ACADEMY PUBLIC POLICIES

9.1 Seasonal affective disorder (SAD)

Someone told me about a condition called SAD. How does this affect you?

SAD stands for seasonal affective disorder – mood disorder related to the seasons of the year. Some people do describe feeling particularly low during the dark winter months. Of course, good weather cheers everybody up, and bad weather can make one gloomy, but for a few people seasonal climate changes do appear to trigger off real symptoms of depression. It seems to relate to shorter daylight hours. It seems that these people are particularly sensitive to the stimulating effects of sunlight.

How common is it?

One study of 443 Aberdeen nurses found that 3% had SAD, and about 10% had a milder form of SAD. Twice as many women suffer from it as men, and it seems to start in people in their 30s.

How is it different from ordinary depression?

 Answer: People still get typical depressive symptoms of feeling low, irritable and having a lack of energy. However, rather than loss of appetite and weight, and early morning waking, people with SAD may sleep more heavily than usual, eat more and put on weight – almost as if they’re going into hibernation – and of course they describe a clearcut seasonal variation.

How can I tell if I’ve got it?

 The term is applied if you have had 3 or more episodes of mood disorder within the same 90-day period of the year, for 3 or more consecutive years. There will also be a pattern of improvement, and remission, within another 90-day period of the year. These are the strict research criteria for the illness. However, many people who have a tendency to be depressed might show their own particular pattern of relapse. The winter and early spring are often difficult, but some can become ill in the summer or autumn. Other factors then come into play – it may be the anniversary of bereavement, or the breakdown of a marriage, for instance.

9.2 Chronic fatigue syndrome

I think I’ve got ME. My doctor says it doesn’t exist and that I have chronic fatigue. What is the difference?

 ME is an abbreviation for myalgic encephalomyelitis. This is not a widely accepted term, since there is no real scientific evidence that there is an isolated illness process involving muscles and the brain that accounts for the symptoms of fatigue. The great difficulty with using the label ME is that there is an expectation that rest, and more rest, is the treatment of choice. This has been challenged. What is perhaps more helpful, is to say that there are a significant number of people who become chronically fatigued – or tired all the time. In some people this follows a clearly defined viral infection. Their fatigue can be incapacitating and very debilitating. Because there are no diagnostic tests for chronic fatigue, it does not mean that it is imaginary. It is a very real illness with very real and serious consequences. There do seem to be links with stress. If you had the viral illness and were stressed at that time, you are more likely to have developed postviral fatigue, than someone who was not stressed. Also, there is an increased risk of chronic fatigue developing if there was an uncertainty about what caused the original illness. People who can be given a clear diagnosis from the outset of their viral illness are much less likely to develop chronic fatigue.

Can chronic fatigue be treated?

Very definitely it can. One of the main problems, however, is that, if you feel very weak and vulnerable, you may not feel able to cooperate with the treatment. The fatigue will need to be consistently and gently challenged.

Treatment will include a system of graded exercise (gradually increasing physical activity). There should be a new routine about times to get up in the mornings and to go to bed at night, and a schedule for taking naps. It is often helpful to keep a diary of activity achieved, and feelings. This might well show a connection between daily stress and levels of fatigue.

Finally, if mood is low (and it often is), or there is excessive anxiety present, it could be very helpful to take an antidepressant. Any medication taken is normally started at a very low dose and increased slowly depending on progress. People with chronic fatigue are perhaps more likely to experience side-effects from medication – hence the slow start.

This package of treatment can be reasonably expected to produce significant improvement in at least two-thirds of sufferers. Treatments advocating very long periods of rest and special diets are very unlikely to produce good results and may indeed be positively harmful.

 Can dental fillings or diet cause chronic fatigue?

No. There is no good evidence that dental fillings, or diet (particularly yeast in the diet), cause fatigue. There is also no good evidence that candida (a yeast infection) causes chronic fatigue, although this is often suggested by alternative therapy practitioners.

People who have chronic fatigue are often desperate for help and very vulnerable. They will ‘try anything’ in an attempt to feel better. Generally speaking, the more extreme the treatment (and sometimes the more expensive) the less it is likely to help.

9.3 Dementia

Grandad is 69, and he’s becoming increasingly forgetful and slow. He left the gas on the other day and got lost when he went shopping. He doesn’t seem his usual self at all. Would antidepressants help him?

Probably not. Failing memory in the elderly, together with reduced functioning – such as poor personal hygiene or loss of social ability – is more likely to indicate the onset of dementia.

The commonest causes are poor circulation within the brain (causing mini-strokes), or Alzheimer’s disease, a condition which damages brain tissue itself. It is not part of normal ageing, although it is normal for older people’s memories to gently become weaker as time goes by; 10% of over 65-year-olds, and 20% of over 80-year-olds have this illness. Relatives are often the first to recognise that someone is suffering from dementia. The following features can all become evident as part of this condition:

• Increased forgetfulness

• Poor judgement

• Coarsening of the personality

• Irritability

• Loss of interest in usual hobbies and social activities

• Getting in a muddle when away from usual routine

• Not recognising people

• Difficulty in expressing oneself.

People may have little insight, and not realise that they are becoming less able in this way.

When a person – or more likely a relative – comes with these concerns, a physical examination is needed to exclude any treatable reason why they may not be functioning well.

Thyroid disease, severe anaemia, kidney failure, vitamin deficiency, tumours, certain infectious diseases, or the side-effects of other medication are among the possible causes of deteriorating mental functioning in older people that we can do something about.

Severe depression can also present in this way. People with dementia place great pressures on their carers. Sadly, these conditions are likely to be progressive, and it is important that carers receive support from both Health and Social Services.

Home helps, day care, meals on wheels, laundry services, the Attendance Allowance and other benefits, can all help to support those living at home. People who are more severely ill may need residential placements. Support groups can be a great help to carers.

9.4 Alcoholism

 Perhaps no medical topic arouses more confusion, dismay, and passion in both the public and the medical profession than alcoholism. Although alcohol is often associated with joy and celebration, ritual, and reverence, alcoholism is associated with sorrow and moral failing, disease, and death. No other disease entity can be conceived as having such extreme attributes.

This is particularly evident in United States since its inception, where attitudes toward alcohol consumption have swung back and forth from liberal use to strict prohibition.

The debates that stirred the American Revolution occurred more often in taverns than churches. Witness the most recent popular movie Sideways, in which wine brought out the best and worst of two friends, arousing aesthetic appreciation, love, passion, anger, and betrayal, but ultimately humor. Wine was never blamed, and sales of pinot noir increased dramatically.

Contrast that movie with an earlier one, Leaving Las Vegas, that also garnered critical acclaim but with less popular appeal. It portrayed a man who was inevitably successful in drinking himself to death. At one extreme, alcohol represented bacchanalian reverence, and at the other, it represented a living hell.

We currently live in a culture that has little tolerance for risk; thus, drugs such as Vioxx and Ephedra are banned from the market because of their perceived dangers. This perception of risk is based on emotion, however, not on fact.

Society’s decision to ban certain substances while allowing others to be freely available has little to do with the dangers inherent in any particular substance, and it has more to do with the emotional out cry that a particular substance engenders. For example, consider the seemingly benign over-the-counter medication acetaminophen, or Tylenol.

Tylenol was first introduced in 1956. About 150 acetaminophen-related deaths are reported every year in the United States alone. Add to that the associated morbidity and mortality from those requiring liver transplants from Tylenol overdoses, and the numbers become even greater. Contrast that with Ephedra, a once hugely popular drug for weight loss and bodybuilding that has been linked to a grand total of 155 deaths.

The deaths from Vioxx are more difficult to calculate because these deaths are primarily from patients already suffering from cardiovascular disease and not from the direct effects of the drug itself. The estimates suggest up to 34,000 deaths since its introduction in 1999.

The outrage leading to its removal had more to do with the company’s refusal to acknowledge the risks than the risks themselves. Alcohol, however, is responsible for approximately 85,000 deaths annually from injuries or diseases directly related to the use or abuse of alcohol. Thus, people often judge the risks and benefits of a particular substance based more on cultural, religious, and moral beliefs than on scientific fact. Alcohol is a prime example.

Alcohol is the single most unique intoxicant because it is a legal, nonprescription, and culturally sanctioned substance that causes more devastating effects to human lives than any other known drug, whether available by prescription or over the counter or on the street. Prohibition, the one attempt in American history to prohibit alcohol use, was a miserable failure, with the cure being worse than the illness. Although it successfully cut the deaths from cirrhosis in half, it came at the cost of increased crime and social unrest.

Ingesting anything—medicine, an illegal drug, or even food—is an act that entails a degree of risk. Therefore, people should understand the risks and the alternatives before ingesting anything. Informed con- sent is both a legal and an ethical responsibility of health care providers to ensure that their patients are knowledgeable about the drugs they are ingesting, including over-the-counter medications, herbal remedies, street drugs, food, and alcohol.

We live in a time when there is a belief that scientific facts will ultimately help in legislating morality. The culture wars, whether they are fighting over health care, the environment, or other social issues, muster their troops of “scientific experts” when calling on the “facts” to forge political, legal, and moral policy. This is no more evident than the “war on drugs,” in which both sides argue persuasively for the need to continue or abandon current policies.

Although the institution of medicine has accepted the concept of alcoholism as a disease, the larger culture with its personal values and beliefs, which includes health care providers themselves, continues to debate the issue, with many still viewing alcoholism as a moral failing.

The controversial perspective about alcoholism is discussed: Is it a disease or a moral failing? Hopefully a path may be developed in order to find the way out of this no-man’s land, where emotions, rather than reason, have left a field littered with the broken lives of those who this horrible affliction has devastated.

 Is depression part of recovery from alcoholism?

 There is a question about teenagers and alcohol.

Abuse of alcohol and other substances, such as street drugs, is associated with depression, because of their effect on neurotransmitter levels. It is not unusual for a temporary depression to occur during substance abuse or after withdrawal. It is sometimes difficult to say which came first: the depression or the drink, but these depressive episodes are often self-limited. If this sort of depression does not resolve within 4–6 weeks, antidepressant medication may well be necessary. Anyone who has been drinking heavily will have noticed adverse effects on their mood. Mood and well-being continue to improve for several months after abstinence.

Coming back into the real world can be very difficult for people who are overcoming alcohol or drug problems. They need to put new ways of coping with life’s stresses into place. Some organisations provide group support, and maybe one-to-one help from other people who have ‘been there and done that’ themselves.

This includes ways that others have found to get by, tactics and strategies for surviving. When your mood is low and brittle, small problems – an unexpectedly large electricity bill or just a funny look from a colleague – can become quite large difficulties to overcome.

Of those who fail to stop drinking, many simply have not got coping mechanisms in place to deal with day-to-day problem. They fall back on their favourite remedy, the one that always works for a while – and relapse.

My dad gets very low and drinks a lot. He is also very depressed. Are the two things linked?

 They could well be. A considerable number of people use alcohol to try and feel better when they are depressed. They can sometimes go on to develop an alcohol dependence problem. Alcohol will make a depressed person feel better fleetingly. However, alcohol is a mood-altering drug – for every period of relaxation, there will be some rebound anxiety.

Secondly, alcohol is a very powerful depressor of mood. Alcohol misuse is a potent cause of depressive illness. People who are depressed should attempt to cut down their alcohol intake to very modest levels. This in itself may well help the mood considerably.

  What can I do to help someone who gets low and drinks too much?

Try not to be judgmental. They are likely to be feeling very bad about what is happening. Point out the low mood may be there because of the drinking, so encourage them to cut down. People are often reluctant to admit that they are drinking too much. Your family doctor would also be very willing to discuss this.

Al-Anon is a very helpful organisation in United Kingdom and other countries for relatives/loved ones or people who are abusing alcohol. They give clear guidance about how to help and, equally important, what not to do. There is a tendency to take over the responsibility from the person who is drinking, or ‘facilitate’ the drinking.

I can’t get to sleep without a large drink. Does that really matter?

 Yes it does. A small measure of alcohol can help you drop off to sleep, but if you have large drinks, you will disturb your sleep rhythm. You will sleep well initially (you are anaesthetised), but will wake later, then quite frequently. A restless night follows when the alcohol effect wears off.

Alcohol dampens down REM sleep (rapid eye movement sleep). This is much needed and, if curtailed, will result in unrefreshing sleep.

 How much alcohol is too much?

  The Health Departments suggests a weekly healthy limit of 14 units for women and 21 for men. This is because women metabolise alcohol less effectively and risk very serious physical consequences of alcoholism. Cirrhosis in women, for example, tends to occur after a lower overall intake of alcohol than in men.

A unit is half a pint of ordinary beer in England, or a pub measure of wine or a single shot of spirits. It’s good advice to have alcohol-free days too. Enjoy alcohol as a treat not as a habit. Have it as a blessing, not as a curse. Never use alcohol as a drug.

9.5 . Drug abuse

My grandson is 16 and has become very moody. I know he smokes cannabis. He just sits in his room all the time, and doesn’t seem to want to go out with friends. Is smoking cannabis harmful to him? Isn’t it addictive?

Teenagers do often go through the most awful moody phases. Another thing that teenagers tend to do is experiment with whatever they come across, particularly if it is likely to be the subject of parental disaproval. Although pretty hair-raising forparents, this is a natural part of growing up, and is an important part of the process of finding one’s own limits. We poor old parents just have to try to indicate what’s safe and what isn’t, be reasonably consistent, perhaps under provocation that would try the patience of a saint, and ‘be there for them’.

In the scale of awful things that teenagers can get up to, smoking cannabis is certainly less harmful than making yourself violently sick with too much vodka, certainly much less harmful than sniffing glue or taking stimulant drugs such as Ecstasy, and nowhere near as dangerous as playing around with the very addictive hard drugs such as heroin, which are now horribly cheap.

However, despite the recent changes in its legal status, it can still get you into trouble or excluded from school. There is na argument that someone who sells you cannabis may also sell you something worse if you have the money.

Anything carried to excess can cause problems, and some people seem more vulnerable to getting into trouble with this sort of thing than others. Contrary to popular belief, cannabis can be addictive – some people do become very heavy cannabis smokers. They may demonstrate mild but definite features of addiction, such as tolerance, craving and withdrawal symptoms.  Because cannabis has a very long half-life (that’s the time it stays

in the blood stream), withdrawal symptoms may occur over a period of weeks in a mild form (rather than severely over a few hours, as happens with people who become addicted to alcohol). Occasionally, cannabis can be associated with a psychotic illness. It is not a harmless drug, but a potent mind-altering substance.

Sometimes it becomes apparent that unhappy or depressed teenagers are medicating themselves with street drugs of one form or another. They may be using drink or drugs to blot out difficult moods, horrid thoughts or bad feelings. Someone who doesn’t socialise much may indeed be quietly becoming depressed.

Someone who seems to be using drink or drugs heavily and is becoming a recluse, losing touch with their friends and interests is potentially in a very serious situation. Drawing them out of their shells can be pretty difficult. Perhaps the best way to start is by showing that you recognise that there is somethingwrong, and you realise that they are unhappy, by talking to them about it. Grannies can be very good at this.

I’m 19 and I do think I get depressed sometimes. Loads of my friends take ‘E’(Ecstasy) in the clubs. I feel much more cheerful and lively when I do. Why shouldn’t I?

Many people do take Ecstasy and it’s certainly often used in clubs as part of the dance culture, but there are casualties – both physical ones, because of its effects on the heart (remember Leah Betts and others?) and the brain. It is a stimulant drug, and is related to amphetamines. Amphetamines were given to exhausted pilots in the last war to keep them awake while flying, and were also used as an appetite suppressant in the 1950s and 1960s. Known as ‘Purple Hearts’, amphetamines became widely used as street drugs because of their stimulant effects (see the film Quadrophrenia for a Picture of their use).

They mimic the effects of adrenaline release. This is the chemical that is released in the body in response to stress: the ‘fight or flight’ response. This raises your pulse, breathing rate, blood pressure, alertness, and dilates your pupils, but the amphetamine family of drugs are stimulants, not – repeat not – antidepressants. It is possible to feel agitated and depressed at the same time – an unpleasant experience. This group of drugs can merely make you feel more agitated, not happier.

The other downside of this group of drugs is that they are physically addictive. They can also lead, when used heavily, to really unpleasant paranoid feelings, even to a psychotic breakdown, a loss of contact with reality. They are dangerous in the setting of normal mood too. The effects can be unpredictable and sometimes catastrophic. They are best totally avoided.

P.S. They’re illegal too – getting arrested is really bad for you!

 9.6 Schizophrenia

Can depression turn into schizophrenia? My daughter was very depressed as a teenager, then had a serious breakdown in her 20s. The psychiatrist says she has a form of schizophrenia.

Depression does not turn into schizophrenia. They are separate illnesses, but they can coexist. However, schizophrenia can sometimes announce itself with a depressive episode.

There can be a general feeling of unease and change, educational performance can fall off, and mood become very low and apathetic. Some months later, a much clearer picture may emerge, with signs of a schizophrenic illness.

The situation can be more complex again. Young adults can develop a schizoaffective disorder. This means an illness in which there are changes in mood (up, down, or mixed), plus some schizophrenic features – perhaps hearing voices, or feeling controlled. This illness is usually brisk in onset and there are clear stresses leading up to it – perhaps the breakdown of a relationship.

The schizoaffective disorder almost always has a clear beginning and end, and it does not linger. Once over the episode, the person can look back on the illness and see it for what it was.

My son’s personality just seems to have changed. He’s lost his job, doesn’t bother with his friends, and neglects himself. He seems bothered, sluggish and depressed. He won’t talk to us about it. Could he be suffering from depression?

He certainly needs a medical assessment to see what the matter is. Someone whose personality changes so greatly could be at the beginning of a psychotic illness. This is likely to be something more serious than just depression.

Schizophrenia is a psychotic illness involving loss of contact with reality. About 1% of the population suffers from it. Featuresinclude hallucinations, usually hearing voices and, rarely, seeing visions. People tend to lose their drive and interest in others, and become emotionally flat. Some may experience paranoid ideas, feeling that there is some conspiracy against them.

Schizophrenia is fairly evenly spread throughout the world: some areas, such as northern Sweden and the south-west of Ireland, have more people affected. There is now evidence that prompt treatment improves the outlook for people with schizophrenia.

Early treatment with modern medication has transformed the lives of people with this long-term illness. Seeing a relative develop and try to cope with this sort of illness is a huge stress for a family. One mother said, ‘It was a relief when at least we knew what it was.’