Why Worry: 'I have been battling depression for years, but recently it has become worse'

I have one sibling and I am the youngest one. I was very much attached to my mother. The sudden death of my mother shattered the entire family and the most affected was me.

Slowly I transformed to a new child who doesn’t want to go out of the house, interact with anyone, etc.

My father was also in shock of the sudden death. My situation went unnoticed for several years. One of my teachers noticed me and she felt there is something wrong with me as I don’t interact with others, always absent minded, etc. She called up my father and said about the situation and advised him to take me to a psychiatrist.

My father couldn’t accept it and even he didn’t want to see me as a mental patient. I come from a small town and going to a psychiatrist is like a very big thing. My father didn’t want to see people being looking at me like a mental patient. So he tried to cover it up. Gradually the situation got worse and I started to drop out from my classes.

Psychotherapy sessions

My teacher gave me a contact of a psychologist and I went and saw him without informing anyone. He did some psychotherapy sessions and the same time he advised me to see a psychiatrist and he gave me a referral letter to the psychiatrist. The medicines given to me by the doctor transformed my life.

I really became the person I was before, excelled in my education. I took the medication for almost two years. I moved to the UAE in 2010 for work.

Until 2017 everything was fine but then I started going back to the same old depressed state. I consulted many psychiatrists in and around UAE, however whatever medicines they gave me didn’t improve my situation.

The psychiatrists have tried almost all medications that they can but that gave me only 20 per cent improvement. They tried various combination of anti-depressants, but nothing seems to improve my situation. One German psychiatrist even did various brain scan, doppler test, EEG, ECG and whatever he can but nothing helped. I am unable to spend time with my kids and wife. I am extremely tired all the time. If someone asked my son where is your father, his answer will be he is always sleeping.

Even if I sleep 24 hours a day still I’m sleepy. My kids always complain that I don’t take them out, my wife complains I don’t show love towards her. I have lots of love in my heart towards everyone but I am unable to express it. I don’t even like talking to them. I don’t want to get out of my house. I go out only for my work and when it comes Thursday my hearts starts pounding as the kids and wife wants to go out, I too wish the same but I have no energy at all for anything.

Recently my doctor added a new medication, after that I started to gain weight tremendously. I consulted an internal medicine doctor and he did a thorough check up and found out that I have high BP, high cholesterol, sugar level on the borderline and fatty liver. He prescribed medicines for me for that along with that he prescribed for me for the pain (I had severe knee pain ).

A surprising thing happened when I started taking the painkiller. Not only was the pain relieved and at the same time I started feeling good, I started spending time with my wife and kids, played with them.

I told my psychiatrist about this medicine which was given to me for pain, which had helped very much on depression. However he said he will not be able to prescribe me that medicine as the purpose of that medicine is to treat pain.

Now, I am in a state where most of the anti-depressants aren’t working on me.

I feel jealous when I see other parents taking their kids to park, playing with them, I wish to do the same but I can’t. Those who are suffering from depression understand that well.

Hoping tomorrow will be a better day.

Wish to stay anonymous.

Question answered by Dr. Sreekumar V. Nair, Specialist Psychiatrist, NMC Specialty Hospital in Dubai

Dear Friend,

Thanks for the detailed description of your problems and concerns.

Depression is a very common illness, which affects our mind and body. In fact, it is so common that Seligman (1973) said that depression is the "common cold" of psychiatry.

You have mentioned about the sudden and unexpected demise of your mother, which led to the severe depression. You have also mentioned how your father and others close to you failed to recognize it and even reject it when it was brought to their notice. This is quite understandable given the awareness the society has about anything to do with mind. The stigma is even held by people who are learned and educated.

Even today, though the awareness is better, there is a lot of misinformation regarding mental illness and its treatment. There is a need for spreading authentic information regarding the illness and the treatment. There should also be restraint on misinformation.

Causes of depression

Biological, psychological and social factors play a role in the causation of depression.

Sigmund Freud, while accepting that biological factors could be a reason for depression, believed that loss of or neglect by a parent could lead to depression.

I am not going into a detailed description of depression since you are well aware of the symptoms and how it feels.

Your depression, 22 years back was as a result of prolonged or complicated grief. The irreplaceable loss led to the profound grief. This was taken as normal by others as they two were experiencing similar emotions, and hence was not addressed in an appropriate way. Another factor was that at 15-years of age, you were old enough to understand the meaning of the loss, but probably not mature enough to handle it.

Loss of a loved one is one of the most distressing experiences. Someone who is expressing a normal grief has a period of sorrow, numbness, emotionally charged thoughts about the loved one, feelings of anger and guilt, etc. But these gradually ease and one is able to accept the loss and detach the emotions attached to it, and move forward.

For some people the feelings of loss are disabling, painful and severe and does not improve with time. This is called complicated grief.

During the first few months the symptoms of normal and complicated grief could be the same. While normal grief gradually improve, complicated grief worsens.

Management of complicated grief needs the support from your significant others and sometimes from a professional trained in handling this. One has to learn about normal grief, complicated grief and how it is managed. Explore ways of adjusting to the loss and redefining life goals.

Analyze the thoughts and gradually learn to detach the negative emotions attached to it. Engage in social activities. Gradually focus back on one's regular routine activities.

In your case though there was significant disruption in your studies and life, one positive things is that someone actually recognized your problems and guided you to undergo the right treatment. It's better late than never, isn’t it?

And as you have mentioned, with the right treatment you regained your real self and did well in your life thereafter.

Biological, psychological and social factors

Now, it is not clear from your description as to when the treatment was started. But it is very clear that you were completely well for many years.

As I had mentioned before, biological, psychological and social factors play a role in causation of depression.

What you had at the age of 15 years is a reactive depression, in reaction to the loss.

What you had in 2017 is probably biological or endogenous depression, where an external triggering factor may not be evident.

You were probably always vulnerable to get depression or you might have become vulnerable after the first episode.

The symptoms and problems described by you show that you had severe depression.

You have mentioned that many medications were tried and none were helpful.

Usually, the medication, which was effective in the previous treatment is tried first. Hope it was tried in your case too, but failed. Yes, this is possible. One of the reasons could be, as I mentioned before, this time there was stronger biological causes for the depression. Many medications have been tried and many tests have been done. Hope the thyroid function, vitamin D, etc., were checked and found to be normal?

You have mentioned that one particular painkiller given for your knee pain cured your depression also.

This brings us to the area of biology of depression, of which the last word is yet to be said.

It was in the 1950s, that the first clinically useful antidepressant was available. From there on the understanding of the biological mechanisms behind depression grew manifold.

The main focus was on the role of neurochemicals called monoamines (serotonin, norepinephrine, dopamine etc). It was found that medications that improve the presence of these chemicals in the brain, relieved the symptoms of depression. This led to the synthesis of effective and much safer medicines for depression.

But it was found that still there were a significant number of people who did not get relief from these medicines.

So search for other possible mechanism continued and still continues.

An important one, among others, is the opioid system in the brain, (opioids are morphine like substances either naturally present in the body or artificially made).

In fact "Tincture opii" was used, as early as 1930, to treat depression. But the results were modest.

Research has led to the current understanding that dysregulation of the endogenous opioid system could also contribute the causation of depression and influence its progress, in many patients.

I have put this in a very simplistic way, but the real interplay between these and other mechanisms are complex.

Let's come to the main concern you have experienced.

The painkiller you took belong to the opioid group. It has significant analgesic effect. In your case the involvement of the endogenous opioid system could be the reason why your depressive symptoms also improved an opioid.

Incidentally, your medicine also increases the presence of serotonin and norepinephrine like other antidepressants. Norepinephrine also helps in pain control.

Misuse of opioids

Though at normal doses this medicine does not have high potential for addiction, it is not approved for treatment of depression, and is still being misused extensively. In fact it has a wide therapeutic range.

It is well established that psychological stress due to social separation/loss, disruption or betrayal of pre-existent significant interpersonal bond is mediated by activation of the ‘separation – distress’ system. It is also known that this kind of stress can be soothed very effectively by very low doses of endogenous or exogenous opioid.

Studies have shown that misuse of opioids leads to depression.

It is also true that depressed persons using opioids are more likely to get addicted to the substance.

Current studies have tried a combination of opioids, similar to those used in treatment of opioid addiction, for the treatment of depression. One drug in the combination negates the addictive potential of the first thereby making it safer.

The nasal spray you have mentioned is a medication which is not an opioid.

It is not completely clear as to how it helps in depression. But it does have an effect on the opioid system.

And FDA has approved it for use in depression in March 2019.

There are certain side-effects that one need to be aware of, though they are transient, such as the psychotomimetic effects like, feeling weird, hallucinations, dissociating into another state of mind, etc. Other effects like increased BP, blurred vision, dizziness, headache, etc. can also occur.

This medications also has potential for abuse and addiction.

About your concern about availability of these medication for genuine patients.

We know that some substances, even recreational drugs, have been used for medication purposes in some places. Some places allow over the counter sales too. But there is ample evidence that there can have serious adverse effects. So it is questionable if such use should be allowed.

So, the law regarding use of these medication differ from place to place.

The rules are put in place after considering many aspects including the socio - cultural aspects.

The medications you have mentioned have not been approved for treatment of depression here. Even in other places, the opioids are not approved. But as I have mentioned trials are on. No long-term effects have been studied. It is better to wait for robust trials and experience before adopting any type of treatment.

So, these treatments will be available once the competent authorities are convinced about its safety and efficacy.

Meanwhile, you should review your treatment done till now and see if all options have been exhausted. There is a protocol for treatment resistant depression. You can discuss with a psychiatrist and plan the treatment.

Now, one thing to remember is that medicines are just one part of treatment of depression.

Through the therapies we achieve quite a bit. We analyze and try to resolve past and present unresolved psychological stress. We analyze our thoughts, the consequent behavior, how and where the thoughts deviated from the normal and became dysfunctional, how to bring it back to the normal and cope with the situation appropriately, etc.

Hence it enables us to look at life with a different perspective. So, psychotherapy helps to resolve issues and teaches to cope with issues in a more appropriate way. A trained Clinical Psychologist would be able to help you in this regard.

Let’s also hope more medication options are available soon and bring relief to many more who have not responded adequately to current treatment options.

If you have questions that you would like answered by a mental health professional in the UAE, please write in to readers@gulfnews.com. Also, please let us know if you'd rather stay anonymous.

Disclaimer: This blog is a conversation and is not an alternative for treatment. The recommendations and suggestions offered by our panel of doctors are their own and Gulf News will not take any responsibility for the advice they provide.