Depression Overlooked: Tips on Clint Eastwood Depression

Vickie, I recently gave a full day presentation at a local university, some of which involved this very subject, so a short answer will be insufficient simply because every one of these folks, children or adults, have quite complex presentations clinically. The days of superficial diagnosis, on mood swings alone, are rapidly passing, and the days of complex measurement of multiple other variables from endocrine to immune to neurotransmitter function are here. The relatively new terminology is Neuro-Endo-Immune evaluation - and every part does not need to be done right up front. The layers can be peeled away one test at a time as indicated. If the multiple possibilities are sitting there in the office I order a array of panels. Yesterday a woman came in with years of severe and unmanaged estrogen dominance [hormone symptoms relevant to psych issues], clear immune dysfunction [BM 1-2/wk since childhood] and obviously refractory response to psych meds for about 9 years including loosing her job and marriage due to exhaustion and depression that didn't respond to SSRI's - and to top it all off a completely unrecognized ADHD condition. Every psych problem intensifies in this context, and each is remarkably refractory to intervention based upon no neurotransmitters - see this CorePsych ADHD medication post for a similar story. At CorePsych we do evaluate children and adults with these multiple problems everyday, and would be happy to discuss by phone details if you wish by calling CorePsych Admin - Caitlin. Honestly, without intending to be self serving, very few have the vision for this entire comprehensive perspective. The closest I could come would be a good Defeat Autism Now Doctor. Best wishes - and BTW, I am not saying your child is 'autistic,' I am saying you do very likely need a more biologically comprehensive review, and DAN docs are deep into neurophysiology. cp

Dr. Parker, Thank you for all the great info and for writing the book on ADHD Meds. Lifesaving stuff in there. I am preparing to meet with a new primary care doc in January. As always I feel a lot of anxiety about this because I am not very good at giving doctors the succinct, orderly information they require in order to make decisions. I talk fast (mindful of the limited face time one gets with docs and because I am anxious), forget stuff, present info out of order, and get sidetracked easily. In other words I make a terrible first impression. To try to combat this problem I am working on writing a one page list of my concerns that I can just hand the doc when i arrive at their office. My feeling is that ADHD is my primary issue right now. Not being able to stay on track or focus properly increases my stress level greatly which in turn makes the ADHD seem to get worse. Add to that the feelings of frustration at myself for never seeming to be able to get anything done (or only one thing a day out of the 100 things I need to get done), the difficulty sleeping and the predictable work issues related to untreated ADHD and the result is not good. Prolonged stress is causing health problems. I feel extremely anxious, frustrated, and sometimes feel like I am spiraling downward into a whirlpool of failure from which there is no escape. To the doctor I look depressed. I even feel quite depressed sometimes....increasingly so However, antidepressants do not work well for me (I have tried about 8 or so). Bad side effects and sometimes they increase the feelings of frustration and irritability...in bad ways since I still have the impulsivity of ADHD. The only good thing any of them has done is that sometimes they helped regulate my sleep better. The problem is that all the doctors seem to get fixated on the stuff that sounds like depression and they just want to throw antidepressants at me and they seem to ignore what seems to Me to be the bigger problem...ADHD. Have mentioned neurotransmitter testing to them before but they don't seem to know anything about it or they just look at me with a blank stare like I just grew a second head or something. When the ADHD is properly treated I do not have these feelings of hopeless frustration and despair ....I do still have cognitive anxiety but it is way more tolerable. My questions - Is it possible that my problem with the feelings of hopelessness are not serotonin at all? Is it possible that feeling bummed out is the symptom and not the primary problem here? I am wondering if it is possible for a person to -feel- depressed and not -be- depressed (neurochemically)....and I feel that feeling depressed is a reasonable reaction when ones life circumstances are unpleasant and appear to not be entirely under ones own control. I realize I am possible delving into chicken vs egg territory............but am curious to know you think and what you have seen in your experience with seeing folks with untreated ADHD. How might I talk to my doctor about this in a more productive way so I have a better chance of them feeling I am trying to be informed and engaged . It feels like talking to doctors effectively is an even bigger challenge with ADHD than it is for most folks who do not have ADHD. My ADHD med history: I have not tried any of the new ADHD meds and most are not covered by insurance. I don't do well on stuff from methylphenidate family. Adderall (non-generic) works at lower doses between 10-30mg(IR) but has *horrible* effects at higher doses. Also there is a rough rebound effect that is dose dependent and gets worse with higher doses. Dextrostat works and does not have a rebound but IR is even shorter acting than Adderall. Have been wondering if I ever get back on ADHD meds if adding guanfacine would work with either of the last two as well as the literature seems to say it works with methylphenidates. I have not taken ADHD Rx for 2 years now. I am open to trying anything that seems like it might help......but not excited aboout trying any more antidepressants. thanks in advance for your time, Pam

Pam, Glad you like ADHD Medication Rules! Yours is a subtle series of nuance problems, and the longer I'm at this process of ADHD diagnosis and management the more I see how many suffer from these nuance problems- are not just straight up/simple presentations. The complexity is almost always there, but often unrecognized until too late with ADHD Meds. Your problems are likely associated with these several observations: 1. You have learned that precise titration is absolutely necessary based upon [especially in your presentation] likely metabolic challenges. 2. Your Narrow Therapeutic Window and titration problems are very likely downstream from a. insufficient neurotransmitters b. an immune system dysregulation contributing to the neurotransmitter decline c. highly likely bowel issues which I won't ask you about here - [do the Transit Time on the Testing Options Page] 3. Likely you do have some serotonin issues, but not possible to say with these cursory remarks. Depression and apathy often arises downstream from untreated ADHD, and may be purely secondary to ADHD - not a primary issue requiring its own special intervention. 4. Read the last chapter of the book for guidelines on doc talk... then customize your message for improved targets and titration. Your doc may appreciate my book if he is at all interested in ADHD treatment. Stay tuned in 2011 as I will be cranking up my videos to help folks like you get a better handle on what-to-do-with-meds and diagnosis. Happy Holidays, where ever you are! cp

Thanks Dr. Parker! In reading your comment about my narrow therapeutic window I went back and re-read the section in your book on the importance of breakfast. While I was taking ADHD meds ..and even now...breakfast has never been a regular part of my day. You are right that no breakfast plus stimulant meds equals no lunch also....I was quite guilty of that combo. I have started making sure to eat something (no poptarts!)with Protein in the mornings, even if I don't feel particularly hungry. It seems to be making a noticable difference already. It does seem that my immune system is under extreme duress at the moment...and has been for some time. My previous primary care doc told me that it was like my body is starting to fall apart from the chronic stress....that was right before they said my problems were too complex for them to deal with, gave me a 2 page list of doctors to try, and reminded me to pay the nice lady on my way out the door......it was a very demoralizing experience for me. I will follow up on your other suggestions and will definitely be taking along a copy of your book and white papers when I visit my new doctor (who hopefully will be less averse to working with complexity). thanks again and I hope you have a safe and wonderful holiday! Pam

Pam, Thanks for the update, glad you are having a positive response, and hope your next doc loves the details! cp

Melody, 1. The most frequently overlooked depression and often the most dangerous is the *cognitive, the Clint Eastwood, depression*... apathy, indifference, don't care, and avoidance. from the Stranger in High Plains Drifter - isolated and negative people are more likely to isolate further and kill themselves. Not just a male presentation, does not look depressed, does not feel depressed, but does not care. 2. The *affective depression* is more easily seen and traditionally evaluated - sadness, sullen, with all the usual depressive symptoms. 3. The other point I often raise is the asking of the suicide question, which can clearly intensify the acuity and dangerousness of the situation, and will change treatment patterns. So often people are asked the question from an implicit "would you do it?' perspective, to which the answer is an easy 'no.' e.g. "Are you sometimes suicidal?" On the contrary: I strongly recommend that we always ask that question from the purely cognitive vantage point, a perspective more easy to tease apart: "Even though you wouldn't do it, has the thought of harming yourself ever crossed your mind, even briefly?" Then we can follow with how often and when and do you have plans, have you had plans etc. This question is far less ambiguous, far more directed precisely to the essence of the diagnostic coding, and more useful for the next moments of intervention. Thanks for thinking further about these important matters, cp