29 May 2015

Cognitive Reapprasial, Behavior Therapy, and Women

That I should be concerned with matters of mental health treatment should come as no surprise to you, Dear Reader. Recently, two different articles have come to my attention. I'd like to share and discuss them here. (Spoiler alert: Since this is my blog, that's what's about to happen.)

The first article is An Experimental Study on the Effectiveness of Disclosing Stressful Life Events and Support Messages: When Cognitive Reappraisal Support Decreases Emotional Distress, and Emotional Support Is Like Saying Nothing at All, written by Anika Batenburg and Enny Das, edited by Daniel Houser. This piece was published online 22 December last year on PLoS One, which bills itself as "a peer-reviewed, open-access journal".

What Batenburg and Das explored is whether there is the answer to the $64,000 question, "How can we best support others in difficult times?" They identified three support messages (i.e., what you say to be helpful): cognitive reappraisal (dissecting things), socio-affective (emotional support and comfort), and "no response"; matched with two kinds of disclosure conditions: cognitive reappraisal and emotional disclosure (sharing emotions).

For their study, they had half of their participants write "about their deepest emotions about a current most stressful event that affected them and their lives"; the other half, "about positive and negative consequences of a current most stressful event, their perceptions of the stressful event, challenges and opportunity arising from the event, cognitive reappraisal of their coping strategies and their positive thoughts about the stressor". All participants were given fifteen minutes in which to write. (I hope the latter group had more than fifteen minutes just to read their instructions!)

The thinking was that the emotional disclosure group (the one sharing their deepest emotions) would benefit more from socio-affirmitive support messages, and that the cognitive reappraisal group would benefit more from cognitive reappraisal support messages. Seems a bit obvious, right? If you're sharing emotions, you want someone to offer comfort; if you're trying to work things out, you'd rather have someone offer some perspective to help you do that.

Except, it didn't go that way.

It turned out that both groups benefited more from cognitive reappraisal support messages. In fact, socio-affirmitive support messages weren't all that noticeably more helpful than no response at all. To be honest, I'm not surprised by this. I don't find "there, there, it'll be okay" helpful in the slightest. If anything, socio-affirmitive support messages often convey to me that the other person is at best naive about what I'm facing. They don't understand what I'm going through, and the best they can offer is to try to mollify me. I don't have any higher threshold for being patronized than the next person, so I find this kind of support fairly useless.

I take it for granted that anyone I feel close enough to that I would come to them during a crisis wants me to feel better. That is, after all, why I go to them. This isn't to say that I'm dispassionate, or that I'm somehow above being comforted on an emotional level. Just last week, for instance, I sought out one of my friends and just asked her for a hug. I outright sobbed for several minutes. I needed that. It's rare for me to seek that kind of support; so rare that I think even members of my inner circle will be surprised to read about that.

The participants in the Batenburg and Das study engaged in "expressive writing", explained here:
"Lepore, Greenberg, Bruno, and Smyth suggested that expressive writing enables three important underlying mechanisms to cope with trauma; directing attention to the stressor and related emotions, habituation to the emotions, and cognitive restructuration."
I've worked diligently over the years to align my speaking voice with my writing voice, and I think those with whom I converse regularly will attest that having a verbal conversation with me is a lot like what it's like to read something I've written. (It's just more interactive and I'm funnier in person.) If expressive writing leads to those three coping mechanisms, then it stands to reason that expressive talking (if such a thing is recognized) would also lead to them. That's precisely why I share what I share, whether privately or publicly in this blog. I'm an expressive dude.

That brings me to the second article that caught my attention last night, How bias in mental health care hurts women, from the lab to the medicine cabinet, written by Erin Anderssen and published Tuesday on the Canadian website, The Globe and Mail. Anderssen makes a compelling argument that mental health care has done very little to recognize the sex-specific impact and needs of women with mental health concerns. She covers everything from the higher incidence of heart problems related to depression in younger women down to the fact that even most of the lab rats used in research are male.

The key specific matter addressed by Anderssen is that in Canada, mental health is treated primarily through pharmaceuticals rather than therapy. That's certainly true here in the United States as well, and I imagine that's true of most countries. Just taking the pills isn't enough, she argues, and my own anecdotal experience can attest to that.
The disorders most commonly diagnosed in women – depression, anxiety and insomnia – are also the ones most likely to respond to therapy, an approach that women are significantly more likely than men to prefer over drugs.
Drawing on commentary from doctors and researchers, Anderssen makes clear that therapy is the most prudent form of treatment for women with mental health issues. At present, though, the attitude toward therapy continues to regard it as some kind of luxury indulgence rather than a necessary form of treatment. For instance, she cites a pilot program in New Brunswick that offered twelve weeks of peer support to women with postpartum depression. Only 12% of the women treated by the program were still depressed when it concluded. Despite the success, the city rejected funding a full version of it at $142,000 a year.

I find discussing most anything in monetary terms disgusting, and particularly something like mental health, but even if we're to reduce the matter to dollar signs, "the cost of providing peer support would be roughly half the amount of the average hospital stay for a woman with postpartum depression," says the doctor discussing that program. Maybe the problem is that the New Brunswick city council didn't include enough women. I don't know, and Anderssen doesn't say, but we know that most legislators are male, and most of them consistently display detachment from issues that are women-centric. The most obvious proactive solution there is to elect more women to office.

Or there's the example Anderssen gives of insomnia, which "is diagnosed twice as often in women as men. It has a circular relationship to mental illness: People with it are five times more likely to have anxiety and depression, and having it makes you more likely to be depressed and anxious." Research shows that cognitive behavior therapy is even more effective in treating insomnia than are sleeping aids, but it isn't nearly as readily available. Women over 65 years of age are twice as likely to be prescribed sleep aids than are their male counterparts. These sleep aids are understood to cause quite a few falls and fractures among the seniors taking them, which costs Canada something like $2 billion a year. Anderssen notes that a forthcoming study projects that if even 20% of the seniors who fall can be kept from doing it - which cognitive behavioral therapy is shown to accomplish - that alone could save Canada "hundreds of millions".

So if the argument is that therapy is expensive, my response is, "Duh. You know what else is expensive? Treating all the things that arise because a patient didn't receive therapy."

Now, back to Batenburg and Das, who reported that two-thirds of their participants were women. In the section on Limitations and Future Research, they recognize this as a limitation. However, the 2:1 ratio of engagement is consistent with the figures cited by Anderssen about incidence of mental health in women as well as response to therapy treatment. They note that
"...It could be that gender has an effect on moderators of the psychological process, such as personality traits or coping strategies. For example, a meta-analysis focused on gender differences in coping showed that females cope by engaging in social relationships and they try to create change (in cognitive and actual terms) more frequently than men do. On the other hand, males rely more often on stress reduction activities or they tend to distract themselves (i.e., diversions)."
If cognitive reappraisal is the more effective means of support messaging, and if women respond more favorably to therapy, then it seems to me a no-brainer that mental health systems need to get past the obsolete idea of therapy being some kind of self-indulgence for those who can afford it. (On an entirely selfish note, my hope is that as we expand access to therapy, that I can get in on it myself.)

28 May 2015

Look! A Poll! →

I should have thought to write this post sooner, but I didn't. If you look to the right of this very sentence, Dear Reader, you'll see a poll atop the sidebar. I'm looking for feedback about the kind of content that you want to read here. I lost my self-confidence about writing last year, and while I've yet to restore it, I've accepted that you can't get out of a slump sitting on the bench. The only way out is to get out there and just keep swinging until you hit your way out of it. (Also, my doctor all but formally ordered me to return to writing and despite what she may think from time to time, I really am a compliant patient!)

Polling ends in just a few days, but you don't have to have an account or sign into anything in order to vote. Just click the boxes that cover your interests and that's all there is to it. Easy peasy.

12 May 2015

Crohn's Disease, Isolation, and Driftin'

My favorite Hank Williams song is "I'm So Lonesome I Could Cry". Not only are its lyrics rich and vivid and not only does Hank sound appropriately mournful, but there's a deftness to its title that I don't think is as fully appreciated as it ought to be. The song could very easily have been "I'm So Lonesome I Could Die". Same syllables, same rhyming sound. But if it had been "Die", the song would have felt hyperbolic, even if everything else in that recording remained exactly the same.

Admitting that you're so lonesome you could cry, though, conveys biting harshness. It doesn't even matter how prone to crying you may be; what matters is that you know where your breaking point is, and Hank is telling you he's just about there and it's because of how godawful lonesome he is. There's a duality to the song. Maybe we empathize with him, because we know what it would take to make us cry. Maybe, though, we feel he's the one empathizing with us, because he knows what it would take to make him cry, and here he is singing a song about it on our behalf. Does it matter? Not really. The point stands that it's the word choice of "Cry" rather than "Die" that gives the song its heft.

I've been fighting a Crohn's flare for five weeks now. After a few days of realizing it wasn't going to subside, I started a Prednisone taper, which typically does the trick. It brought a little relief on the first couple of days, when the dosage was strongest, but by the taper's end, they had become just a few more pills in my nightly regimen. Two weeks ago, I went in for IV treatment: steroids, antibiotic, anti-nausea medication, saline, and vitamins. I was thrown off at first because the physician who saw me wasn't my regular one, but at least she trusted that I knew my condition and didn't treat me like a WebMD-obsessed hypochondriac like a lot of doctors regard patients these days. I felt better that evening, though I was in and out of the bathroom until the next morning and I slept most of the next two days from exhaustion.

I'd been given a second Prednisone taper to begin after the IV treatment, hoping that the extra boost of the fluids would help the pills finish the job they couldn't on their own. Again, though, the Prednisone failed. I spent almost all day in bed on Sunday, alternately sleeping and writhing in pain. I returned to see my doctor in the morning. This time, we took images to see what was taking place inside me.


That's what I looked like on the inside, if you were to look right up (or is it down?) through me. At the top is a thing that looks like a snake's skeleton. That's my digestive tract. What we learned from that and a blood test is that a decade of Crohn's has essentially permanently damaged part of that area. This current flare isn't being caused by inflammation, which is why the steroids failed but the IV treatment that included an antibiotic brought me relief. We did another round of IV treatment this afternoon.

I sat there in a puffy chair in a room all by myself while my cocktail was delivered to me a drop at a time. I'd brought my iPod and played the Quantum of Solace soundtrack. Originally, I picked it because one of the few things for which I've had any enthusiasm at all of late has been Bond and I think I've only played that soundtrack maybe twice since I bought it.

Then again, though, maybe subconsciously I picked it because the last time I was hospitalized was in October, 2008 just a few weeks before Quantum opened here in the U.S.

I've avoided hospitalization throughout the intervening years largely through a combination of being vigilant about monitoring my condition and maintaining what I suspect most would regard as a low quality of life. I've contemplated myself just where I fall between "existing" and "living" on many occasions. There's a chicken-and-the-egg relationship between my physical and mental health, and I have a hard time sorting out which is responsible for a given funk like the one I've been in since late March/early April.

The last time I was hospitalized, I had my wife with me every step of the way. She was fiercely protective, and having worked in various capacities in the medical field over the years, she knew the language and protocols well enough to be my ambassador, my translator, and my guardian all in one. I could focus my energies on recuperating while she asked the questions I didn't know to ask, or the ones she knew I wanted to ask but was too miserable to put forth myself.

Sitting there today with IV fluids running into my left arm and James Bond music piped into my ears, it dawned on me how truly lonesome I felt. During one of my hospitalizations in 2008, I used up a great deal of energy fending off an aggressive gastroenterologist who wanted to start slicing and dicing on me and berated me for not being on Remicade. He ran a Remicade clinic, which he reiterated a few times. I never heard a physician concerned for my health speaking; I only heard a relentless salesman who had power over me. Ironically enough, it was the surgeon who agreed with me about my approach to give my treatment time to work before cutting into me.

Dr. Remicade also insisted my appendix needed to go while I was being cut on anyway, incidentally. A decade later, I still have it. If/when the time comes that I have it removed, I might ask if I can keep it. Take it to a taxidermist and get it turned into a trophy of some kind, maybe. I haven't thought it out yet.

If dealing with that guy was as exhausting for me as it was seven years ago when I had a devoted defender at my side, how can I possibly get through it on my own if it comes down to being hospitalized again?

It isn't that there's not another person in my life who cares about me or wouldn't try to be there for me. I've said for years that if I've only ever done one thing right in my entire life, it was surely to have surrounded myself with truly wonderful people. I have an enviable inner circle. It's not an exaggeration for me to say that I probably have more Friends than a lot of people even have Acquaintances. I've got so many Friends these days that it makes incredulous my insistence that I don't confer that title casually, but I really don't. Anyone I have designated a Friend has earned their stripes over the years.

But there's only so much that even a Friend can do when you're hospitalized.

They can check in on you, whether in person or remotely, of course. They can tell you they're thinking of you and they hope you get better soon, and of course they do. They can say that if you need anything, just to ask them, but there's no way to ask of them what you really need, because what you really need is to not be so lonesome you could cry.

That feeling can hit you at any time during a hospital stay. It can be when you first wake up and realize you're still there. It can be during breakfast when the patient in the next bed gets scrambled eggs and you get literally nothing because you're not allowed to eat or drink anything beyond the sip or two it takes to wash down your pills. It can be when you want to murder the scrambled-egg-eating patient next to you because he insists on watching Judge Judy as loudly as the TV will go...so that he can nod off and snore through it. It can be when the nurse comes in and you ask when someone will come by to tell you what the game plan is and they have no idea. It can be when you realize your hair is absolutely gross because of how long it's been since you showered.

It can also be when you start trying to outline the possible and probable courses that your health will take in the coming minutes, hours, and days. What if something goes wrong? What if it goes right but it just doesn't work? What if I'm in far worse shape than anyone realized? It gets uglier from there in a hurry.

The point is, that feeling of lonesomeness can - and does - strike at any time. Your Friends are on the outside, living through their hectic but scheduled daily lives. They're dashing to work in the morning, picking up kids in the afternoon, trying to attend meetings, practices, performances, tend to household errands, and even carve out an hour somewhere in all that for themselves to decompress. They can't be expected to burst into the room like the Kool-Aid Man just before you agree to a course of treatment that makes you squeamish because the physician has succeeded in wearing you down with his bullying. There's only a quantum of solace in knowing they would if they could.

I was asked earlier if surgery had been discussed with me at this point regarding my current flare. It scared the hell out of me.

I'd already recognized the possibility and even shared my anxiety over it with a few Friends, but somehow being asked about it pointblank spooked me even more. I'm not even ready to have someone ask me if surgery has been discussed. How would I go into it, if that's what it comes down to at the end of the week? (See: Three paragraphs up.)

Friday, 15 May, will mark the tenth anniversary of when I was told by an ER doctor that I "likely" had Crohn's disease. Being an ER doc, he wasn't allowed to diagnose it, but he was pretty sure and it turned out he was right. I'd been misdiagnosed with merely having GERD a year before that, and had suffered through symptoms for a year before even that, but I regard 15 May as my Crohnniversary.

I brainstormed months ago about "celebrating" (defying) the occasion by trying to get together as many Friends as possible to do something I enjoy that Crohn's has kept me from doing nearly as much as I would like. I settled on mini-golf. I truly love mini-golf, particularly at night. On a mid-May evening, it would still get dark early enough for the excitement of nighttime while still being warm enough to be comfortable.

I haven't formally canceled the outing, but it's almost certain that I'll have to. Even if this current antibiotic treatment works as hoped, these episodes are exhausting. If it doesn't work as hoped, I'll almost surely cry.

03 May 2015

On Self-Care; or, How Can I Help You?

Though the concept of self-care is not new, it's become increasingly commonly discussed through social media and blogs. It originated in the medical field as a term for identifying things that a patient can do to help manage their own care (a fairly self-evident definition, I should think). For instance, taking your medication as prescribed would be a simple and probably obvious act of self-care. Learning to identify triggers and developing healthy coping mechanisms is a more complicated, but also fairly obvious component.

Attack of the Crohn's

Three weeks ago, I began yet another Crohn's flare. I began a Prednisone taper, which tends to do the trick if I start it quickly enough. It failed, and by Wednesday last week, I realized I needed to go in for IV treatment (hydrating fluids, steroids, antibiotics, supplemental vitamins, and a partridge in a pear tree).

This wasn't the first time I've had to do that since my marital separation, but it certainly wasn't any easier, either. It's still scary, despite living with this stupid disease for just under a full ten years. Facing it alone reminded me how vulnerable I really am. Yes, it was self-care to recognize the warning signs of the flare and to begin treatment in a timely manner and to seek more treatment when that failed, but this self-care left me more demoralized even though it seems to have worked to stave off greater physical calamity.

Self-Care Is What, Now?

Self-care is something that's sort of evolved outside its clinical scope, and can be generalized as a "Treat Yourself" philosophy. I'm not here to pass judgment on the debate that has arisen from this expanded interpretation of the concept; that's not my place. But it is something that's on my mind right now so here we are.

I used to write about my experiences with depression regularly. Initially, I received strong, encouraging - and truly humbling - feedback. But then it seemed each post found a smaller audience than the last, and I realized all I was doing was adding to the world's white noise. I felt my series on depression had outlived its usefulness, and I largely got away from not just sharing those experiences, but blogging at all.

What Does Writing Have to Do with Self-Care?

One of the key things to managing my chronic depression is to feel useful. Sharing my experiences gave me that feeling, at least in the beginning. It bolstered my sense of self and it was something proactive I could do. Whether that meets the more stringent, clinical definition of self-care, I don't know, but I like to think it's a bit more substantive than "treating" myself to something that may make me feel like a proper human being instead of the stigmatized fugitive that I sometimes perceive myself as being, trying to keep myself going without drawing too much unwanted attention. I've been very fortunate to have been overlooked by the vicious trolls that seem obsessed with attacking mentally ill people's writings online, but at the same time I've also failed to really build any kind of audience that would let me know that what I've written has any value or merit.

So far, 2015 has been the worst year of either of my two lives (you may recall I regard my time as a patient at Our Lady of Peace as delineating my "first" and "second" lives). The first four months were endlessly brutal, not just to me personally but to just about everyone close to me. My family has been harangued by exhausting internal matters, including the passing of my grandfather in February and other things I won't go into publicly. Friends have been bombarded with everything from breakups to severe health issues, from job loss to the deaths of their loved ones. It's felt like everyone I know has been under siege for months, with no sign of relief in sight for any of us. That's exhausting and exasperating.

It also reinforces my sense that I'm useless.

What's All This "Useless" Business?

I haven't felt that I've made any meaningful difference for ages now; nothing that couldn't have easily been done by someone else if they'd just had the kind of time on their hands that I do when I'm not bedridden or trapped in a bathroom (which has been most of the last three weeks, not that that really matters). Well-meaning friends have cited examples of me being helpful to others, and while I don't deny that I've done those things, I also don't feel they justify my existence.

I've come to realize that I feel driven to redeem myself, though for what I can't say. Maybe Doc Holliday would speculate, "Being born". I've certainly held deep-seeded resentment about even existing since my youth. I can remember lying on the couch in our living room, inwardly seething at even being alive. I never shared those thoughts, because somehow I instinctively knew that rather than being understood or helped, I would at best be written off as "odd" but more likely chastised for not being sufficiently grateful about my life. As I've said on numerous occasions, though, depression doesn't have a damn thing to do with gratitude.

So What Kind of Self-Care Have You Practiced About Any of This, Hoss?

Recently, as I've tried to make myself engage with some of those closest to me about all this, including my remarkably patient physician, they've all come back to my writing. I became disillusioned with writing more than two years ago, which I think is evidenced by the noticeable decline in content published in this blog during that time. I tried starting to write a second novel at least twice, failing to gain any traction either time. I've become little more than a bench player over at Flickchart, where I've written next to nothing for nearly two years now.

Still, I have to concede that there for awhile, writing was a part of my self-care. It was a way to break through the isolation that depression creates around its prey, for one thing. It was also a way to use whatever aptitude for writing that I may have in a constructive, proactive way. I hoped I was helpful to others every now and again with something that I shared, whether to give them a new insight into what their loved one was facing or just to know someone else knew the view from where they stood. In short, writing was central to my self-care plan, and I got away from it.

I don't even feel useful to my loved ones - certainly not through writing, or anything else that I've been able to do for them here and there - much less have I felt useful to the world at large, which I know full well wouldn't miss me if I didn't wake up from my next nap. And if I'm being entirely honest, right now, I wouldn't miss much from this world if I didn't wake up from my next nap, either. Some people (don't make me name names; if you think you're one of them, you are). The cats. Doughnuts. My bed cocoon. I think that's about it.

Why Did I Just Read (skim) All of This? What Do You Want?

Firstly, let me say that I'm not sharing it because I want to read any comments about how "valuable" I am. I don't believe I have any value or worth, and I never have. I appreciate the effort you may want to make to get through to me, but trust me; your energies are better spent elsewhere.

As with previous sharing, on some level I guess I'm hoping those who may identify with where I am take something positive from it. Maybe just knowing that this happens to more people than just you might make it somehow less maddening for you, and if so, then I'm glad you found this piece, and I hope you find the peace that has been eluding me of late.

I do have something of a request, though, Dear Reader. I'm not recommitting to writing, as I still don't believe that what I write really matters, but what might be helpful for me is if I had an idea what you might find helpful. I've asked this before without much feedback, but I'm asking it again: If you could have me address something in writing, what would it be? It doesn't have to be about Crohn's disease or mental health. All I ask is that it be a subject - the more specific, the better - about which you genuinely would like to read if I addressed it in writing.