Chapter Eleven

THERAPEUTIC INTERVENTIONS WHEN THINGS ARE FALLING APART

“Don't give up five minutes before the miracle.”

—Alcoholics Anonymous

In the preceding pages, I outlined a systematic, step-by-step 12-week plan for recovering from depression and anxiety. There are times, however, when the disabling affects of these disorders can make it difficult or impossible to start this program—or to complete it.

I know this to be true from personal experience. At the height of my “agitated depression,” I could not have participated in the exercises in this book. My ongoing anxiety meant that I couldn't sit still long enough to read. I lost my ability to focus and to concentrate. Most important, when I looked into the future, I could not envision recovery.

If you are in a similar situation where your symptoms are seriously interfering with your ability to function, here are some suggestions:

1) Please turn to the coping strategies for “getting out of hell” that I outlined in the introduction to the Better Mood Recovery Program (pages 135–139).

2) Read the section on pain management (pages 311–318) from Week 11 of the better mood recovery program.

3) Read over the coping strategies for Stage 3 (major crisis) in the chapter on relapse prevention (Week 12, page 334). Make sure that you are in daily contact with members of your support team (your therapist, prescriber, family or friends, etc.).

To further support you in your quest for healing, I would like to share five additional crisis intervention strategies for dealing with intense pain:

1) hospitalization

2) electroconvulsive therapy (ECT—a way of jolting the brain-back into balance through an electrical stimulus.

3) two “milder” forms of ECT—rapid transcranial magnetic stimulation (RTMS) and vagus nerve stimulation.

4) suicide prevention.

Let's explore these now.

Hospitalization: When Is It Appropriate?

The very idea of going to a psychiatric hospital is an anathema to most people. Being “locked up” in a “funny farm” or “loony bin” elicits feelings of shame and stigma. Columnist Art Buchwald recounted how he felt “humiliated” and “a total failure” when he was hospitalized for his manic depression.

There are, however, times when a person who is severely depressed or anxious should consider committing himself to a psychiatric ward for a period of time. Hospitalization may be a positive option for you when:

If you need to go to the hospital, remember that it is a temporary situation that is designed to keep you safe. Try to let go of any feelings of shame or failure. You are still a worthy person regardless of your external circumstances.

Unfortunately, hospital stays are shorter than they might ideally be. When William Styron experienced his depressive breakdown in 1985, he convalesced for six weeks, a respite that he credits with saving his life. Today, in the age of managed care, such multi-week stays are unheard of, unless one has the money to pay for a private hospital that specializes in long-term residential care. While I am not advocating returning to a time when chronically mentally ill people were warehoused in large institutions, it is clear that the pendulum has swung too far in the opposite direction.

Electroconvulsive Therapy: The Method of Last Resort

By far the most controversial modality in the treatment of depression is electroconvulsive therapy (ECT), also known as electric shock therapy. Much of the public's concerns about ECT arise from the gruesome way in which the treatment has been portrayed by the popular media. Many people still cringe when they recall the memory of Jack Nicholson being punished with ECT treatments in the film “One Flew Over the Cuckoo's Nest.” The idea of having electrical currents forced through one's brain inspires fear and terror while conjuring images of Frankenstein, mad scientists and electrocution. Can such a seemingly barbaric practice be effective in treating severe depression? In the following pages, we will explore the pros and cons of ECT.1

What is ECT?

Electroconvulsive therapy is a treatment for severe mental illness in which the brain is stimulated with a strong electrical current which induces a seizure, similar to those of epilepsy. In a manner that is not understood, this seizure rearranges the brain's neurochemistry, resulting in an elevation of mood.

ECT was first introduced in the United States in the 1940s and 1950s. During that time, the treatment was often administered to the most severely disturbed patients residing in large mental institutions. As often occurs with new therapies, ECT was used for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective, and some even harmful. Moreover, ECT was used as a means of managing unruly patients for whom other treatments were not then available. This contributed to the perception of ECT as an abusive instrument of behavioral control for chronically ill patients. With the introduction of effective drugs for the treatment of mental illness, the use of ECT declined. Recently, however, as safer and less traumatic ways of administering ECT have evolved, the treatment has made a comeback.

How effective is ECT in treating mental disorders?

The efficacy of ECT has been established most convincingly in the treatment of delusional and severe endogenous depressions (the latter is what I experienced), which make up a clinically important minority of depressive disorders. Some studies find ECT to be as effective as antidepressants, while others find ECT to be superior to medication. The literature also indicates that ECT, when compared with antidepressants, has a more rapid onset of action.

A nurse at one hospital reported, “I have seen severely depressed people who were unable to dress or feed themselves; I had to change their diapers because they were so regressed and withdrawn. By the end of their ECT treatments they were smiling, eating and drinking on their own. It's as if they were brought back from the dead.”

Although ECT can jolt people out of severe depression and mania, recovery is not necessarily permanent. Relapse rates in the year following ECT are likely to be high unless maintenance antidepressant medications are subsequently prescribed. In other instances, “maintenance doses” of ECT are given two to six times a year to prevent relapse. ECT is also useful in certain types of schizophrenia, although antipsychotic drugs remain the first line of treatment.

How is ECT administered?

During an ECT treatment, a number of medications and muscle relaxants are given to the patient, and stimulus electrodes are placed on the head, either on one or both temporal lobes (for unilateral or bilateral ECT, respectively). After the muscle relaxant has taken effect, the brain is stimulated with an electrical pulse lasting from a quarter of a second to two seconds. The pulse induces a seizure which usually lasts from 30 seconds to two minutes, during which time the patient is closely monitored. After the treatment, the patient is brought to a recovery room where he or she remains until waking.

The number of ECT treatments in a course of therapy varies between six and twelve. Treatments are given three times a week, for two to four weeks. Following ECT, most depressed patients are continued on antidepressant medication or lithium to reduce the risk of relapse. Sometimes, physicians give maintenance doses of ECT to their patients on an outpatient basis.

What are the risks and adverse effects of ECT?

ECT is clearly less dangerous than it once was. Over the years, safer methods of administration have been developed, including the use of short-acting anesthetics, muscle relaxants, and adequate oxygenation, which have reduced the risk of physical injury and mortality. Yet even under optimal conditions of administration, the ECT seizure produces two main reactions—transient post-treatment confusion, and spotty but persistent memory loss.

Immediately after awakening from the treatment, the patient experiences confusion, temporary memory loss, and headache. Some people compare their experience to having a bad hangover. The time it takes to recover clear consciousness may vary from minutes to several hours, the exact length depending on the type of ECT administered (stimulating both hemispheres produces more confusion than unilateral ECT), as well as individual differences in the patients’ response patterns.

The second side effect of ECT is memory loss which persists after the termination of a normal course of treatment. This amnesia seems to surround events that occurred around the time of the treatment, either several weeks before or after. For example, the patient may not remember who took him to the hospital or what gifts he gave a month before the treatment. The ability to learn and retain new information does not seem to be adversely affected, although learning difficulties may exist during the first few weeks after the treatment.

Because there is also a wide difference in individual perception of the memory deficit, the subjective loss can be extremely distressing to some and of little concern to others. For example, many patients who complain about autobiographical memory loss say that being free of depression is well worth whatever memory disruption they experience. Others insist, however, that they have suffered a terrible disruption to their memory and to their lives. Although the second group is in the minority, accounts of their suffering must be taken seriously. Such accounts indicate that ECT carries definite risk and that it should be used only if the depression or manic depression is severely debilitating or life-threatening.

Conclusion

ECT remains controversial despite its potential benefits. This controversy is perpetuated by the following factors: the nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, and uneven distribution of ECT use among practitioners and facilities.

Nonetheless, ECT has been shown to be effective for a narrow range of severe psychiatric disorders—delusional and severe endogenous depression, manic episodes, and certain schizophrenic syndromes. There are, however, significant side effects, especially confused states and persistent memory deficits for events during the weeks surrounding the ECT treatment. Proper administration of ECT can reduce potential side effects while still providing for adequate therapeutic effects.

Much additional research is needed into the basic mechanisms by which ECT exerts its therapeutic effects. Studies are also needed to better identify groups for whom the treatment is particularly beneficial (or toxic) and to refine techniques that will maximize the treatment's effectiveness and reduce side effects. Moreover, rigorous double blind studies must be implemented:

In this manner, ECT can be administered in the right way, at the right time, for the right patients.

Rapid Transcranial Magnetic Stimulation: Magnetic Healing of the Brain

While ECT can be an effective means of treating serious depression, its invasive nature has been a longtime source of controversy. Now there is a promising alternative that works on the same principle as ECT, but may be less traumatic. An experimental procedure known as Rapid Transcranial Magnetic Stimulation (RTMS) uses a powerful magnet to deliver an electric jolt to the brain in the same manner as ECT, but without electrical stimulation to unnecessary parts of the brain. Scientists believe that the technique works like a heart defibrillator. The electric voltage that passes through the brain causes its neurons to fire at once and somehow this action seems to reset the rate at which the brain releases its various neurotransmitters.

In clinical trials, some people who have failed to improve by using medication and other therapies have responded to RTMS treatments within six days, while the majority are significantly better after two weeks of twenty-minute treatments. Because of its newness, no one knows if these benefits will last longer than six months, but preliminary indications are promising. Like ECT, RTMS will most likely be used to “jump start” the brain so that other forms of medical care can then be used to maintain the patient's well-being over the long haul.

Magnetic therapy has been a viable medical therapy for thousands of years. Having a “gentler” form of ECT available is exciting news for people who suffer from long-term treatment-resistant depression.2

Vagus Nerve Stimulation

A second alternative to ECT that uses the same principles but in a milder fashion is called vagus Nerve Stimulation. Like ECT, Vagus Nerve Stimulation (known as VNS) attempts to rearrange the brain's chemical soup through electrical stimulation. The key to its success is the vagus nerve (in Greek, vagus means “wanderer”) which like a winding river, meanders for about twenty-two inches through an adult's upper body. The vagus functions as the brain's information superhighway, carrying signals to and from the brain from the vital organs below. When you feel your heart racing, the information is being transmitted to the brain through the vagus nerve.

Here's how VNS works. Doctors implant a device much like a heart pacemaker into the chest and run a wire to the vagus nerve in the neck. The vagus nerve carries signals from the battery-powered device into the brain (a 30 second impulse is sent every three minutes). According to doctors, more than 80% of the electrical signals applied to the vagus nerve reach the brain and activate areas that regulate moods.

The battery operated device, about the size of a stopwatch, lasts for five to ten years. Doctors can adjust the signals sent to the brain by using a computer and a wand with a magnet. Patients can also turn the device on and off with the magnet which is important since the device can change their voice when it sends out a signal, although the change is hard to detect during normal conversation.

The vagus nerve stimulator is still in its experimental phase, although initial findings are extremely promising. A number of success stories have been published in the press, and the VNS stimulator is now being marketed in Europe and Canada. A preliminary study is underway in the United States whose results are due to be published in the spring of 2002. You can learn about this study and the VNS device by visiting the web site www.cyberonics.com.

How to Cope With Suicidal Feelings—in Yourself and Others

The ultimate tragedy of mood disorders is suicide. Suicide is a double disaster. Not only does it prematurely end a life, it wreaks havoc on the lives of those left behind. Devastated survivors can be traumatized by feelings of grief, guilt, anger, resentment, and confusion. “There was no time to say good-bye,” and “Perhaps I could have done more,” are examples of comments that are made by shell-shocked friends and relatives.3 Moreover, the stigma surrounding suicide makes it very difficult for family members to talk about what has happened.

Suicide has been defined as a “permanent solution to a temporary problem.” For the person caught in the black hole of depression, however, there is nothing temporary about the hell he or she is experiencing. The resulting sense of hopelessness is the major trigger for suicidal thoughts, feelings and attempts. This hopelessness includes:

When the psyche is assailed by this level of despair, suicide feels like the only way out. If you are feeling suicidal, here are some thoughts that can help you to counter the suicidal urge:

  1. Remember that you are under the influence of a “drug” called depression which is distorting your view of reality. As a result, your feelings of hopelessness do not accurately reflect your true potential for recovery.
  2. Depression, like everything else in the physical world, is cyclic. In most cases, it comes and goes; it has a beginning and an end. A useful affirmation to repeat is, “Nothing stays the same forever. This, too, shall pass.”
  3. An overwhelming majority of people who have suffered from suicidal feelings have fully recovered. The odds that you will get better are in your favor.
  4. If you have family and/or friends in your life, realize that they will be devastated by losing you. Their suffering will only add to the existing suffering in the world.
  5. Use the techniques described in the depression survival plan in this book to increase your coping resources and to keep yourself safe.
  6. Remember that feelings and actions are two different things. Just because you feel like killing yourself, it doesn't mean you have to act on it this minute. This is one time when procrastinating is a good idea.
  7. Do not remain alone when you are feeling suicidal. If you are feeling overwhelmed, ask for help. Set up a suicide support system with people who can spot your mood swings even before you do, and will take action to keep you safe. Make a pact that you will contact them when you are feeling suicidal. If you don't have friends who can do this, try to locate a depression support group at a hospital or clinic.
  8. Use your local crisis hotline as a resource. Their job is to support you through your struggle, one day at a time. If you don't have a local hotline, call (888) SUICIDE—(888) 784-2433.
  9. Regulate anything in your environment that may be used to harm you. Flush old medications down the toilet, keeping only small quantities of those you take regularly. Dispose of all firearms you have, or give them to a support person for safekeeping.

Finally, remember, people do get through this, even when they feel as bad as you do right now. Here is a passage from Kathy Cronkite's At the Edge of Darkness that was very helpful in restoring my hope.

Part of the anxiety and dread of depression is that “storm in the brain” that blocks out all possibility of sunlight. In the depths of despair that by definition murders faith, courage may have to suffice. Keep slogging. Even if you don't believe it at the moment, remind yourself of the existence of good. Reassure yourself: “Once I enjoyed ‘X,’ I will again.” The disease may have turned off the spigot of love, but it will come back.

When someone you know is suicidal

Many Americans have mistaken ideas about the suicidal feelings that result from major depression. Depressed people who say they are suicidal are often not taken seriously by their friends and family. (For example, a day before a 14-year-old boy went on a shooting spree in a Georgia school, he told his friend that he wanted to kill himself. “You're crazy,” came the reply.) What follows are some do's and don'ts on what to say to a suicidal individual.4

DO ask people with suicidal symptoms if they are considering killing themselves. Contrary to popular opinion, it will not reinforce the idea. “In fact, it can prevent suicide,” says Dr. Joseph Richman, professor of psychiatry at the Albert Einstein College of Medicine in New York. Since the suicidal person feels isolated and alienated, the fact that someone is concerned can have a healing effect.

DON'T act shocked or disapproving if the answer to the question “Are you suicidal?” is “Yes.” Don't say that suicide is dumb or that the person should “snap out of it.” Suicidal feelings are part of being clinically depressed, just as a high white blood cell count is a symptom of an infection.

DON'T lecture a suicidal individual about the morality or immorality of suicide, or about responsibility to the family. A person in a state of despair needs support, not an argument.

DO remove from easy reach any guns or razors, scissors, drugs or other means of self-harm.

DO assure the person that although it may not feel like it, suicidal feelings are temporary.

DO ask the person if he or she has a specific plan. If the answer is yes, ask him to describe it in detail. If the description seems convincing, urge the person to call a mental-health professional right away. If he or she is not seeing a therapist or psychiatrist, offer a ride to the emergency room for evaluation, or call the local crisis line—or (800) SUICIDE—(800) 784-2433.5

DO make a “no-suicide” contract. This means that the person agrees (in words or in writing) that if he feels on the verge of hurting himself, he will not do anything until he first calls you or another support person. You in turn promise that you will be available to help in any way you can. Ideally, it is best if the suicidal person has prepared a list of people (three or more is ideal) that he or she can contact in the midst of a crisis.

DON'T promise to keep the suicidal feelings a secret. Such a decision can block much-needed support and put the person at greater risk. If a person needs help from a medical professional or a crisis-intervention center, make sure that he or she gets it, even if you have to go along.

DO pay particular attention to the period after a depressive episode, when the person is beginning to feel better and has more energy. Ironically, this may be a time when he or she is more vulnerable to suicide.

DO assure the person that depression is a treatable illness and that help is available. If the individual is too depressed to find support, do what you can to help him or her find support systems—e.g., psychotherapy, medical treatment, and support groups that are described in this book.

 

Coping With Suicidal Pain

The image of the scales, which we used in our section on pain management (page 311) also offers a model for understanding suicidal pain. One the one side of the scale is pain; on the other are your coping resources. Suicidal thoughts flood the mind when your emotional pain exceeds the resources for coping with the pain. To get the scales back in balance, you can do one of two things: discover a way to reduce the pain, or find a way to increase your coping resources. The tools in this chapter (and throughout the book) are designed to do both.

images

 

DO call a suicide hotline or crisis hotline if you have any questions about how to deal with a person you think may be suicidal. Help is available for you, the caregiver.

Finally, there exist a number of telephone hot lines and Internet sites that can provide immediate support and relief for anyone who is struggling with feelings of suicide.

1. National Suicide Prevention Lifeline (800) 273-TALK (800-273-8255). This nationwide suicide telephone hotline provides free 24-hour crisis counseling for people who are suicidal or who are suffering the pain of depression.

2. National Suicide Prevention Hotline (800) SUICIDE (800- 784-2433). The nationwide toll-free suicide hotline under the auspices of the Department of Health and Human Services (HHS) provides free 24-hour crisis counseling.

3. The Samaritans Suicide Prevention Hotline (212) 673-3000 or e-mail: jo@samaritans.org. They will respond to your e-mail within 24 hours.

 

Facts About Suicide

Statistics

Youth

Depression

Alcohol and Suicide

Firearms and Suicide

Figures are based on 2006 United States statistics.

Source: American Foundation for Suicide Prevention.

 

4. Covenant House Nineline (800) 999-9999
http://www.covenanthouse.org
This hotline provides crisis intervention, support and referrals for youth and adults in crisis, including those who are feeling depressed and suicidal.

5. Internet site: http://www.metanoia.org/suicide/
This is an excellent Web site which I visited when I was suicidal. I credit it with being one of the factors that prevented me from taking my life.

6. Internet site: http://www.save.org/index.html
This is the Web site for SAVE (Suicide Awareness Voices of Education), whose mission is to educate others about suicide and to speak for suicide survivors. I also frequented this Internet site when I was suicidal and found it to be extremely helpful.

These phone numbers and Internet addresses are repeated in Appendix C, along with other resources.

1 The information for this section was taken from the National Institute of Health's Consensus Development Conference Statement, June 10-12, 1985. This statement was originally published as: Electroconvulsive Therapy. NIH Consensus Statement, 1985 June 10-12; 5(11):1-23. I am covering the subject in depth because of the fear and misunderstanding that still persists about ECT.

2 Schrof, Joannie M. and Stacey Schultz, “Melancholy Nation: Depression Is on the Rise, Despite Prozac. But New Drugs Could Offer Help.” U.S. News and World Report, March 8, 1999, Volume 126, Number 9, pg. 63.

3 A good friend of mine told me that her heart “shut down” for thirty years after her older brother committed suicide when she was nineteen.

4 Taken from Caryl Stein, “Why Depression is a Silent Killer,” Parade Magazine, September 28, 1997, pp. 4-5.

5 If the person is drunk or high, the risk of self-harm is greatly increased.