This is a story about being objective...
If you want to compare two measurements you have to use the same yardstick. If you are comparing two subjective things then how can you possibly draw any concrete conclusions?
At times, I have kept a mood diary. I rate my mood from 1 for worst to 10 for best. Who's to say that if I rate myself as "1" during prolonged depression that's comparable to "1" on a bad day when otherwise I've been feeling mostly normal?
During a lengthy period of depression, where nothing seems to hold any pleasure or enjoyment: subjectively, life is terrible. I also have periods when I'm generally in a much better mood, but something really shitty will happen. The shitty thing might feel like the end of the world at the time, but I'm not going to kill myself over it: I'll quickly get over it and move on with my life... so can it really be a "1" even if it feels like it at the time?
If your mood slowly improves or declines, over the course of several weeks or months, can you spot the trend? If you're suffering a lengthy depression, does your yardstick change? You might have a day where you just feel normal, but now you rate that 10, because it's the best you've felt in as long as you can remember.
Do you even remember how you used to feel, before you got depressed?
This might be why I have a tendency to invite hypomania, because at least it's clearly some kind of polar opposite from depression, even if I don't exactly feel "happy".
Defining "happy" has started to get really hard.
Going in search of happiness has been a disappointing experience. Anhedonia means the loss of pleasure and enjoyment of things that you used to get a kick out of. Finding that you no longer love the things you've always loved to do, is terrifying, because it's further confirmation of the way that you feel: "everything is shit".
I ended up completely rebasing my whole idea about what made a happy day:
- "Got to work only an hour late"
- "Didn't quit my job"
- "Only drank one bottle of wine instead of two"
- "Survived another week without being sacked"
- "Got out of bed at the weekend before it went dark"
- "Went to the shops"
I know that I must be unwell, because I used to have happy days that were more like this:
- "Cooked a healthy dinner"
- "Went for a walk or a bike ride"
- "Took some cool photographs"
- "Went to an event"
- "Made a new friend"
- "Did some work I'm proud of"
Now, I could do those things, but I don't feel like it. Often when I try to force myself to do things, I get very stressed about it and I find it really exhausting. When I get home I feel wiped out and that I shouldn't have bothered. I find myself out taking a walk and nothing takes my interest enough to photograph it. That's weird. I used to live behind the lens.
So, I started to bring in more objective measurements: movement data, alcohol consumption, number of social engagements, number of words written.
When I analyse the data, I think the most reliable predictors of my subjective feelings of depression, are movement and alcohol. Looking at last year, I was averaging 12,000 steps a day, and although I had alcohol binges, my average consumption was reasonably low. This year, I'm averaging 7,000 steps a day and drinking excessively nearly every day.
Now, you might think "walk more, drink less" would be the solution, but this assumes a causal relationship. Perhaps I was more in the mood to walk more and drink less, last year. Perhaps the relationship is the other way around and my poor lifestyle 'choices' are actually due to depression.
We often tell people to eat healthier and exercise more, to improve their mood, but perhaps it's the people who have a happier mood who are the ones more likely to eat right and be active. In actual fact, healthy eating and being more energetic could be a good predictor of happier people.
The cause-effect relationship is not always clear. Psychologists had published a paper that appeared to show that smiling made you feel happier. However, when the experiments were repeated, the results could not be reproduced. If you can't reproduce the results of your experiment, it's not good science.
A friend made the following amusing observation:
"People who are dying of dehydration can't just mime drinking water to quench their thirst"
I think this hits the nail on the head perfectly. While depressed people can eat healthier and go to the gym, they're just going through the motions. They're not getting the benefits that their happy counterparts are getting, and in fact it could be pure torture for them.
There's an experiment where a pigeon is fed at a computer-controlled random interval. What the researchers found was that whatever the pigeons were doing the first time they got fed, they then decided they needed to do again, in order to get fed. Let's say the pigeon was cocking its head to the side when the food was released, the pigeon will then start repeatedly cocking its head, and believe that it is causing the food to be released, when in fact it's completely random. Essentially, the pigeons had become superstitious.
It seems relatively random - unpredictable - when a depression is going to lift. Let's say you were trying acupuncture or homeopathy at the time when your mood started to improve: you might assume a causal relationship between the alternative treatment and the lifting of your depression.
Even a double-blind placebo trial is not exactly fair. Psychiatric medications do make you feel noticeably different. I would be able to tell whether I was taking an inert placebo pill, or something psychoactive. I would know whether I was in the control group or not. Placebos don't work if you know you're taking a placebo, so this could explain some of the mood improvements seen with antidepressants. The antidepressant might look effective, when compared with the control group, but it's the placebo effect.
Antidepressant clinical trials generally only take place over 6 to 12 weeks. Many common antidepressants take 6 weeks before their effects can even be felt. There is no focus on long-term outcomes in these trials, only that the medication should perform better than placebo.
Many trials of longer duration have shown that being unmedicated might be more effective in the long-term, than taking antidepressants. Pharmaceutical companies are not concerned with long-term outcomes. In order for a medication to be sold to the public, it merely has to be safe and proven to be marginally better than placebo.
You would have thought that taking antidepressants would be a lot better than not taking them, right? In actual fact, there might only be a 15% chance of you feeling better, but there's a 15% chance of unpleasant side effects. The very process of going to your doctor, being listened to by somebody nonjudgemental, and then feeling something even if it's not actually better, might convince you that you're improving, when actually your depression could be lifting quite naturally anyway.
Culturally, we have developed a strong superstitious belief in the power of medicine. We believe there's a pill for every ill. We believe that a man in a white coat can wave a magic wand and we'll be cured of any ailment; discomfort.
You only have to go into any pharmacy during the winter, to see signs that say "we have no medication to treat your common cold". The fact that doctors and pharmacists have to tell people not to waste their time with an incurable virus that has unpleasant but non-life-threatening symptoms, shows how strongly we believe in the power of medical science to save us from even a runny nose.
There is a clear difference between "feeling a bit sad" and depression. Depression is life-threatening. Depression has a massive impact on people's quality of life. However, we are often medicalising a non-medical problem.
If somebody who's feeling down visits their doctor and receives some medication that's basically a placebo that makes them feel a bit different - drugged - then their pseudo-depression will lift, because it was going to anyway. The non-judgemental medical consultation will also have marginally assisted.
However, those who have prolonged severe depression - to the point of suicidal thoughts - may find that their quality of life is actually reduced by medication, because it gives no real mood improvement, but it does have unpleasant side effects. The longer-term studies seem to back this up.
Through extensive research, I found a number of medications that are very rarely prescribed, but have been used for treatment-resistent depression. These medications are dopaminergic not serotonergic.
There are a whole raft of medications used to treat Parkinson's disease, that have been shown to exhibit antidepressant effects and can successfully treat patients who had previously been treatment-resistent.
In the most severe cases of depression, deep-brain stimulation has been employed with remarkable efficacy. Deep-brain stimulation had previously only been used on patients suffering from Parkinson's disease, to stop their tremors.
The idea of having electrodes implanted into my brain does not sound immensely appealing. Rats who have had electrodes implanted in their lateral hypothalamus will starve themselves to death, in order to press a lever thousands of times an hour, to stimulate their brains. Do humans who have had the same procedure, just stay at home hitting the button as often as they can? We have wandered into the territory of the neurological basis for addiction.
This is how I arrived at my decision to use a medication that helps people to quit smoking.
My very first addiction was to nicotine. I had no choice in the matter. My parents forced me to breathe their second-hand smoke. Because I was a tiny child, the concentration of nicotine in my bloodstream would have been very high. Second-hand smoke was responsible for inflicting an addiction onto me in my infancy.
In the UK, nightclubs, bars and pubs used to be filled with smoke, until July 2007. My addiction was therefore maintained through passive smoking. The timing of the ban seems to correspond with my first episodes of depression.
The stop-smoking drug called Zyban is actually France's most popular antidepressant. The French have found that Bupropion - the active ingredient in Zyban - is also effective for treating alcoholism. The link between addiction and depression seems clear.
I have a theory that my brain is in mourning. I was subjected to second-hand smoke throughout my childhood, and I spent a lot of time in smoky clubs and pubs. Nicotine withdrawal was something I was used to experiencing again and again, but what I'd never been through was a prolonged period of withdrawal, because I would regularly get a hit of second-hand smoke. It wasn't until the age of 27 that I was finally able to escape nicotine, because of the smoking ban, even though I have never smoked in my life. You would expect that such a prolonged addiction would produce a profound psychological effect, when my brain realised it was never getting any nicotine ever again.
I then experienced a later period of addiction. Although there were periods of abstinence, these never exceeded 3 or 4 months, and the total amount of time that I struggled with addiction is close to 5 years. The addiction was extreme. The drugs I was using have a much more profound effect than cigarettes. Still today, after 6 months of total abstinence, I get shaky sweaty hands and feel sick with anticipation at even the merest thought that I might be able to obtain some drugs.
Although Bupropion is a poor substitute for the addiction I once had, it does at least slightly soothe the aching sense of loss... the mourning.
Thinking about this more now, it seems obvious that I should mourn the loss of the love of my life. My addiction was so obsessive, overwhelming, all-consuming. How on earth can you let something like that go, with just a 28-day detox, or a 13-week rehab, if it's been a huge part of your life for years?
It should be noted that my mental health problems, which predated my addiction, compound the problems. To give an official name to my ailment: it's called dual-diagnosis. That is to say, Bipolar II & substance abuse. Yes, substance abuse is a kind of mental illness. Take a look at the kind of self-harm that addicts are inflicting and tell me that's normal behaviour. That is why substance abuse is classified as a disease.
Bipolar II is a motherfucker, because it comprises both clinical depression and hypomania, which are both destructive. Therefore, I'm actually suffering with triple-diagnosis and trying to fix 3 illnesses... although the hypomania is something that most people with Bipolar II wouldn't give up, and substance abuse is hard to stop because of addiction.
I haven't had a hypomanic episode in almost a year, and I've been abstinent from drugs of abuse for 6 months, therefore the final nut to crack is this damn depression, which might turn out to simply be the fact that - subconsciously - I'm depressed that I can't take drugs anymore. It feels like the love of my life has died, hence why I'm describing it as mourning.
How long it will last, I have no idea, and I've lost patience... hence resorting to a mild form of substitute prescribing. I successfully beat addiction once before using Bupropion. I beat it using progressively weaker drugs, until I was weaned from my addiction.
You wouldn't ask a smoker to quit without nicotine patches. Why would you expect somebody with an addiction to harder drugs could quit with willpower alone? The only slightly unusual thing is that the stop-smoking drug seems to be just as effective for addictions to things other than nicotine.
Perhaps we will one day treat all addictions as compassionately as we treat nicotine addictions. Certainly, there doesn't seem to be a lot of appliance of science, when it comes to treating addiction to anything other than smoking.
Subjectively, cold-turkey & willpower is a fucking awful approach to beating addiction. We have the scientific data to show that smokers are 4 times as likely to successfully quit, with nicotine replacement therapy and smoking cessation medications like Zyban.
Of course, a relapse would be disastrous, but haven't I already relapsed back into depression?
I've been on medication for 5 days now, and Bupropion should start to be effective within a week, so perhaps I will feel an improvement in my mood any day now. Certainly, my suicidal thoughts seem to have stopped, but that could be psychosomatic and also because my horrible contract ended.
You see what I mean about how hard it is to control the variables? Human lives are messy and complex. It takes vast quantities of data to be gathered over many years, not a 6 to 12 week trial with 30 people.
Also, there's an argument to say that your subjective yardstick is altered by your experiences. Your perfect 10 can become unattainable, except through the use of powerful narcotics. Does that also mean that the best you can ever hope to feel is mildly depressed, now that the bar has been set so high? My only hope is that my brain "resets" itself over time. The brain can downregulate parts that are overactive, in order to maintain equilibrium, so it can also upregulate... eventually. The big concern is neurotoxicity: have I irreversibly "burnt out" the reward centres of my brain?
6 months isn't long though. I'm going to see what happens if I can make it to a year. Presumably, there might be marginal improvements that have happened already, but are too subtle for me to perceive. The data actually bodes well: instead of spiking back up into hypomania, things have plateaued during the last couple of months.
This unethical self-experimentation doesn't yield any results worth publishing but it does give clues as to what could be worth researching. A sample size of one is not statistically significant, but it's important to me, because my life depends on it.
Tags: #bipolar #depression #mentalhealth #addiction
