Sad, grieving or depressed?
Sad, grieving, or depressed, that is the question. Everyone knows sadness, it has many sources. The frustration of not having what we want or being able to make significant progress toward achieving our dreams or follow through on plans generate sadness. Sadness is a normal reaction and somewhat of a sanctuary until we are ready to try again or change plans.

Grieving is about loss; usually most painfully about the loss of love or a loved one. Even small losses may result in the emotional pain known as grieving. Sadness and grieving respond well to therapy and are most likely to dissipate on their own overtime. These states are often diagnosed inaccurately as depression, they are not. Nor will they respond to antidepressants, because there is no significant chemical imbalance, for the antidepressant to address.

Depression is a whole different thing. Depression may eventually result from multiple underdressed grief and sadness issues that have rotted for so long they have become the homeostatic condition of the biochemistry of individual. In this case antidepressants and therapy are both appropriate. But that’s not the only kind of depression there is. Many people, usually the descendents of biochemically depressed individuals are born biochemically depressed individuals. All the therapy in the world will not do any good. If the person is fortunate they may find antidepressants or a combination of antidepressants that effectively lift their mood and allow them to operate on a whole different, non-depressed, level. These people could also benefit from significant therapy after the depression has lifted, but not until then. Why therapy after the depression has lifted? Because a person who is primarily depressed and has always been primarily depressed will be confronted with whole new ways of being in the world that would benefit from and be supported by a therapeutic relationship. This is the best way to prevent relapse. Rarely is a person who has been depressed for a significant amount of time, that is years or decades, in a financial position to maintain the medication and therapy necessary to stay well.

25 years ago, when I was being treated for depression, I had excellent insurance. I worked for the County of Santa Barbara psychiatric inpatient unit and had access to the best psychiatrist, the best resources. I had the privilege of being a patient of Dr. Joseph Johnson, who would on a weekly basis, spend an hour with me. At that time, that was the standard. I had the best medications and excellent therapy. Consequently, it was one of my most “well” periods. Then came managed care. Dr. Johnson was permitted 15 minutes per patient. He could no longer do psychotherapy; he could no longer even do a decent medication assessment. He went from being a very happy appearing person to being a very frustrated, border on angry appearing, person. Just before resigning from the clinic, he briefly expressed to me that he could no longer work under those conditions, that wasn’t fair to his patients. Nothing has been the same since managed care and as far as I can see none of it is good.

Recently in the New York Times there have been several articles on the inability of antidepressants to address mild and moderate depression. Some of that information is provided in the post just prior to this one. I will be commenting on that for the next couple days. I will say, at this time, the issue of depression has become much too simplistic. Saying “depression” is like saying “cancer”. There are hundreds if not thousands of types, severities and causes. In general, every successful treatment starts with an accurate diagnosis. Spare no cost in getting an accurate diagnosis, it is your life you are wasting if you don’t.

Now here’s the challenge, if I’m treated for a disorder someone needs to get paid. If there is going to be a payment through some type of insurance, there must be an ICD code, specifically a selection from ICD-9 codes 290-319: mental disorders, in the case of a mental illness. This code does not contain sadness or grieving, consequently, anyone who is sad or grieving will be given a depression or anxiety code. We are now comparing apples to oranges in any study and getting poor inaccurate results.
Let’s take a look at this on a very basic level. I’m running antidepressant trial. Included are 6 individuals who are really sad, 10 individuals who are grieving, and 15 individuals who are truly clinically depressed. Just to complicate matters, five of the 15 depressed individuals actually had a bipolar disorder, which is usually first diagnosed as depression. In short form, the result of my trial will be useless. The result of a meta-analysis based on a number of such trials will be just as useless. You begin to see why we have made such poor progress with the treatment of depression in the past 50 years.

I don’t remember much that would be pertinent prior to seven years old, but by the time I was seven my fingers were often bleeding because I had bitten fingernails so low. I lay in bed at night waiting for the sound of my father’s truck returning, from some bar. Then I got down on the floor next to the register to listen to the fight between my father and my mother, which happened often. I was waiting night after night. I was ready to save her, when my father tried to kill her. I felt afraid all the time. It became worse after my brother and I intervened when he was trying to choke her. That however was not the big problem for me at 7 or 8, I accepted that my father would kill my mother and he would be taken away. The big problem was I was sure that left me to take care of my brothers and sisters and I couldn’t figure out how I was going to do it. In fact, every night I went to sleep trying to figure out how I was going to take care of them and that thought cut a groove into my little brain.
The thing I most remember about grade school was looking out the window, watching the leaves turn, watching the leaves fall, observing the subtle shades of gray in the bark of sleeping trees disappear from awakening trees. I concentrated on how soon I could detect buds, and how many shades of green leaves progressed through as they moved toward summer. I lived for summer, when I could get out of school and escape it all.
The only problem anyone identified with me was my severe stuttering. The more anxiety I had the less I was able to talk. Consequently, I was assigned to be harassed weekly by a speech therapist. I made the requisite chart and reported my progress weekly until I graduated. My first therapeutic failure-my fault. My brother who was 16 months older than I was had much worse problems, which would later be identified as childhood schizophrenia. One of my sisters was two and half years younger than I am, had much more obvious problems, dyslexia and behavioral problems. With these challenges and four additional children, my quiet disassociation was welcome.
The only thing I’ve found to take some perverse pride in was my ability to do no homework and still pass tests, usually with very good grades. I have found that somehow, I am and have always been able to soak up huge amounts of information from whatever environment I’m in without consciously focusing on it. Having a very high IQ is one component of that however I’ve had several instances where it became obvious I’m able to acquire information from several sources simultaneously. I believe everyone can do this I’ve just developed it to a greater degree than most people, of necessity. It is a nice trick, it in no way makes up for some of the deficits associated with my psychic condition. I stood out only as an artist.
When I was 14 I started drinking alcohol. I quickly understood why my dad was so devoted to it. It was immediate relief from the horrible situations inside my head. I drank as much as I could for the next six years. It became more important than anything else-I drank until I nearly died. Right at that point, I got sent to the nation’s most noted alcohol rehabilitation program. It worked; I tossed my valium and quit drinking. (Do not try this at home!)
A soon as I quit drinking, however, my mental health problems became glaring! I regularly had panic attacks that lasted two and three hours at a time and spent day after day after day in bed, so depressed I could not or would not answer the telephone or the door. Occasionally I would wander into the kitchen to watch the dishes turning green in the sink. That activity was so exhausting I would have to go back to bed. There was really nothing I could do about it, the alcohol rehabilitation program, disallowed medications for my condition. The first few years, I tried and tried, working steps over and over, feeling like more of a failure every time it didn’t result in an obvious “spiritual awakening” or put me on “the road to happy destiny”. The answer to my complaints, according to the gods of the rehab. Program, was to “work with a newcomer”. I worked with a few dozen, some disappeared, and many stayed sober worked their steps and became happy and comfortable. Of course I could no longer relate to those who became happy and comfortable-so I would have to go find myself another newcomer. I churned through a couple dozen jobs. Killing myself became a frequent comforting thought. I wouldn’t tell anyone for fear of being locked up, like my aunt, my father and my older brother. That went on for seven or eight years, until I became imminently suicidal. At the time I was working as a psychiatric nurse in a maximum security state mental hospital.

More tomorrow-Now a bit about ADHD / ADD

A Missed or Wrong Diagnosis
An inaccurate diagnosis remains a common reason for a delayed diagnosis of ADHD and this problem usually results from incomplete diagnostic formulations. Often, depressed mood becomes the focus of treatment, usually to the exclusion of ADHD.[13] The phenomenon of patients with ADHD receiving a diagnosis of depression is both understandable and unfortunate. Patients with untreated ADHD become frustrated with their symptoms. They are angry at themselves and irritated by their pervasive procrastination and chronic disorganization. Their employers abhor their tardiness and after repeated episodes of overdrafting bank accounts or impulsive overspending, their spouses regard them as irresponsible. Psychiatrists may misinterpret this frustration as depression, and antidepressant medications may be prescribed reflexively. Of course, sometimes depression is present, along with ADHD, and the depression is identified while the ADHD remains undiagnosed.

Yet frustration is not always related to major depression, and if the individual’s issues primarily stem from ADHD rather than depression, then conventional antidepressant treatment will be ineffective.[5] Ideally, a failed trial of an adequate dose of antidepressants should alert the clinician to reexamine the underlying diagnosis; however, in standard practice, many clinicians move from 1 antidepressant to another, perhaps switching from a selective serotonin reuptake inhibitor to a selective norepinephrine reuptake inhibitor or adding bupropion or a low-dose atypical antipsychotic to the antidepressant. Unfortunately, the most commonly referenced study regarding strategies to address treatment-resistant depression does not emphasize the necessity of an accurate diagnosis.[14] In this algorithm, the use of stimulants in tandem with antidepressants receives little notice.[14]

Adults with ADHD may be misdiagnosed with bipolar disorder. Although mood lability is not part of the diagnostic criteria for ADHD, the reality is that patients with undiagnosed ADHD may overreact to simple stimuli and demonstrate mood inconsistency. This characteristic can be amplified in the treated state as well; mood swings may occur as the stimulant level wanes.[15] This end-of-dose effect might be misidentified as a bipolar disorder and inaccurate treatment can occur for years.

Atmaca and colleagues[16] describe a patient with mood swings that were initially diagnosed as bipolar disorder. The authors detail a 6-year history of multiple psychotropic treatment failures, including an unproductive psychiatric hospitalization. In the end, the patient consulted another psychiatrist, was diagnosed with ADHD, treated with stimulants, and dramatically improved.[16]

ADHD can mimic other conditions. Comprehensive screening of all patients who present in psychological distress necessitates an assessment for anxiety, depression, mania, substance use disorder, and also ADHD. Developing and then confirming a differential diagnosis reduces the likelihood of overlooking this highly prevalent and debilitating disorder, and treating a patient unproductively. Screening tools for ADHD can achieve this goal.[17]
Raw data from a recent, not yet published survey of adults treated for ADHD show that 59% reported a 2-week period of depressed mood. Nearly half of those surveyed reported panic attacks, and 60% endorsed generalized anxiety (Young JL, Saal J. A survey of outpatient adults with ADHD. 2009. Unpublished raw data).

ADHD is a disorder that originates in childhood and thus always predates the onset of anxiety and mood disorders. When these conditions do co-occur in adults, ADHD is often not identified.[18] Existing data on the treatment of comorbid conditions is limited; a study of young patients with both ADHD and generalized anxiety revealed that atomoxetine improved both symptom complexes.[19] Only a few trials have examined comorbid ADHD and depression but combining selective serotonin reuptake inhibitors and stimulants is a common practice.[20]

As I study, I will share interesting possibilities. These are NOT recommendations.

Rhodiola rosea

Rhodiola rosea (Golden Root)
Scientific classification ,Kingdom: Plantae, Division: Magnoliophyta, Class: Magnoliopsida
Order: Saxifragales, Family: Crassulaceae, Genus: Rhodiola, Species: R. rosea

Binomial name: Rhodiola rosea

Rhodiola rosea (Golden Root, Roseroot, Aaron’s Rod) is a plant in the Crassulaceae family that grows in cold regions of the world. These include much of the Arctic, the mountains of Central Asia, the Rocky Mountains, and mountainous parts of Europe, such as the Alps, Pyrenees, Carpathian Mountains, Scandinavia, Iceland, Great Britain and Ireland. The perennial plant grows in areas up to 2280 meters elevation. Several shoots grow from the same thick root. Shoots reaches 5 to 35 cm in height. Rhodiola rosea is dioecious – having separate female and male plants.
[edit] Uses
PlantRhodiola rosea may be effective for improving mood and alleviating depression. Pilot studies on human subjects[2][3][4] showed that it improves physical and mental performance, and may reduce fatigue.

Rhodiola rosea’s effects potentially are related to optimizing serotonin and dopamine levels due to monoamine oxidase inhibition and its influence on opioid peptides such as beta-endorphins, [5] although these specific neurochemical mechanisms have not been clearly documented with scientific studies.

Rhodiola is included among a class of plant derivatives called adaptogens which differ from chemical stimulants, such as nicotine, and do not have the same physiological effects.

In Russia and Scandinavia, Rhodiola rosea has been used for centuries to cope with the cold Siberian climate and stressful life.[citation needed] Such effects were provided with evidence in laboratory models of stress using the nematode C. elegans,[6] and in rats in which Rhodiola effectively prevented stress-induced changes in appetite, physical activity, weight gain and the estrus cycle.[7]

Rhodiola has been used in traditional Chinese medicine, where it is called hóng jǐng tiān (红景天).

[edit] Phytochemicals and potential health effects

Withering flowerRhodiola rosea contains a variety of compounds that may contribute to its effects,[8] including the class of rosavins which include rosavin, rosarin, and rosin. Several studies have suggested that the most active components are likely to be rhodioloside and tyrosol,[9] with other components being inactive when administered alone, but showing synergistic effects when a fixed combination of rhodioloside, rosavin, rosarin and rosin was used.[10] Also, the word Rosavin is a trademarked brand name for a particular brand of Rhodiola extract from Ameriden International, Inc.

Although rosavin, rosarin, rosin and salidroside (and sometimes p-tyrosol, rhodioniside, rhodiolin and rosiridin) are among suspected active ingredients of Rhodiola rosea, these compounds are mostly polyphenols for which no physiological effect in humans is proved to prevent or reduce risk of disease.[11]

Although these phytochemicals are typically mentioned as specific to Rhodiola extracts, there are many other constituent phenolic antioxidants, including proanthocyanidins, quercetin, gallic acid, chlorogenic acid and kaempferol.[12][13]

While animal tests have suggested a variety of beneficial effects for Rhodiola rosea extracts,[14] only for depression is there scientific evidence for Rhodiola components having anti-disease benefits in humans. A clinical trial showed significant effect for a Rhodiola extract in doses of 340–680 mg per day in male and female patients from 18 to 70 years old with mild to moderate depression.[15] Studies on whether Rhodiola improves physical performance have been inconclusive, with some studies showing some benefit,[16] while others show no significant difference.[17]
[edit] Dosage
Dried Rhodiola rosea rootRhodiola rosea extract is mainly used in the form of capsules or a tablet, though tinctures are also available. The capsules and tablets often contain 100 mg of a standardized amount of 3 percent rosavins and 0.8–1 percent salidroside because the naturally occurring ratio of these compounds in Rhodiola rosea root is approximately 3:1. Some companies believe that there are as many as 12 active biochemical compounds in the plant and do not subscribe to what they perceive as “artificial” standardization on only two of those compounds. One company (Verde Botanica) states that 28 compounds have been identified in Rhodiola rosea, and that their proprietary extract MBS-13® is standardized to 13 of these in chromatographic assays.

A typical dosage is one or two capsules or tablets daily; one in the morning and when taking two, one in the early afternoon. Rhodiola rosea should be taken early in the day because for some it can interfere with sleep. Others can take it in the evening with no effect on sleep patterns. If a user becomes overly activated, jittery or agitated then a smaller dose with very gradual increases may be needed. It is contraindicated in excited states.[citation needed]

The dose may be increased to 200 mg three times a day if needed. A high dose is considered to be daily intakes of 1,000 mg and above.[citation needed]

Rhodiola rosea may be beneficial to increase energy and mental performance for people suffering from Hashimoto’s disease.[citation needed]

In a 2007 clinical trial from Armenia, total effective doses were in the range of 340–680 mg per day for people aged 18 to 70. No side effects were demonstrated at these doses in the treatment of mild to moderate depression.[18]