feite te laat verbygaan en om bereid te wees om die argument te verloor, om die VERHOUDING te red.

C.4.  IRRASIONEEL agv EMOSIONELE OORBELADING

Onthou dat ‘n persoon in so ‘n situasie  emosioneel so oorlaai is dat hy
GLADNIE INSTAAT IS  om ‘n Rasionele gesprek of argument te volg nie.
Jy mors net jou asem as jy met hom probeer argumenteer oor sy PERSEPSIE of vir hom raad wil gee.
Boonop voel die ander persoon daarna “Hy verstaan my ook nie” en hy voel nog meer alleen en verwerp.

Die emosies wat die ander persoon verwar lê in sy onderbewussyn en dit beheer ongeveer 75% – 95% van sy lewe sonder dat hy dit besef of sonder dat hy beheer daaroor het. In die proses van Aktief Luister moet jy probeer raai watter emosie die ander persoon waarskynlik beleef het. Dan moet jy vir hom sê:
1.  Watter emosie jy vermoed hy beleef, byvoorbeeld:
Dit lyk vir my jy voel …………….. (sê die emosie wat jy geraai het se naam)
As jy reg geraai het sal die ander persoon waarskynlik dadelik sê “ja” en sy lyftaal sal instemmend wees. Hy sal dadelik ook meer inligting gee oor die hele situasie waaroor hy begin praat het.
As jy verkeerd geraai het sal die persoon sê nee of sal sy kop skud. Dan moet jy verder soek en raai, hoe nader jy aan die regte emosie kom, hoe meer instemming sal jy in sy lyftaal kan sien.
Die depressiewe persoon beleef dan “Aha nou verstaan jy my uiteindelik”
As jy reg geraai het en hy ook die emosie se naam kan sê skuif dit uit die onderbewussyn na die bewussyn. Nou het die emosie of gedagte slegs 20% – 25% beheer oor sy lewe. Nou kan hy vir die eerste keer begin besluit wat om te doen.
As jy so toelaat dat die depressiewe persoon sy slegte en negatiewe gedagtes en emosies kan uitspreek voel dit dalk of jy hom toelaat om al dieper in die depressiewe gat weg te sak. Dis nie waar nie, die teendeel is waar, jy laat hom toe om in homself te grawe en te soek en beter in kontak te kom met sy innerlike mens.

WOMEN WITH MAJOR DEPRESSION AT RISK OF RELAPSE DURING PREGNANCY

Contrary to common belief that the hormonal changes associated with pregnancy provide a protective effect against depression, women with major depression who discontinue antidepressant medication during pregnancy are at risk of relapse.

In a study published in the February 1 issue of JAMA, Lee Cohen of the Massachusetts General Hospital and Harvard Medical School conducted a study to determine the risk of relapse in pregnant women with major depression who discontinue or attempted to discontinue antidepressant medication close to conception compared with those who maintained treatment with these medications.

The study included a total of 201 pregnant women who enrolled between March 1999 and April 2003 at three centres with specific expertise in the treatment of psychiatric illness during pregnancy. The participants had a history of major depression prior to pregnancy, were less than 16 weeks’ gestation, and were currently or recently (less than 12 weeks prior to last menstrual period) receiving antidepressant medication.

The researchers found that 43% of women in the sample relapsed during pregnancy, and half of those relapsed during the first trimester. Among women who maintained their medication throughout the pregnancy, 26% relapsed compared with 68% of those who discontinued their medication.

Health industry news from the publishers of Medical Chronicle 01 February 2006

HEADACHES

What causes Headaches?

Headache was one of the first symptoms recorded by man, and today it is the most common of all medical complaints. More than 70% of people get headaches, ranging from an occasional aggravation to chronic, crushing head pain. Headaches cost society a large fortune each year in lost productivity.

There are many structures in the head which may become inflamed, compressed or irritated, leading to headache pain. These include nerves, blood vessels and muscles of the face, scalp and neck, teeth, the lining of the brain, sinuses, joints and other soft tissues. A number of chemicals released by arteries and nerves may set up “vicious cycles” in these structures or tissues causing a headache to become long lasting or continuous.

Investigating a Headache

Many types of headaches have a recognizable pattern. For this reason, a detailed clinical history is essential in making a diagnosis. Occasionally, additional tests may be necessary. Blood tests may screen for thyroid disease, anaemia, or infections. X-rays may be taken to rule out bony abnormalities or sinus infection. Occasionally patients with unusual headaches may require a computed tomographic (CT) scan or magnetic resonance imaging (MRI) which demonstrate internal brain structures or biochemistry of the brain. An eye examination may be done to check for weakness in the eye muscle or poor eyesight. In certain cases an angiogram may be undertaken to reveal any abnormalities in the blood vessels in the brain. If meningitis is suspected, a Lumbar Puncture may be performed.

Types of Headache

Headaches without underlying disease are termed “primary”, and include tension, migraine and cluster headaches. About 95% of all headaches are primary. Less than 5% of headaches signal a serious medical condition.

TENSION HEADACHE

90% of primary headaches are tension-type, affecting men and women about equally. They are usually diffuse with pain over the top of the head or back of the neck. It may feel like fullness or pressure, as if a constricting band is surrounding your head. Neck and shoulder muscles may be tense. The pain may go away after an hour, may last several days, or may become chronic. The headache pain waxes and wanes. They are most often caused by anxiety or stress and occur more commonly in people with poor posture, those who strain their neck and shoulders a lot and people who work at stationary, repetitive tasks.

CLUSTER HEADACHE

These are relatively uncommon, but very severe, affecting men far more often than women. Sufferers are typically heavy smokers. They have an abrupt onset and can occur at any time, but they most commonly occur 2 to 3 hours after you fall asleep. They are characterized by intense burning, boring pain frequently located in or around one eye and temple or in a cheek or jaw. The affected eye may be bloodshot and teary. The nostril on that side may be blocked or run profusely. Other features may be reduced pupil size on the painful side, a drooping eyelid, a flushed face and a sweaty brow. The pain intensifies within 5 – 10 minutes to a peak that persists for up to 2 hours. They can occur daily for days, weeks, or months, before a remission period.

MIGRAINE

About 6% of primary headaches are migraine. It has a strong genetic component, and is about 3 times more common in women than men. Most often the disorder begins between the ages of 5 and 35 years old.

Migraine headaches are characterized by intense, throbbing head pain, worsened by physical activity. It is felt in the forehead, temple, ear, jaw, or around the eye. Most migraines are one-sided. They are long lasting (from 4 to about 72 hours), and often associated with nausea, vomiting, and sensitivity to light and/or sound. Aura. About 10-20% of migraine patients have auras. These are neurological symptoms that usually precede the headache and include visual disturbances, tingling, numbness or weakness on one side of the face or body, speech problems or confusion.

What causes Migraine?

Migraine sufferers appear to have blood vessels that over react to various triggers. These cause spasm and constriction of the nerve-rich arteries in the brain followed by dilation of certain arteries within the brain, neck and scalp. Pain-producing substances called prostaglandins and a chemical called serotonin are involved. The release of these chemicals and the dilation of arteries stimulate pain receptors in the head, resulting in a throbbing headache pain.

Migraine Triggers

These activate an already existing imbalance of chemicals in the brain. Common triggers include hormone changes, diet (alcohol, especially red wine or beer; aged cheeses; chocolate; pickled foods; monosodium glutamate; aspartame and caffeine), stress, weather changes, season, altitude, time zone, sleep patterns or meal times. Bright lights, unusual odours, medications or polluted air may also trigger migraines.

OTHER CAUSES OF HEADACHE

Some headaches, called “secondary” headaches, result from a medical condition. These conditions include sinus infections, abnormalities of the Temporomandibular joint (TMJ) connecting the jaw to the skull, brain tumours, middle ear infection, head trauma, eyestrain or eye infections, arteritis (inflammation of arteries), meningitis (inflammation of the brain’s outer covering) and head or neck neuralgia (inflammation of nerves).

Treatment of Headache & Migraine

Rest, heat or ice packs alone may relieve an occasional headache. If not, try an over-the-counter pain reliever. Take the minimal dose needed to relieve pain. Overuse may cause chronic daily headaches (“rebound” headaches). If these measures fail to control the headache, other medication may be necessary. Migraine medications fall into two broad categories: abortive drugs to stop or reduce pain after a headache starts and prophylactic drugs to prevent headaches. Abortive medications include “Serotonin agonists,” which work by influencing the behaviour of serotonin; vasoconstrictors, which prevent blood vessel swelling; anaesthetic nasal drops; anaelgesics and Non Steroidal Anti-Inflammatories. Prophylactic medications include antidepressants, Serotonin antagonists, Beta-blockers, calcium channel blockers and anti-seizure drugs. Inhalation of 100% oxygen has been shown to be effective for cluster headaches.

Other measures

Over the long-term, combat headaches by controlling triggers, careful use of pain relievers to avoid “rebound” headaches, stopping smoking and avoiding alcohol during a headache, (especially cluster headaches). Manage stress and exercise regularly. Treatments such as physiotherapy or biofeedback may be effective.

Danger Signs

Headaches may signal a serious medical condition. Contact your doctor if your headache:

  • is accompanied by confusion, unconsciousness or convulsions
  • involves pain in the eye or ear
  • is accompanied by fever or nausea
  • occurs after a blow to the head
  • is persistent in someone previously free of headaches
  • is recurrent, especially in children
  • interferes with normal life.

Dealing with headache takes determination combined with a well-rounded approach. It means balancing use of medications with exercise, regular and nutritious meals, and adequate rest. Your goal is to attack headache pain from all sides. Together with advances in understanding headache, the reward is that you control your pain so that the pain doesn’t control you.

INSOMNIA

Having sufficient restful sleep is a critical human requirement. It is vital to emotional and physical well being. Most adults sleep between 6 and 8 hours per day, without interruption. A few nights of poor sleep do no harm, but prolonged sleep disturbances can have serious consequences.

The Physiology of Sleep

People function according to a natural cycle that repeats itself about every 24 hours. This is known as the circadian rhythm, and it governs our sleep-wake cycles. As it gets dark, the cells in the retina of the eye send a message directly to a part of the brain called the hypothalamus, which then signals the pineal gland located in the hypothalamus to produce the hormone melatonin, which causes a drop in body temperature and sleepiness. At the same time there is a reduction in the chemicals responsible for arousal, like histamine, noradrenalin, and serotonin. In a normal person, this sequence brings on sleep. There are two types of sleep: rapid eye movement (REM) and nonrapid eye movement (NREM). NREM has four stages, with stage 1 being transitional sleep, stage 2 light sleep and stages 3 and 4 deep (delta) sleep. Delta sleep is the most restful kind. During NREM sleep, brain activity and body functions slow. During REM there is increased activity – body functions speed up and a person dreams. A person moves from one phase of sleep to another during the night.

Insomnia

What is Insomnia?

Insomnia is a sleeping problem in which there is either inadequate sleeping time, or poor quality sleep, occurring on a regular or frequent basis, often for no apparent reason. A person with insomnia may have difficulty falling asleep, may wake up too early, wake up intermittently during the night, or may wake feeling unrefreshed.

During the day a person with insomnia may suffer from general tiredness, lack of energy, difficulty concentrating, and irritability. Sleep deprivation also impairs memory, reaction time and alertness. Tired people are less productive at work, less patient with others, and less interactive in relationships. Sleep deprivation can also be dangerous for people who have to drive. When people are deprived of sleep over long periods, the body’s immune system becomes depressed, lowering resistance to disease and infections.

Insomnia is very common – between 20% and 30% of adults suffer insomnia to some degree, and about 10% to 15% of people have insomnia which is chronic or severe. Insomnia is more of a problem in the elderly, and is more common in women. Sleeping pills are amongst the most prescribed medicines in the world.

Types of Insomnia

Transient insomnia is a temporary disturbance of the normal sleep pattern. It generally lasts no more than several nights, and usually disappears on returning to a regular sleep pattern. Travel or relocation may cause it.

Short-term insomnia lasts for 2 – 3 weeks and can accompany worry or stress. It often disappears if the cause is resolved.

Chronic insomnia disrupts sleep for extended periods of time – sleeping problems occur for at least 3 nights a week for one month or more. It is a complicated disorder with potentially serious effects.

What causes Insomnia?

Insomnia is usually the result of an underlying condition. Discovering the cause is the most important step in relieving insomnia.

Lifestyle factors are common causes of insomnia, particularly transient or short term insomnia. These include factors like high stress or anxiety, an uncomfortable sleeping environment, eating a heavy meal or drinking alcohol or caffeine-containing drinks before bedtime, exercising just before bedtime and cigarette smoking.

Medical conditions may cause chronic insomnia. These include chronic illnesses like kidney disease, heart failure or asthma, painful illnesses like arthritis or cancer, and hormone imbalances like hyperthyroidism, menopause or pregnancy.

Psychiatric conditions like depression, anxiety disorders or schizophrenia may be associated with chronic insomnia.

Medications are a common cause of insomnia. Some antidepressants, high blood pressure and steroid medications can interfere with sleep. Many painkillers, decongestants and weight loss products contain caffeine and other stimulants which will keep a person awake. Reducing or stopping your regular dose of sleeping pills may also cause insomnia.

Certain sleep disorders may result in insomnia. Restless leg syndrome is a condition where a person experiences unpleasant sensations in the legs or feet, preventing sleep. Periodic limb movement disorder is where uncontrollable twitching of the legs or arms prevent refreshing sleep. Obstructive sleep apnoea is a condition in which people intermittently stop breathing for short periods during sleep, causing them to wake frequently. Circadian rhythm disorders develop due to time zone changes (jet lag), or in people who do shift work.

Psycho Physiological Insomnia is one of the commonest causes of insomnia affecting about 5% of people. It develops when a person experiences a poor night’s sleep and then has increased anxiety the next night, which again prevents him from falling asleep. This “vicious cycle” is repeated night after night, leading to chronic insomnia.

How Is Insomnia Diagnosed?

The many potential causes of insomnia mentioned above can be determined by assessing lifestyle factors, by reviewing physical or psychiatric symptoms and by performing a physical examination. Certain laboratory tests and special investigations may be necessary. A sleep diary, which provides a record of how long and when you sleep, may also be helpful. In some patients an assessment at a sleep clinic may be necessary.

Treatment of Insomnia

Chronic or severe insomnia should be discussed with a doctor to rule out any medical or psychiatric condition.

Lifestyle changes: Regular moderate exercise, a balanced diet and avoiding excessive alcohol or caffeine will improve health and sleep. Reduce tension, promoting better sleep.

Behavioural therapies may also be used to treat some patients with insomnia. Relaxation therapy uses special techniques to calm the person and relax the muscles. Sleep restriction is a program that initially permits only a few hours of sleep per night, then gradually increases the nightly sleeping time. Reconditioning teaches the person to associate a bed with sleeping (and sexual activity), not daytime naps.

Drug treatment: If insomnia is transient or short-term, and sleep hygiene (see below) or non-medical treatments are not helpful, medication may be effective to prevent psycho physiological insomnia. In chronic insomnia, it is important to diagnose any underlying medical or psychiatric condition, and treat this effectively. Prolonged use of pills, without addressing the root cause may result in dependency. Hypnotic (sleep-inducing) medications, like the benzodiazepines, should be used for a few days at a time, to try to break a pattern of sleeplessness, while addressing any underlying problem. They should be used for short periods only, as they may become addictive. Antidepressants are effective in patients in whom depression has been diagnosed. Some Antihistamines have sedative effects and may be effective in the short-term. Melatonin may help insomnia by shifting the phases of the circadian rhythms, but is still undergoing further studies.

Sleep Hygiene is a holistic approach to sleeping. Good sleep hygiene prevents or relieves insomnia, and makes sleep more restful and pleasurable.

  • Establish a regular time for going to bed and waking up.
  • Use the bed for sleep or sexual activity only, not for reading, TV, or work.
  • Avoid naps, especially in the evening.
  • Exercise before dinner – exercising close to bedtime, however, may increase alertness.
  • Take a hot bath about an hour and a half before bedtime.
  • Do something relaxing in the half-hour before bed like reading or a walk.
  • Keep the bedroom cool and ventilated.
  • Do not look at the clock. Worrying about the time and “forcing” yourself to sleep makes it more difficult to sleep.
  • A light snack before bed can help sleep. A large meal may do the opposite.
  • Avoid fluids just before bedtime to reduce the need to urinate.
  • Avoid caffeine in the hours before sleep.
  • Quitting smoking eliminates the effects of nicotine on sleep loss.
  • People who can’t sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until sleepy again.
  • If a person with insomnia is distracted by a sleeping bed partner, a couple of nights apart may be useful.

Tips to beneficial sleep and feeling energized day after day: While many strategies are available, it is important to experiment and discover what works for you, what works for one person may not work for another!

  1. Take control of the stressors in your life.
  2. Focus on what’s really important in life.
  3. Make time for two or three quiet moments during the day and before retiring for the night.
  4. Fitness through exercising.
  5. Exercise will lower anxiety and tension.
  6. Heart and lung fitness, a direct result of exercise, promote healthy sleep.
  7. Easy stretching should precede all exercise.
  8. Exercises such as walking, dancing and aerobic work outs should be done in the late afternoon.
  9. Stay alert during the day.
  10. Keep yourself busy and involved during your daytime activities.
  11. Involvement with other people allows you to reduce stress by focusing on issues other than your own.
  12. Eat balanced meals.
  13. Make this part of the total, personal health plan.
  14. Strive for a balance between vegetables, protein and carbohydrates.
  15. Avoid a large meal within four hours of going to bed.
  16. Alcohol and bedtime do not mix.
  17. The effects of alcohol are greatly magnified by sleep deprivation.
  18. Sleep apnoea can be aggravated by drinking at bedtime.
  19. Avoid alcohol within three hours of bedtime.
  20. Develop a bedtime ritual.
  21. Read for pleasure.
  22. Gradually dim the lights.
  23. As your mind clears and you become drowsy, turn off the light.
  24. Cleanse the mind.
  25. Commit your worried thoughts to an index card on the night stand.
  26. Add some points about the potential solution.
  27. Leave the card there in case you awaken during the night.
  28. Relaxation at bedtime
  29. Play mind games with yourself.
  30. Mental imagery.
  31. Deep breathing.
  32. Time in bed: Only as long as is necessary
  33. You may go to bed earlier than usual due to stress and worries.
  34. Stay in bed only for the period that you usually need for sleep.
  35. Sleep until you are refreshed.
  36. Consult a sleep specialist if needed.
  37. Always share your sleep problems with your doctor.
  38. He/she may give you valuable advice or refer you to a sleep specialist.
  39. Awaking with shortness of breath or chest pain requires prompt attention.
  40. Your doctor must be told if you are falling asleep at inappropriate times.

Reference: Maas J.B. (1999): Power Sleep, New York: Harper Perennial p84-99

Courtesy of Medical Essentials, Health Information

The Comorbidity of Major Depression and Anxiety Disorders

Recognition and Management in Primary Care
Robert M. A. Hirschfeld, M.D.

Depression and anxiety frequently co-occur, especially in primary care settings. These co-occurrences manifest themselves in several ways and have different clinical courses. This review was written to help the clinician to identify what is and is not important in the diagnosis and treatment of patients with comorbid depression and anxiety in the primary care setting. The scope of this review is limited to major depression and not other forms of depression such as bipolar depression or dysthymic disorder. Literature was reviewed by 2 methods:

(1) a MEDLINE search (1980–2001) using key words depression, depressive disorders, and anxiety disorders; comorbidity was also searched with individual anxiety diagnoses; and
(2) direct search of psychiatry, primary care, and internal medicine journals over the past 5 years.

The scope and impact of depression and anxiety disorders worldwide are overwhelming. The watershed Global Burden of Disease study found that major depression ranked fourth among all medical illnesses in terms of its disabling impact on the world population. 1,2 The authors
estimated that by the year 2020 depression would be second only to ischemic heart disease. Anxiety disorders rank close behind major depression, contributing additional disability.

The prevalence of depressive and anxiety disorders in primary care settings is high. Between 10% and 20% of adults in any given 12-month period will visit their primary care physician during an episode of mental illness (although frequently not because of the episode). Depression and anxiety disorders contribute to the majority of those visits. If unrecognized and undiagnosed, depression and anxiety disorders contribute to high medical utilization in the primary care setting. Twenty-four percent of high utilizers (the top 10%) have been found to suffer from current major depression and 22%, from an anxiety disorder.

In primary care, presenting complaints for behavioral problems are more likely to be somatic than psychological. Back pain, chest pain, shortness of breath, heart palpitations, problems with sleep or appetite, and fatigue are among the most frequent presenting symptoms.

Although much work still needs to be done to increase awareness of depression and anxiety, the last decade has witnessed enormous progress in both the recognition and management of these disorders, especially in the primary care setting, which has long been recognized as the she is a bad wife and mother. She is no longer interested in sex. Lately, the patient admits that she does not really care that much about anything she has lost all of her interests.

more…

FAQ’s

This Q & A page is new. Please feel free to post your questions here.

Does people with Bipolar disorder hallucinate or struggle with hallucinations?

  • Yes, it is possible to have hallucinations in the Hypo-manic and manic state of Bipolar disorder.
  • Although not everybody with Bipolar disorder have hallucinations.

Is having sleepless nights a symptom of Depression.

  • Yes, Depression and Bipolar Disorder does cause sleeping problems in which there is either inadequate sleeping time, poor quality sleep, or over sleeping.
  • Sleep disorders might be caused by stress related illnesses, but theses illnesses is not the only cause op sleep disorders.

DIABETES, DEPRESSION AND STRESS

Depression is not generally listed as a complication of diabetes. However, it can be one of the most common and dangerous complications. The rate of depression in diabetics is much higher than in the general population. Diabetics with major depression have a very high rate of recurrent depressive episodes within the following five years. (Lustman et al 1977) A depressed person may not have the energy or motivation to maintain good diabetic management. Depression is frequently associated with unhealthy appetite changes. The suicidal diabetic adolescent has constant access to potentially lethal doses of insulin.

At this point in time, it is well accepted that psychological factors and psychiatric conditions can affect the course of medical illnesses. There is some suggestion that the stress of depression itself may lead to hyperglycemia in diabetics. The interaction between cardiovascular disorders (such as heart attack and high blood pressure) and depression has been extensively studied. Anxiety and depression can also affect other conditions including irritable bowel syndrome, headache and skin diseases. Treatment of anxiety and depression may lead to a better medical prognosis and well as a better quality of life.

For over three hundred years, physicians have suspected an interaction between the emotions and the course of diabetes mellitus. Studies have examined whether stressful events or psychiatric illness might precipitate either Type I (insulin-dependent) or Type II (Non-insulin dependent) diabetes. So far, study results are not conclusive.

Now that we have more accurate methods of measuring glucose control, it has become easier to measure both short-term and long-term effects of emotional factors on blood glucose level. One study found that children judged to have a “Type A” personality structure had an increased blood sugar elevation in response to stress. Children with a calmer disposition had a smaller glucose rise when stressed. (Stabler et al. 1987) A 1997 study suggested that Type I patients with a history of a psychiatric illness might be at increased risk for developing diabetic retinopathy. Those patients with a psychiatric history were found to have a higher average glycosylated hemoglobin. (a measure of long term diabetic control) (Cohen et al. 1997) Children whose relatives made more critical comments had significantly poorer glucose control. Interestingly enough, emotional overinvolvement between family members was not correlated with poor diabetic control. (Koenigsberg et al. 1993) Diabetic adolescents had a higher incidence of suicidal ideation than expected. Those with suicidal ideation took poorer care of themselves. Not living in a two-parent home was associated with poorer long-term diabetes control. (Goldston, et al. 1997)

Recent studies have suggested that effective treatment of depression can improve diabetic control. In a study by Lustman and colleagues, glucose levels were shown to improve as depression lifted. The better the improvement, the better the diabetic control. (Lustman et al. 1997a)

Being diagnosed with diabetes is a major life stress. It requires a large number of physical and mental accommodations. The individual must learn about a complex system of dietary and medical interventions. Lifestyle, work, and school schedules may have to be altered. This can consume a lot of energy for both the individual and his or her family. Just as important, are the psychological adjustments. One must adjust to a new view of oneself. For those who liked to see themselves as invincible, this may be particularly difficult.

Many newly diagnosed diabetics go through the typical stages of mourning. These are denial, anger, depression and acceptance.

Denial: This can be one of the more dangerous stages of the grief process. It may not occur only once. Many individuals cycle back to this phase several times. The honeymoon phase, associated with early Type I diabetes, may reinforce denial. Denial is a common stance for adolescent diabetics.

Anger: It really does seem unfair. The type II diabetic, trying to lose weight, may envy heavier people who seem to enjoy good health. One might erupt at someone who innocently offers a desert. Unfortunately, anger can drastically affect glucose levels.

Depression: Mild depressive feelings are a normal part of grieving and adaptation. As long as they are not pervasive or prolonged, they may not be harmful. However, when the depression lasts a long time, becomes severe or interferes with diabetic management, one should seek prompt treatment.

Acceptance: Individuals achieve different degrees of acceptance and inner peace. Some will need to experience the denial, anger and depression several times as they move through different phases of life and different stages of diabetes. Some people move through a chronic disease to a state of much greater self-knowledge. They may actually say that the diabetes was, in part, a blessing. Through their close attention to diet and exercise, and their close monitoring of stress levels, they have arrived at a deeper understanding of themselves and their relations to others. They realize that for all human beings, life is vulnerable and precious.

Often, individuals with depression do not realize that they are depressed. It is easy to attribute the symptoms of depression to the diabetes. This is particularly difficult since depressed diabetics may have poorer glucose control. Sometimes a spouse or close friend can give good feedback. However, medical professionals or mental health clinicians may be the best ones to determine what is the diabetes and what is due to depression. A psychiatrist has had medical training before specializing in mental health. He or she can sort out the diagnosis, communicate with your regular doctor and help coordinate the treatment of the depression with treatment of the diabetes.

Symptoms of Depression: These are based on the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition. (DSM-4)

  • Depressed mood for most of the day
  • Decreased pleasure in normal activities
  • Difficulty sleeping or significantly increased need to sleep
  • Weight loss or weight gain.
  • Feelings of guilt or worthlessness
  • Low energy level
  • Difficulty making decisions of concentrating
  • Suicidal thoughts
  • Treatment of Depression:

The most important starting point is an accurate diagnosis. There have been major advances in the treatment of depression. There are specific medications and specific psychotherapy techniques that have been shown to help depression. Often individuals do well with a combination of antidepressant treatment and psychotherapy. Be sure that your clinician is willing to take the time to communicate with your diabetes team. Ideally, the mental health clinician should be familiar with your type of diabetes.

Antidepressants: Today, we have a much wider variety of antidepressant medications than were available fifteen years ago. Because we have more medication choices, we can often minimize annoying side effects. The older tricyclic antidepressants can increase glucose levels in non-depressed diabetics. However, when depressed diabetics take them, diabetic control improves. (Lustman et al. 1996) Selective Serotonin Reuptake Inhibitors (SSRIs such as Prozac and Zoloft) are easier to administer and have fewer side effects, so they are more often used as the first line antidepressants. Sometimes they can cause decreased sexual desire. This may be a sensitive issue for some diabetics, especially those who have some sexual difficulty due to their diabetes. This is not a reason to avoid treatment. Keep an open dialogue with your psychiatrist. If the medication does affect sexual functioning, dose adjustment or a switch to another type of antidepressant can usually take care of the problem. Often, treatment of the depression can result in much better sexual functioning. Other types of antidepressants, such as Bupropion (Wellbutrin) or Venlafaxine (Effexor) add to our treatment options. Some people respond to the first medication. Other people may have to try several medications before they hit upon the right one.

Psychotherapy: Recently, researchers have made an effort to do good psychotherapy outcome studies. It turns out that several forms of psychotherapy really do work better than simple “tincture of time.” Cognitive psychotherapy is one of the methods that has demonstrated good results for depression. In this type of therapy, the individual identifies thought patterns associated with a depressive, hopeless outlook. Frequently these thought patterns are based on erroneously assumptions about self and others. The therapist helps the patient monitor such thoughts and to replace them with more effective positive ways of thinking. Cognitive therapy can also be helpful in non-depressed individuals who are having trouble with their diabetic management.

Anxiety and stress can also cause large jumps in blood glucose levels. Panic attacks may resemble hypoglycemic episodes and vice-versa. (When in doubt, treat it as hypoglycemia.) People respond differently to stressful situations. Given the same subjective level of stress, one diabetic may have a different glucose response from another. Because of this, one should monitor blood glucose more frequently during periods of stress. On the positive side, a conscientious diabetic may have a unique barometer of stress unavailable to the general population. There are a number of specific anxiety disorders that are treated differently. As with depression, there are specific medications and therapies that have been shown to work. If anxiety is severe, it is important to identify the specific type, so that one can embark on the right treatment. We will not cover all of these treatments in this article. The following are some general suggestions for dealing with stress and mild to moderate anxiety.

Examine your lifestyle for sources of stress. Are there stressers that can be eliminated?

Learn relaxation techniques. Yoga, meditation, prayer, and hypnosis may help. Make sure that you are getting enough sleep

Exercise. The body’s primitive stress response was designed to prepare the individual to fight or to run away. In our society, we do not usually respond to stress with physical activity. Exercise helps our bodies deal with the physiological results of stress.

Make a list of the things that are worrying you. When you have a concrete list, the problems often look more manageable.

Many people do not like the idea that they may have emotional difficulties. Some find it easier to attribute everything to physical problems or life circumstances. However, good diabetic management is dependent on the development of self-knowledge. Many of the things that other people’s bodies do automatically, diabetics must do consciously. This includes closer monitoring of both one’s blood glucose and one’s emotional state. Ultimately, the years of deliberately imitating natures beautiful and complex feedback systems can lead to a greater understanding and appreciation of body and mind.

References:

1 Lustman, PJ, Griffith, LS, Freedland, KE, Clouse, RE; The course of Major Depression in Diabetics Gen Hosp Psychiatry 1997; 19(2) 138-143.

2 Stabler B, Surwit, RS, Lane JD, et al. Type A Behavior pattern and blood glucose control in diabetic children Psychosomatic Medicine 1987; 49: 313-316.

3 Cohen, ST, Welch, G, Jacobson, AM, et al The Association of Lifetime Psychiatric Illness and Increased Retinopathy in Patients with Type I Diabetes Mellitus Psychosomatics 1997; 38: 98-108.

4 Koenigsberg, HW, Klausner, E, Pelino, D et al. Expressed Emotion and Glucose Control in Insulin-Dependent Diabetes Mellitus American Journal of Psychiatry 1993.

5 Goldston, DB, Kelley, AE, Reboussin, DM Suicidal Ideation and Behavior and Noncompliance with the Medical Regimen among Diabetic Adolescents American Journal of Child and Adolescent Psychiatry 1997.

6. Lustman, PJ, Griffith, LS, Clouse, RE et al. Effects of Nortryptiline on depression and glycemic controlin diabetes: Results of a double-blind, placebo-controlled trial. Psychosomatic Medicine 1997;59(3) 241-250.
By Carol E. Watkins, MD
Northern County Psychiatric Associates