I receive updates from the American Psychiatric Association about new findings related to psychiatry and addiction.  I thought that the following article about a connection between video games and psychiatric conditions, notably depression and anxiety, is worth sharing.

I find it interesting (and worrisome) that we tend to move forward with technology without ever a pause to consider the long-term impact of our inventions on our mental health, not to mention our physical health.  We act as if every bit of progress is ‘good,’ just because it is more advanced, smaller, faster, and more interesting.  I’m no technophobe;  I love using my iphone, and appreciate being able to share my thoughts with whoever stumbles across my blog, regardless of the reader’s nationality.  But it does not take a great deal of insight for those of us older folks to see what the younger generation has given up, in return for all of their amazing gadgets.  I have certainly seen individual students and young adults who would benefit from fresh air.  And I have worked with people whose marriages suffered and failed, in part because of the easy escape from engaging conversation to mind-numbing fantasy games.

The article, complete with links to more extensive information:

Bloomberg News (1/16, Lopatto) reported, “About nine percent of children play such long hours of video games that they are pathological gamers, increasing risks of anxiety, depression, bad grades and social phobia,” according to a study published online Jan. 17 in the journal Pediatrics. In a two-year study encompassing some 3,034 youngsters in third, fourth, seventh, and eighth grades, researchers found that “the compulsive gamers played for a weekly average of 31 hours compared with 19 for kids not deemed pathological.” For study purposes, “gamers are considered pathological when their playing interferes with everyday life, and their behavior is described as being similar to that of gambling addicts, according to background information in the paper.”

“Over a two-year period about 84% of those who started out as excessive gamers remained so, indicating that this may not simply be a phase that children go through,” the CNN (1/17, Wade) “The Chart” blog reported. “Boys were more likely to show symptoms of excessive gaming.”

HealthDay (1/17, Gordon) reported that pathological video gamers appear to “have trouble fitting in with other kids and are more impulsive than children who aren’t addicted.” And, “once addicted to video games, children were more likely to become depressed, anxious or have other social phobias. Not surprisingly, children who were hooked on video games also saw their school performance suffer.”

One of the most common complaints that I hear from people in my practice is that they are not ‘happy.’  Today I cam across a quotation about happiness, and the written words rang true with my own observations about the pursuit of happiness.  For example, happiness seems to be something that people remember, much more often than they actually experience.  And there is clearly an inverse correlation between intelligence, memory, or ‘depth,’ and the state of happiness– a state of affairs that doesn’t quite sit right!

I enjoy reading quotations; they often contain a great deal of wisdom, and can be, at times, a very efficient means of obtaining insight.  Some thoughts on happiness:

Most folks are about as happy as they make up their minds to be.

Abraham Lincoln (1809 – 1865)

Happiness is nothing more than good health and a bad memory.

Albert Schweitzer (1875 – 1965)

A person is never happy except at the price of some ignorance.

Anatole France (1844 – 1924)

Happiness is that state of consciousness which proceeds from the achievement of one’s values.

Ayn Rand (1905 – 1982)

Content makes poor men rich; discontentment makes rich men poor.

Benjamin Franklin (1706 – 1790)

The pursuit of happiness is a most ridiculous phrase; if you pursue happiness you’ll never find it.

C. P. Snow (1905 – 1980)

Happiness is always a by-product. It is probably a matter of temperament, and for anything I know it may be glandular. But it is not something that can be demanded from life, and if you are not happy you had better stop worrying about it and see what treasures you can pluck from your own brand of unhappiness.

Robertson Davies (1913 – 1995)

All sanity depends on this: that it should be a delight to feel heat strike the skin, a delight to stand upright, knowing the bones are moving easily under the flesh.

Doris Lessing (1919 – )

Slow down and enjoy life. It’s not only the scenery you miss by going too fast – you also miss the sense of where you are going and why.

Eddie Cantor (1892 – 1964)

To be stupid, selfish, and have good health are three requirements for happiness, though if stupidity is lacking, all is lost.

Gustave Flaubert (1821 – 1880)

Many persons have a wrong idea of what constitutes true happiness. It is not attained through self-gratification but through fidelity to a worthy purpose.

Helen Keller (1880 – 1968)

Man is the artificer of his own happiness.

Henry David Thoreau (1817 – 1862)

The foolish man seeks happiness in the distance, the wise grows it under his feet.

James Oppenheim (1882 – 1932)

The bird of paradise alights only upon the hand that does not grasp.

John Berry in ‘Flight of White Crows,’ 1961

True happiness is of a retired nature, and an enemy to pomp and noise; it arises, in the first place, from the enjoyment of one’s self, and in the next from the friendship and conversation of a few select companions.

Joseph Addison (1672 – 1719)

It is pretty hard to tell what does bring happiness; poverty and wealth have both failed.

Kin Hubbard (1868 – 1930)

Happiness is when what you think, what you say, and what you do are in harmony.

Mahatma Gandhi (1869 – 1948)

Happiness isn’t something you experience; it’s something you remember.

Oscar Levant (1906 – 1972)

No man is happy who does not think himself so.

Publilius Syrus (~100 BC), Maxims

One of the keys to happiness is a bad memory.

Rita Mae Brown (1944 – )

Remember that happiness is a way of travel – not a destination.

Roy M. Goodman (1930 – )

Happiness comes of the capacity to feel deeply, to enjoy simply, to think freely, to risk life, to be needed.

Storm Jameson (1891 – 1986)

Depend not on another, but lean instead on thyself…True happiness is born of self-reliance.

The laws of Manu

Happiness is an imaginary condition, formerly attributed by the living to the dead, now usually attributed by adults to children, and by children to adults.

Thomas Szasz (1920 – )

The only true happiness comes from squandering ourselves for a purpose.

William Cowper (1731 – 1800)

I’m sorry for the hiatus in posting; I have another blog (related to addiction) plus there always seems to be tons of paperwork this time of year– not to mention getting things together for the tax season.  With taxes in mind, perhaps it is appropriate to write a post that has to do with the FDA. 

I am going to share an e-mail exchange with a patient about a medication that is part of the changing landscape for treating depression.  Since the replacement of ‘tricyclic antidepressants’ like amitriptyline and desipramine by SSRIs (serotonin reuptake inhibitors), the general approach to medication for depression has been SSRI, second SSRI, SNRI, then augmenting the SNRI, then augment with something else, and finally consideration of ECT.  There are other treatment choices in the algorhythm such as psychotherapy, bupropion, or mirtazepine, but the general pattern of SSRI— second SSRI—- SNRI has been the backbone of treatment in the modern era of psychiatry.

At the same time there have been other medications that are thought of as ‘mood stabilizers,’ including a group of medications known as the atypical antipsychotics.  To use their trade names, the medications include Zyprexa, Risperdal, Seroquel, Geodon, and Abilify. Recently two of these medications have received FDA indication for uses other than for bipolar mania or for schizophrenia, and there are indications that the lines between medications thought of as ‘antidepressants’ and medications considered ‘mood stabilizers’ will become more blurred going forward.  This should be a good thing, as we are gaining additional options to treat mood disorders– a group of illnesses that cause considerable suffering in the country and world.  But the new medications have powerful effects, and so like most medications have potential side effects– in this case the risk of increasing blood glucose, cholesterol, and triglyceride levels, and increasing the risk of weight gain and diabetes. 

The e-mail exchange relates to the issue of medication side effects, and when should a person disregard the scary print at the bottom of the advertisement (or the ridiculously-fast-spoken list of side effects at the end of a TV commercial).  The patient has struggled with depressive symptoms for a number of years, and has been treating the symptoms with the ’safest’ medications– i.e. SSRIs– avoiding medications with greater risks and side effects.  I have been her psychiatrist for a short period of time, and we are not yet certain whether her symptoms are part of Major Depressive Disorder or are instead the depressive side of Bipolar Disorder.   I recently suggested to the patient that we look at the big picture– that the depression is taking a toll on her life, that the depression has affected her relationships and career path, and that the depression has even put her at risk for suicide.  I think I will let the exchange finish the point I tried to make.  She is a bright patient who reads up on whatever we discuss, something that sometimes makes my work easier, and other times makes my work more challenging– albeit in way that medicine SHOULD be challenging.

I suggested considering a more potent medication, such as Seroquel.  She sent a message that included the following comment:  

I looked up Seroquel…and get freaked out by things like this:  http://www.usatoday.com/news/health/2009-04-08-fda-seroquel_N.htm  I will let interested readers go to the link on their own, but the link is to an article questioning the wisdom of the FDA in giving Seroquel the new indications.  As I mentioned earlier, I think that more choices are a good thing– providing we have bright doctors who take the time to educate their patients, who take the time to learn enough about their patients, and who make reasoned decisions based on ‘risk to benefit ratios’– assumptions that may or may not be valid.  I have written about my disdain for psychiatric practices that do ‘7-minute med checks’, and I believe that those practices may serve their patients more safely by sticking to the SSRI’s!

My long-winded response to the patient:

I am not pushing Seroquel- only suggesting that when you look objectively, there may be a case for more aggressive treatment of your depression.  I want to point out a couple things in the USA Today article, an article that is clearly written by someone with certain preconceptions.

First, the article correctly reports that the FDA found that the risk/benefit ratio of Seroquel does not favor using the medication as a  first-line agent.  But it is important to note that after reviewing all of the data, the FDA DOES favor approving the use of the medication for treating depression in people who (like you) do not achieve remission of mood symptoms from first-line treatments like Prozac. 

There are a couple comments in the article that I find misleading; for example, the quote of lawyers who said ‘the company knew Seroquel caused diabetes.’  Seroquel doesn’t ‘cause diabetes’.    There is an increased risk of diabetes in people taking Seroquel, but the risk varies with dose and length of time taking the medication.  The drug is used at 600-800 mg for mania or schizophrenia but only 300 mg for depression, and people who take it for a short period of time at a lower dose are at lower risk.  The risk of diabetes in patients taking Seroquel goes from around 3% to around 6%.  For an individual, the risk of NOT getting diabetes goes from 97% to 94%.    The effect can be worded in a scary way—‘the risk of diabetes doubles’- but going from 97% to 94% odds of NO diabetes is less frightening—especially when the odds ratio takes into account the risk and pain of experiencing years of depression.  The risk if diabetes can be greatly reduced, by the way, by monitoring blood sugars and stopping the medication if glucose tolerance changes.

It is important to distinguish between the risk to an individual vs. the risk to a population.  The FDA looks at the latter, but the individual should look at the former.  For example, much has been made of the risk of suicidal ideation in children and adolescents taking antidepressants.  The result of the FDA black-box warning of this issue has been a significant drop in antidepressant prescriptions for children and adolescents, and at the same time (coincidentally?) a significant increase in suicides in the same age group.  The warning came because retrospective evaluation of pooled research data showed that ‘suicidal ideation and behavior almost doubled’ in depressed patients starting antidepressants compared to depressed patients starting placebo tablets.  A ‘doubling’ sounds bad… but there was no increase in actual suicides, and the data may reflect something benign.  For example, perhaps kids on antidepressants talk about their thoughts more.  Looking at the data beyond the ‘doubling’ headline, in the placebo group about 2% of the depressed patients had increased suicidal thoughts.  In the treatment group the number was around 4%.  This is in fact a ‘doubling’ of suicidal thoughts, but we can look at the exact same data in a different way.  In the placebo group, 98% of the patients did not report increased thoughts of self-harm, and in the treatment group 96% had no increased thoughts of self-harm.  This way of looking at the data is much less likely to scare a mother into dumping her child’s Prozac down the drain… but is also less likely to catch your eye in the check-out aisle where the papers are sold! 

I will again point out that no suicides were attributed to antidepressants.  But meanwhile, suicide IS one of the leading causes of death in that age group, and most of those suicides occur in adolescents with untreated depression.  There has been less dramatic reporting of similar increases in suicidal ideation in patients taking virtually any of the anti-seizure medications, and in similar effects from other medications—like Singulair, a medication for asthma. 

Government health agencies look at fractional risk multiplied times 200 million people.  A 5% risk of diabetes means an additional ONE MILLION people with diabetes!  But an individual still has a 95% chance of NOT having the illness.  I remember going through a similar calculation back in med school, when I contemplated giving up the bacon that I loved to lower my risk of heart disease.  For now, I am still eating bacon!

I want to leave this discussion making two primary points.  First, it is important that patients know the true balance of risk to benefit for any treatment or medication, and that they try to learn the truth behind the headlines.  This point is a perfect segue for a plug for my practice.  I see at most two patients per hour for follow-up visits, and find that even the 30 minutes that I set aside at minimum is a short period of time to adequately explain all that the patient should know– particularly when most of the appointment must be used to collect information from the patient, not the other way around.  I have no idea how people gain anything from the typical 7-minute appointment.  If you are a dissatisfied patient, give me a call through my telepsychiatry practice!

Second, at some point it may become time to treat a mood or anxiety disorder or some other psychiatric condition with more potent medication, including medication that has temporary side effects.  When a person develops gallstones, he/she usually ends up with either a number of small scars from laparoscopy or one big scar under the right ribcage from an open procedure.  In either case, the person experiences significant pain for a number of days.  I sometimes think about the different tolerances people have for the treatment of different conditions, from the financial perspective and from the perspective of tolerable side effects.  People think little of spending thousands of dollars for anything involving a scalpel or anesthesia… my teenage daughter’s broken arm took 10 minutes to cast and the orthopedist charge was almost $1000, but I will get nowhere asking an insurer to pay $140 for an hour of my time with a patient!  Likewise, mild nausea from Effexor will keep a patient from taking the medication, even when the illness is so severe that the person is home-bound from panic attacks. After several days of at most mild dysphoria, the medication has a good chance of eliminating the anxiety entirely! 

What are the reasons for the differences?  I have a few guesses, including the stigma of mental illness, the difficult nature of change, and the powerful effects of denial.  In all cases I don’t see significant changes in ‘how things are’ on the horizon… so noncompliance and unwillingness to accept proper treatment will likely remain an issue for psychiatrists to understand and to consider as part of the entire illness.

Thanks, as always, for reading this far.  I wish you all the best.

JJ

Just a quick comment tonight about an interesting report from the American Academy of Child and Adolescent Psychiatry 56th Annual Meeting– in Hawaii, of all places (gnashing my teeth in jealousy, but it should pass in a few minutes!).  As you may or may not know, my practice is split between classic psychiatry (med management and/or psychotherapy from a psychodynamic perspective), treatment of addictions (primarily opiate dependence), and treatment at the interface of chronic pain, psychiatry, and addiction.  Compared to the fatal nature of opiate dependence and the epidemic of cases locally and across the nation, I view pot-smoking as a relatively minor vice for most people.  I have met a number of people who seem to be able to smoke pot fairly regularly without significant harmful sequelae– although I would not be surprised if the pot use is costing something–  a reduction in marital intimacy or in one’s relationship with one’s children, for example.

On the other hand there are clearly people who have negative consequences from use of THC.   One thing that has always stood out, at least in patients I have followed, is that people who are depressed and who are regular pot smokers do not seem to benefit all that well from SSRI‘s– or from other treatments, for that matter.  I have assumed that the reason is more psychological than chemical– that since pot-smokers tend to be more sedentary, and tend to lack good coping skills other than smoking marijuana to deal with stress (whereas non-pot-smokers may deal with stress by exercising, meditating, or taking up a new hobby), they are simply harder to pull out of the ‘funk’ that depressed people are in.  But at the meeting in Hawaii, docs from the University of Pittsburgh School of Medicine reported partial data from a larger study that showed a reduced treatment response to antidepressants by patients using moderate amounts of alcohol or marijuana.

File this report in the ‘evidence backing up common sense’ drawer.  It was not a huge surprise, but it is always a good thing when the science is consistent with the general opinion on a topic.  This was not the case, as some of you may remember, when it came to breast implants and autoimmune conditions– and about a million other things that the media warns us about, that eventually turns out to be a bunch of baloney.  In the case of pot smoking and reduced response to antidepressants, seems that there isn’t much baloney going around.

JJ

Casual Cannabis, Alcohol Use Reduces Treatment Efficacy in Adolescents With Major Depression

A word of warning:  this post is more of an observation than a ‘lesson’;  a question rather than an answer.  I don’t want someone to waste their time reading and expecting a piece of life-changing advice… only to find more things to wonder about! I also need to be brief because I need to get to the office, although perhaps briefness is something appreciated by those who stumble across this site!

I just finished an appointment with a young lady who is facing a number of challenges.  She is 22 and single, and she lives with her preschool-aged daughter in half of a duplex.  In the past month she had quite a run of bad luck.  Her slumlord hasn’t come through with the repairs he promised to make; she has an oven that doesn’t work, doors with broken deadbolts (in one of the more crime-ridden neighborhoods), and a number of other annoyances.  Her attempts to pressure him to fix things culminated in a complaint to a government agency… and now he is taking her to court to evict her, despite assurances in the law that eviction cannot occur after such complaints.

But I’m just getting started!  When the heat comes on,  the unit is flooded with the smell of urine from the unit below, where a disabled crazy man lives with too many cats.  Her child’s doc said that the fecal material from the cats caused the infection that hospitalized her daughter for several days;  the patient’s workplace is too small to honor family leave, so she was fired after insisting that she spend nights with her daughter in the hospital.  Meanwhile the guy downstairs had assumed he had a close friend when she took the upper unit, but at some point she tired of waiting through his several-per-day visits, and asked him to provide some ‘space’.  This angered the mentally disabled man (frankly it is not that safe for a young woman to have this 30-y-o person alone in the house, as obsessions can develop and turn dangerous).  He retaliated by stealing her mail, and eventually convincing the post office that she had moved– causing her to miss deadlines and not get unemployment.

I can imagine dealing with one of these things;  as a 40-something man (for a few more months anyway) I would find the situation frustrating.  It would have been very difficult to deal with these things on my own when I was in my early 20′s!  And to be faced with all of these situations– I cannot imagine what I would do.  I often find that in such cases the problems are self-induced, but with this person that is not the case;  she has done the things that people are supposed to do– but still things have not worked out.  Sick kid, lost job (a crappy job at that), bad neighbor, bad landlord, hospitals, non-functioning appliances, government agencies, court summons for eviction…  and did I mention that all of this is happening two years into recovery from a bad narcotic addiction?  She continues to do well on that front– somehow.

Despite these challenges she has stayed away from narcotics, kept appointments to get her daughter back to good health, found another full-time job, straightened out the Post mistakes, and prepared for court by getting a bunch of supportive papers together.  Pretty impressive for a 22-y-o recovering drug addict!

But now my question…  Why isn’t this woman depressed?  She is not, by the way, taking antidepressants– although she probably should be, just for prophylactic purposes (I am kidding– sort of, anyway)!  Why is it that one person who is twice her age and has half her problems will become stressed and depressed, and she continues to go from day to day, one after the other, without falling apart?  The answer is not ‘Faith’, at least not in any way that I can see;  I have seen patients of strong Faith with severe depressions, and this woman does not have any significant connection to a ‘higher power’.

I know I started by saying that I didn’t have an answer, but one has occurred to me over the past few minutes ( I also said I would be brief!) — an answer that will surely anger many people and that I therefore should keep to myself…  but I won’t.  The reason she hasn’t become depressed is because she can’t.  She simply does not have the time– not with a small child to care for.  I will pause for a moment to let the anger build in people before defending myself in the next paragraph.

No, I am not saying that depression or any other mental illness is a matter of ‘choice’– not conscious choice anyway.  Not in a way that people have any control over.  But I do wonder if there IS a choice component at some unconscious level— I am a big believer in the unconscious, and have watched for years in cases of addiction where the unconscious ‘addict inside’ leads a person around by the nose, destroying more and more of the person’s life.  I have to wonder if in some cases there is an unconscious awareness that ‘this is not the time for a depression’, and in other cases a similar and opposite awareness.

Such a concept would fit with a few observations about society;  the perception that in the ‘old days’ people didn’t get depressed as much– they worked extremely hard on farms and in factories or in kitchens, back when just making a meal would take an entire day to gather, prepare, and cook– not counting all of the other work ‘at home’ before the era of washing machines and dishwashers.  Perhaps in some cases the mind can abort depression by turning to a ‘reserve’ of sorts, recognizing that a depression at THIS particular time could prove fatal for the individual… and for other family members.

I like how in psychiatry we can approach things from ‘psychodynamics’ or rather from a perspective of the mind as ‘chemical reactions’, all mental illness being ‘brain diseases’.  I could do the same with this discussion;  perhaps there is something analagous to the endorphin system for pain, where in horrible injuries the brain is flooded with mind-numbing chemicals that induce analgesia and even euphoria–  perhaps when the psychological stressors become very severe, a similar process occurs that protects us from depression, and that those who DO fall apart in such circumstances are suffering from the dysfunction of such a system.

Even if I am onto something, I don’t know what conclusions should be drawn;  I don’t think it makes sense to recommend that people have lives filled with so much turmoil in order to protect themselves from depression!  But perhaps there is one idea that does follow my logic.  Perhaps we are on the wrong track when we spend all of our resources and energy in the pursuit of a life of ease–  because maybe, just maybe, when we get to that life of ease things won’t be quite as ‘happy’ as we imagine.

I’d love to  hear your responses and thoughts on the issue.

Addendum:  Shortly after writing this post I turned on the TV and watched as the body of David Kellermann, CFO of Freddie Mac was taken from his beautiful home in Fairfax, Virginia.  His tragic death can be interpreted in many ways; I am tempted to try to guess what might have happened but it feels inappropriate to say anything, except to acknowledge the grief of his wife and daughter.  I hope that they can find some peace– after the hoard of reporters are gone, the horrible calls for suicides of CEOs by US Senators subside, and our politicians find better ways to maintain popularity than to stir up class warfare.  Believe it or not, everybody hurts.

JJ

People come to a psychiatrist because they want to change.  At least that is what they think they want.  They get up the nerve to make an appointment, walk through the door– not a small thing!  In fact, considering that psychiatrists are supposed to be the doctors who deal with depression, anxiety, and ‘frailties’ of the mind, it is interesting how much dread they invoke in people!  I think the reason isn’t necessarily because psychiatrists have horrible personalities… at least I hope that isn’t the reason… but rather I think people fear going to psychiatrists for at least two other reasons.  The first is that people think that psychiatrists will ‘see through them’– that we have some special ability to read minds, or determine what a person is REALLY thinking… the second and more important reason is that people tend to push their problems out of their awareness, and when they go to the psychiatrist they have to think about things that they would rather not think about.

There are other reasons, of course–  psychiatrists ‘ain’t what they used to be’, at least in my humble opinion.  They spend way too little time with people, selling their souls to the big systems that have them work on productivity, seeing too many patients for too little time.  And there is nothing worse than getting all worked up to go tell a person your problems, only to have the person totally ignore everything you are saying, or push you out the door before you even got started.  I wish people would just avoid those psychiatrists, because they are giving psychiatrists a bad name and ruining the specialty.

But that isn’t why I am writing… I am writing about change.  People come in saying they want to change… and then they fight that change from that point going forward.  I’m not complaining, because that is just how people are.  But it is something for people to be aware of, so that they understand why they keep making the same New Year’s Resolution year after year!

Because of resistance to change I usually aim fairly low in my expectations of the steps people will take… I don’t for example tell people who are depressed to ‘just start exercising’, and get mad when it doesn’t happen.  On the other hand there are times when it is possible to induce change, and I try to opportunistic– and grab those opportunities if they arise.  Such was the case with the patient I am about to talk about.  As usual, names and details have been changed a bit for privacy.

The patient, ‘Jane’, had been miserable for a long time.  Her husband doesn’t communicate beyond a grunt or two here and there;  Jane has given up a great deal of ‘power’ over the years, in part because she has a recurring substance problem that has been mild so far, but that gives her enough shame to buy into her husband’s comments that ‘she has no right to complain’… about anything.  This is a tough situation for a person to be in, and a frustrating case for a psychiatrist.  The person in such a position is miserable, but not miserable enough to really do anything about it.  I can suggest things, of course– ways to foster communication, tips on relaxation, parenting suggestions… but for the most part people don’t take ‘advice’ to heart.  Now and then I will find an area where the person has a ‘blind spot’– were the person is seeing something in a distorted way, and if I can get the person to see it differently I might increase insight into a problem… this is trickier than it sounds, because I can’t just point it out to the person, as then it will be rejected.  But if I can make it come out in a way where the patient ‘discovers’ it, then it might stick.

Off track again… I should try to write in the morning, as late at night I tend to get a bit tangential.

Opportunism…  if the person gets desperate enough, THAT is when there is the possibility of change.  That is where I was today with Jane, after she wrote me this message:

Hi Dr. Junig,

I left a message at your office last week; but I was unable to get back to you —to get in as soon as possible.

Things feel like they are getting worse than ever…Financially and emotionally with Tom. It’s not only him. It is me. I just want to leave. For the last month the thought of leaving, just driving away to escape my life is a thought that I can’t get out of my mind.

I hate our unorganized mess and life and finances- and when I look around I start to feel like I am going to lose it. I just keep saying, this is not how my life was supposed to be…

Bill collectors are calling all the time. Our furnace isn’t working and Tom doesn’t seem to care. We are all living in the basement of my mom’s house now– pretty sad. I have no energy to do anything at all; except barely get by with the daily activities which are overwhelming. I have gained the 25 lbs over the past three months, strange because I never feel like eating anything.

My girls are the only thing that keeps me going every day. But they can tell there is something really wrong with me.

I used up the valium 2/day, took twice as much cause it didn’t do anything for me at the lower dose. I hardly ever feel relaxed or not un-nerved.

Please call!

My Reply: Again, this is one of those rare times when one swings for the fence.  A person with a ‘small’ substance problem is not going to accept buying into a 12-step program;  people with addictions come in and say ‘doc, I’m so miserable from these drugs… I can’t stand it anymore… I’m broke, my wife left, I have no food in the house– I’ll do anything!  ANYTHING!!  Please, help me’.  I’ll ask them to check out one AA meeting during the next week– one hour, costing one dollar.  The person says ‘Oh no, doc, I can’t.  I have too much to do–  in fact, I’m not really all that bad.  Just forget I said anything!”  People hate AA– unless they know anything about it and have actually opened their mind to it– then they recognize just how effective it is, and they understand that it is NOT about finding sympathy, or whining about problems.  It is about courage, and follow-through, and responsibility, and ‘carrying one’s load’.  And it is life-changing.

OK… my response, finally:

Hi Jane,

I hear you loud and clear. I don’t have an easy answer– I don’t think there is one, because you would have found it by now if there was. But there should be reason for hope; if we look at your life there are reasons to be happy, at least moments of happiness– I don’t want to sound like I am making less of things because I don’t feel that way– I realize that things are really hard right now and you are totally miserable. But you have food and you have shelter– not great being in grandma’s house, but at least you have shelter…

I think about my own despair in 2001 when my addiction came to a head– lost my job and career, marriage sucked, kids didn’t know me, no hobbies, feeling totally stressed out and physically miserable. In my case there was addiction to focus on, which was lucky for me, because the 12 step program really does have the ingredients for some level of happiness— even when everything else is going wrong.

In your case, Jane, there are little things that will improve the situation for you, but I think it will take drastic measures to make a real change in your level of happiness. Anything short of that will be a temporary fix– at best—and you would end up back where you are now. Do you see my point? You need something that is ‘life-changing’– nothing else will make all those things better!

I hate to sound like a salesman, but a 12 step program is the only thing that is going to really help. The good news is that if you are truly desperate– desperate enough to open your mind– a 12-step program will potentially fix ALL of those problems. I know it seems like a stretch, but it really could. And it wouldn’t cost anything except a buck per meeting.

Will you consider that option? I would make recommendations on which meetings to go to– and the goal would be to get off the lorazepam. We have to do something about those anyway– they will only destroy you at the rate things are going. You can’t control them; don’t feel bad, because I wouldn’t be able to control them either. We have to get you off them because there is just no other option– you take them, run out, get sick…. they are not helping, and they are probably making things much worse.

Will you check out a 12-step program?

JJ

After a shot at the fences, people sometimes strike out. Time will tell…  we will take a big step forward… or I may never hear from this patient of two years again.

I’m tired… so… sorry, but this will have to be continued.  I don’t know the ending yet anyway!

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