Q & A – Mood & Relationship Disorders?

James E. DelGenio LCPC

Mood, Depression and Relationship Disorders, Common Questions 

The following is a list of commonly asked questions and answers. I believe this will give the reader an overview of mood disorders and common marital and premarital issues associated with mood disorders. Please review them carefully; I also recommend that these questions be reviewed periodically.

1. What is a mood disorder?
A Mood disorder is a generic term for people experiencing mild to severe depressive disorders, bipolar disorders, situational depression, grief, panic and anxiety disorders, phobias, personality disorders and other disorders which may include alcohol or drug abuse or dependence. (Brown, Wang and Safran, 2005)
Clinical depression and bipolar disorders have become more commonly accepted by society generally and thanks, in part, to high profile actors and professional athletes who have disclosed their disorders to the public. Clinical depression and bipolar disorders are biological/genetic problems that you most likely inherited and are considered no different than the diagnosis of other medical conditions such as diabetes or epilepsy. These require education, medication, and ongoing treatment.

It is also important to note that not all mood disorders are lifelong or require medication.

For the purposes of definition here, I use two very different definitions to describe severe mood disorders. The first reflects denial of a problem and the second reflects acceptance of what is. Which one will you choose? The first definition is as follows:

Various forms clinical depression and bipolar disorders are lifelong disabilities, episodic in nature that may cause chronic dysfunction, asocial behavior, and failed relationships.
Here is a breakdown of this definition:

• Lifelong means there is no cure to date, though new medications, if taken as prescribed, have made many people symptom free.

• Episodic means that sometimes the symptoms are worse than at other times for no apparent reason though stressful life events can also have an impact on symptoms.

• Chronic Dysfunction includes inability to manage day-to-day events, unemployment, and often failed relationships.

• Asocial Behavior is that behavior which is irrational, inappropriate showing poor judgment and a lack of insight into one’s own behavior. This can include poor self-care and appearance. It may also include behavior that is harmful to one’s self or others.

• Failed Relationships include social dysfunction, isolation, withdrawal, marital and family conflict and divorce.

The second definition is as follows:

Clinical depression or bipolar disorder are lifelong disabilities, episodic in nature that the individual can learn to manage with medication, education and a skilled therapist. Other mood disorders may require a skilled therapist for ongoing support but may or may not require medication.

In some instances, denial will create failed marriages and conflictual relationships. These two definitions are separated only by education, psychiatric treatment and ongoing therapeutic support. The key here is management of a disability. You manage it or it will manage you! How do you want to live your life?

2. Why shouldn’t you drink alcohol if you are not an alcoholic?
Where mood disorders are concerned, use may very well be the same as abuse! Alcohol impairs functioning and it affects thinking, behavior, and relationships. Alcohol and substances such as marijuana and cocaine also affect thinking and behavior. Don’t do anything that would make you relapse to active symptoms. It is known fact that alcohol and substance abuse make the symptoms of a mood disorder worse and vice versa. Alcohol is a depressant; one drink at a family gathering may affect one’s mood for days.

Alcohol also “washes out” and therefore may negate the usefulness of the medication. Remember, it takes four to six weeks to get the medication to a therapeutic level. When you drink heavily you affect that level. In addition, one should never use alcohol or substances when taking prescription medication. This can be fatal. It is understood that if you are an alcoholic you can’t have any alcohol. If you are not an alcoholic, you still need to check with your Doctor for approval of one or two drinks on very special occasions. In the days after, monitor yourself to see if it has affected your mood. If it does, use is the same as abuse!

3. Why is a mood disorders and alcoholism often found in the same individual?
The answers here are not completely understood. Some doctors have told me that the sites in the brain that are affected by mood disorders are the same sites affected by addiction. Regardless of the chemistry, research has shown that just casual use of alcohol by a person with a mood disorder may eventually result in abuse or dependence. If you have a severe mood disorder, you shouldn’t have any! The consequences are just not worth it.

4. What is dual diagnosis?
Dual Diagnosis means that two or more independent disorders exist in the same individual. Specifically, for our purposes, when I speak of dual diagnosis, I am referring to mood disorder and alcohol dependence or addiction. Each exists independently of one another and yet each makes the other worse. Both are biological and psychosocial disorders with similar symptoms. They are lifelong disorders, which cause the person to be prone to relapse. Both require integrated treatment that includes psychiatric treatment, medication, psychotherapy, education, symptom management and additional supportive treatment such as Intensive outpatient (IOP), group therapy and Alcoholics Anonymous.

5. What is addiction?
An Addictive Disorder is the preoccupation with acquiring alcohol and/or drugs, compulsive use of alcohol and drugs despite adverse consequences and a pattern of relapse to alcohol and drug use despite the recurrence of adverse consequences (Miller, 1991).

6. What are the symptoms of a mood disorder?
Clinical depression and bipolar disorders are biological disorders that can usually be traced through family history whether it was formally diagnosed or undiagnosed. Check the symptoms under A and B with a check mark. If you have four or more related symptoms, discuss these symptoms with your psychiatrist or therapist.

A. Symptoms of depression, anxiety, panic, grief, loss and situational depression
__ Lack of pleasure, loss of interest and energy.
__ Lack of goal directed behavior.
__ Lack of motivation, lethargy.
__ Inability to structure time, poor concentration.
__ Anger, hostility, irritability, resentment.
__ Strained relationships, marital issues, divorce, loss of friends.
__ Withdrawal, isolation, would rather be alone.
__ Difficulty in coping with the past or stuck in the past.
__ Sleeping too much or too little.
__ Anxiety, worry, sadness, low mood, tearful.
__ Paranoia or false beliefs, negative thinking, rumination.
__ Feeling guilty, stressed or hopeless.
__ Poor self-care including hygiene and diet.
__ Aches, pains, dizziness, headaches, or stomach aches.
__ Unintentional weight loss, gain.
__ Crisis prone, police involvement.
__ Low sex drive.
__ Thoughts of suicide, homicide.

B. What are the symptoms of a Bipolar Disorder?
Bipolar Disorder formerly known as manic depressive disorder is a mood disorder in which people may have mixed episodes of mania and depression. These symptoms may also include some of the above and in addition;
__ Rapid mood fluctuations.
__ Feeling high, euphoric or having inflated self-esteem.
__ Irritability, hostility, anger.
__ Aggressive or risky behavior.
__ Pressured, fast speech, more talkative than usual.
__ Racing thoughts, skidding from subject to subject.
__ Delusions of grandeur, grandiose beliefs or behavior.
__ Poor judgment, lack of insight, false beliefs.
__ Poor self-control.
__ Little or no need for sleep.
__ Increased activity, sexual drive and impulsivity including spending.
__ Easily distracted, poor concentration, short term memory issues.
__ Alcohol and substance abuse.
__ Bizarre dress and appearance.
__ Thoughts of suicide, homicide.

The above symptoms of depression and bipolar mood disorders are widely accepted. Since these disorders have a biological basis; a psychiatrist manages the medication while the therapist provides treatment and support. The therapist support often includes psycho-education, symptom reduction and management, increased coping skills and management of other day to day stressors such as job loss, school failure and relationship issues. The psychiatrist, therapist, family, friends and of course, the patient must work together as a team to construct an effective approach to these disorders. The most important aspect of this is good communication.

There are two types of bipolar disorders. They are Bipolar I and Bipolar II. Bipolar I is considered the more severe of the two disorders and has more extreme episodes of mania or depression. It may also have psychotic features such as delusions and paranoia. This generally includes being out of touch with reality. Bipolar II is characterized by milder swings of mania and depression and may have less serious effect on daily routine, relationships, or employment. Both bipolar I and bipolar II need ongoing treatment and medication to manage the symptoms well.

7. What are the symptoms of addiction?

Many of the symptoms of addiction and mood disorder are the same. Seventy to 90% of people with dependency issues also have a mood disorder. A person has to be drug free for one year in order to see if the mood issues are still present. The term dry drunk refers to a person who is drug and alcohol free but the mood issues remain. Common symptoms include:
Depression
Panic
Anxiety
Irritability
Thought disorders, delusions, psychosis
Mania
Restlessness
Confusion
Drowsiness, Insomnia
Slurred Speech
Memory Loss
Tremor
Diarrhea, Constipation
Cold sweats
Dilated pupils, tearing
Itching, hives
Skin flushing

8. How do these disorders interact with one another?
Mood disorders and alcohol and substance abuse do not interact well. In fact, each makes the other worse, especially when one is using and/or not taking medication as prescribed. One must manage both disorders simultaneously and treatment must be a collaborative effort with the level and the array of services necessary to maintain stability, sobriety, and consistency.

9. Can a mood disorder be compared to a physical illness?
It is helpful to think of someone you know who is diabetic and what it means to be a diabetic. Mood disorders may not be as visible as sitting in a wheelchair, but you do have a disability. Mood Disorders, addiction and diabetes are comparable in many ways. Each is a lifelong, biological problem that requires daily attention, education, and support.

Medication, when taken as prescribed, stabilize each condition but knowledge and training play a very important role in healthy functioning. The comparisons demonstrate that mental illness, like other physical handicaps, can become manageable handicaps; not the global disability it is for some. It is a result of genetics, an imbalance in the chemistry of the brain. No one is at fault and no one is to blame. Mental illness is a lifelong disability, episodic in nature that one can learn to manage, with hope and with dignity.

10. How does a mood disorder affect thinking and behavior?
The symptoms of mood disorder and addiction are very similar. In fact, the treatment is also similar. Once medically detoxified, a person with mood disorder may be prescribed the same medications as in the treatment of substance abuse. It often takes a year or more of sobriety to determine if the person is suffering the effects of addiction or mood disorder or both as in dual diagnosis. You may have heard of the term dry drunk. This refers to someone who is alcohol free but has not addressed the accompanying mood disorder. This includes irritability, hostility and relationship issues and conflict.

11. What should you report to your Psychiatrist?
The Doctor needs your honest input to best help you. If any of the following are problematic, report them to the doctor. Write things down. (See Doctor reporting form in the appendix)
Report on:
1. Medication compliance.
2. Changes in your symptoms including:
a. Sleep patterns
b. Low mood or manic behavior
c. Concentration, poor short-term memory
d. Disturbing thoughts, nightmares
e. Negative thoughts, rumination
3. Drug and alcohol use.
4. Medication side effects or allergic reactions.
5. Social activity or isolation.
6. Self-care.
7. Physical activities, hobbies, chores.
8. Poor money management.
9. Unusual behavior.
10. Thoughts of self-harm or threats to others.

12. Will you have to be in treatment the rest of your life?
I would like to say no but many remain on medication their entire life. Therapeutic support may or may not be necessary after a time, depending on how well one learns to manage their disability. I have clients who see me a few times per year just to check in and reinforce their self-management. Some people with severe mood disorders may go in and out of the hospital their entire life if they remain in denial. This is usually a result of non-compliance with treatment and medication combined with alcohol and/or substance abuse. I try to point out that though you are not sitting in a wheelchair; it is not as visually obvious a disability but if you have a mood disorder you do have a disability. Mood disorders and addiction can be global disabilities or manageable handicaps. Medication and ongoing supportive treatment may be essential for maintaining healthy functioning.

13. Why is medication compliance so important?
The number one cause of regression and recurrence of symptoms is not taking medication as prescribed. This is not like having a headache. When you have an ordinary headache, you take two aspirin and twenty minutes later your headache is gone. For antidepressant medications to work effectively, one must maintain a certain level in the body. When that level in not maintained, debilitating symptoms reappear. These medications take four to six weeks to reach their peak level of effectiveness. When you miss doses of medication you negatively affect that level.

14. How do you cope with the past?
Many people with mood disorders have difficulty coping with the past. Sometimes they appear to be living in the past, unable to get over some stressful life event. This needs to be explored with a doctor and therapist. This is a clear sign of depression and medication will most likely be necessary. When one dwells on the past, they often have difficulty coping with the present. I like the adage, yesterday is done; worry about today and tomorrow will take care of itself.

15. Why are recreation, exercise, and socialization so important?
It is good to have fun. Have fun! People with mood disorders often become engrossed in the past, their illness, and problems. Recreation and exercise (especially walking) are good for depression and anxiety and are a great distraction when one is experiencing symptoms. Any physical activity is likely to be therapeutic. Distraction from symptoms is an important coping skill. The tendency to isolate and withdraw also need to be overcome. The Internet, video games, TV or reading generally do not qualify as distraction for most individuals.

16. What if you don’t feel motivated to do the things suggested here?
Lack of motivation is often a direct result of a mood disorder. It is a symptom. If you wait to feel motivated, it may never happen. Walk 40 minutes per day at least 3-4 days per week with your doctor’s permission. Pick your days and let the day of the week make the decision for you. This will help to avoid, “I don’t feel like it today; I’ll do it tomorrow.” Unfortunately, tomorrow never comes. Do your chores and exercise on the days you have picked to do them. Try to have at least one social activity per week. Plan to have fun. Adding structure to your life addresses many common symptoms of a mood disorder but especially lack of motivation.

17. What are relapse warning signs aka positive symptoms?
Relapse warning signs are also known as positive symptoms. They are positive because they are present, active and uncontrolled by medication. These symptoms are typically a result of medication noncompliance or alcohol and drug use. Without intervention, these symptoms can have serious impact on thinking, judgment and behavior and may also include: psychiatric hospitalization, danger of self-injury and harm to significant others or the community.
Relapse Warning Signs reflect symptoms that include:
1. Thoughts about hurting oneself or others.
2. Changes in one’s sleep/wake cycle, especially little or no sleep.
3. Inability to concentrate, rapid speech, skidding from subject to subject.
4. Rapid mood fluctuations, mania, or depression, especially negative rumination i.e. negative thoughts that repeat over and over again.
5. Hallucinations or delusions.

18. What are the negative symptoms of a mood disorder?
Negative symptoms are traits most often missing in the individual. They are characterized by the absence of:
1. Motivation or goal directed behavior.
2. Pleasure.
3. Insight.
4. Good judgment.
5. Self-care, hygiene.
6. Emotional expression.

These symptoms are only partially controlled by medications. They are often what are left when positive active symptoms are controlled. It is for this reason that a person with a mood disorder still needs guided experiential psychotherapy.

19. What are the most common causes of relapse and regression to symptoms?
1. Medication noncompliance.
2. Alcohol and/or substance use or abuse.
3. Little or no sleep.
4. Social isolation.
5. Family conflict.

20. When should you call your doctor, 911 or go to the hospital?
Call your doctor or pharmacist if you are experiencing medication side effects or an allergic reaction. When you are thinking of hurting yourself or someone else, call your doctor and therapist. If you are actively considering hurting yourself call 911, go to the emergency room, or call the National Suicide Prevention Helpline, 1-800-SUICIDE (1-800-784-2433).

21. What do you do if you can’t sleep at night?
Little or no sleep is a relapse warning sign. Mood disorders cause sleep/wake cycle problems. First stop drinking caffeinated beverages or eating food that contains caffeine. Don’t nap during the day. Take your medication as prescribed. Maintain abstinence from alcohol and substance abuse. Maintain a consistent sleep-wake cycle. Always discuss your sleep issues with your doctor. Insomnia can be a precipitating event for relapse to active symptoms and possibly self-harm or harm to others. In this event, call 911 and/or your doctor.

22. What is the role of the family in treatment?
The role of the family in treatment is simply to monitor and report. The family should observe the patient’s behavior and report anything that may be important to the stable functioning and health of the patient. The patient should not be interfered with directly unless, of course, s/he is a danger to themselves or others. The family’s role in treatment is a collaborative effort in communication. The family should think of themselves as team members. We are all on the same team! Keeping secrets from the doctor or therapist interferes with treatment and may ultimately have serious consequences. Families should call their doctor, therapist immediately or 911 if the patient has any of the following behaviors or symptoms, especially if they are new, worse, or worry you. Call when the patient is:
1. Not taking their medication as prescribed.
2. Abusing alcohol, substances or uses medications not prescribed by a doctor.
3. Severely depressed, irritable, threatens violence or expresses thoughts of suicide or dying.
4. Exhibits behavior which may result in injury or harm to the individual, family, or community.
5. Experience of any relapse warning signs, especially no sleep.
6. Experience of panic attacks, uncontrolled anxiety, or restlessness.
7. Acting on dangerous impulses.
8. Exhibits unusual behavior that is out-of-character for this individual.

In most cases I have treated over the years, I have seen the client get annoyed with friends and family when they say, “You seem crabby, did you take your medication today?” The typical response is “just because I’m angry or upset doesn’t mean I’ve skipped my meds.” The way I see it, if you have a history of noncompliance, you don’t have the right to be angry when asked! Take the medication as prescribed so your family doesn’t worry about compliance or need to be intrusive in your life. They should be relatively assured that you are compliant with medication and treatment. Regardless, it is the responsibility of the family to ask because the consequences of not taking it as prescribed can lead to regression to symptoms, self-injury, or harm to others.

23. What can family members do to minimize the risk of relapse?
The following are frequent causes of family conflict and should be discussed with the doctor and therapist.
1. Monitor and report on medication compliance.
2. Monitor and report on the use of alcohol and drugs.
3. Avoid critical comments. Use “I feel” statements.
4. Avoid over involvement, enabling, unless the person poses a danger to himself or others.
5. Avoid excessive pressure to achieve.
6. Avoid trying to help motivate compliance.

24. How can family members learn to cope?
Mental illness is no one’s fault. It is a bio-psycho-social problem.
1. Avoid placing blame or guilt.
2. Don’t enable! You are not responsible for the patient’s wellness. S/he is!
3. Make regular opportunities to get away from each other. Have outside interests, hobbies, and social activities.
4. Get regular cardiovascular exercise. Join a health club or walk at least 40 minutes on regularly scheduled days each week. In the winter, use a treadmill or stationary bicycle.
5. Learn all you can about mood disorders but do not try to be a therapist.

25. Who is responsible for your happiness?
Who owns the problem? Don’t blame others for your disorder or problems. We have to play the hand that had been dealt us via genetics. That does not necessarily mean that relationship conflicts are not real or are just imagined but they can be exacerbated by the disorder and may need to be addressed in couples counseling or family therapy. Remember, a mood disorder is a biological problem like diabetes. If you don’t manage it, it will manage you.

26. What are the goals of treatment?
The goals of treatment of mood disorders are typically as follows:
1. Be evaluated by a professional to identify if a disorder is present.
2. Have a psychiatrist identify the need for medication, if any
3. Learn about the disorder and to recognize active of symptoms of the disorder.
4. Learn symptom management.
5. Learn coping skills, especially distraction through structure. Structure is created by having regularly schedule of activities, hobbies, and social support.
a. Encourage regular socialization.
b. Encourage regular cardiovascular exercise at least 4 times per week. (Take a brisk walk at least 40 minutes.)
c. Encourage hobbies and attention to daily chores.
6. Be consistent in the use of coping skills.
7. Learn to identify regressive symptoms, i.e., relapse warning signs and triggers.
8. Learn how to make healthy choices.
9. Learn how to be well.

Medical
1. Take medication as prescribed.
2. Report the presence of symptoms, suicidal or homicidal thoughts.
3. Maintain abstinence from alcohol and substance abuse.
4. Avoid caffeinated beverages, especially if sleep is poor.
5. Maintain a healthy diet and daily living skills.
6. Get medical and dental check-up annually.
7. Maintain psychiatric and therapeutic contact.
8. Have lab testing as directed by your doctor.
9. Report your sleep/wake cycle to your doctor.
10. Report medication side effects and allergic reactions to your doctor.

Social activity and support
1. Have at least one social activity per week.
2. Try to avoid napping during the day.
3. Join a club, call a friend, and take a class get a hobby.
4. Make plans for the weekend.

Coping Skills
1. Read goals daily, put a copy on the refrigerator at home.
2. Take a brisk walk 40 min at least 4 times per week.
3. See your doctor, especially when you are experiencing symptoms.
4. See your therapist regularly for support.
5. Check in with family and friends regularly and express your feeling appropriately. Try to avoid conflict.
6. Work on a hobby a half an hour every day or when you are experiencing symptoms as a distraction.

Note: Always consult with your Doctor before starting any exercise regimen.

Daily Living Skills
1. Bathe daily.
2. Dress appropriately.
3. Do chores on selected days.
4. Do volunteer work on assigned days.
5. Go to work, be on time.
6. Manage your finances.

Personal
1. Always maintain civility and respect in your relationships.
2. Make healthy choices.
3. Spend quality time with your family and friends.
4. Improve your self-esteem.

27. What medications do you take?
You should always know the name of the medication, the amount of medication and the frequency of the dosage. For example: “I take 20mg of Escitalopram (Lexapro) in the morning”. This will help ensure that medications given by other physicians will not be contraindicated. In addition, you should always ask your pharmacist about possible drug interactions. Don’t forget to mention any supplements you may be taking. A list of medications and dosages should also be carried on one’s person in the event of an emergency.

28. Why is psychiatric medication useful in controlling symptoms of depression?
Mood disorders are considered bio-psycho-social disorders. They affect thinking and behavior and frequently create relationship issues. Medication and medication management are typically essential in the management of the biology or the chemistry of the disorder. I consider this to be the foundation of treatment. It is difficult if not impossible to treat clinical depression without medication. You can’t build a house without a good foundation. Medication provides that solid foundation. To say it another way, medication does 50% while your management of the disorder does the other half.

Therapy addresses the psychosocial treatment issues including: identification and management of symptoms, daily living skills, coping skills and it can address the relationship issues which often accompany these disorders.

I do on occasion have clients who refuse medication. In the past, I have either chosen to discontinue treatment or say, “we will have ten sessions and see if we can make an impact on your symptoms.” If it does, that’s great. If it does not, I will try to deal with the denial. In my experience, I have found that men have more difficulty with the notion of taking medication then do women. What if I told you that, “You are a diabetic and must be on insulin injections the rest of your life?” Of course, most people wouldn’t like it, but chances are they would do it. Why is this any different? I will also not hesitate to point out that alcohol is a drug and you are self-medicating with a depressant. This may lead to alcoholism or substance abuse and addiction. At some point, I may give up and discontinue treatment. That doesn’t happen very often because I can be very convincing, but it does happen.

29. What if you are inconsistent in taking your medication?
The key word here is consistency. The medication is extremely important to maintaining mental health. It is the foundation of treatment. If you are not consistent taking the medication, you will have difficulty functioning effectively on a day to day basis. This is not a headache. You take two aspirin and twenty minutes later your headache is gone. These medications don’t work that way. Remember, it takes four to six weeks to maximize the therapeutic effect of the medication. You must build up to a therapeutic level. When you miss medication, you affect that level. You may need to ask for assistance from family or friends. If you miss more than five pills a year, I consider you to be noncompliant with your medication. Always take the medication as prescribed. If you have concerns, side effects or allergic reactions contact your doctor or go to the ER or call 911.

30. What are the possible side effects of psychiatric medication?
Know that all medications have side effects. Even aspirin can cause ringing in the ears if you take too much. The pharmacy must list all side effects but that does not mean you will experience them. Most of the common psychiatric medications for depression and mood disorder have very few if any side effects after the first few weeks. First, ask your doctor about allergic reactions and possible side effects and what to do in the event of a serious reaction. Always read the medication information given to you by the pharmacist. S/he is also a good source for questions about medications.

The most common side effects are typically: nausea, diarrhea, blurred vision, sleepiness, insomnia, dizziness, or headache. These usually go away in the first few weeks. If these or any side effect becomes severe or you simply have concerns, contact your doctor, or go to the ER. Know the possible side effects and allergic reactions of your medications. You should always know the name of your medication, frequency, and the dosage in milligrams. Carry a card in your wallet which will tell emergency personnel exactly what you are taking. If you have questions or concerns, direct your questions to your doctor or pharmacist. Dial 911 or go to the Emergency Room for serious allergic reactions and side effects. Ultimately, the more you know the safer you will be. (See Doctor reporting form in the appendix)

31. What are the benefits and purpose of psychiatric medication?
Mental Illness is a disease very much like diabetes. It takes insulin to manage diabetes; it takes psychiatric medication to manage depression and other mood disorders. Some say you just must be tough. “You just have to pull yourself up by your bootstraps and try harder.” This is false. In my opinion, the only way to successfully manage a mood disorder is with education, medication if necessary and ongoing treatment and support.

32. What does one do if there is a medical emergency?
Call 911 immediately!

33. Should the client or family adjust the medication if symptoms reappear?
Always contact the doctor when faced with positive (active) symptoms. Do not self-medicate. A doctor never operates on himself or his own family. Don’t play doctor! Remember, the leading causes of relapse are medication non-compliance and drug or alcohol use. The doctor can’t possibly medicate you properly if he does not know honestly what the patient is or is not taking including alcohol or substance use!

Rule of thumb: Never lie or withhold information from your doctor or therapist.

34. How does one learn to make healthy choices?
Sometimes people do not recognize the choices they make may not be healthy. This falls under the symptoms of lack of insight, poor judgment. Once stable and consistent, some clients simply need to check-in with me a few times per year. Others need ongoing supportive therapy every two to four weeks to remain consistent. The frequency will depend on the individual and how well one manages their disorder. Together with your doctor, therapist, and ancillary supports if necessary for dual diagnosis, you can learn to manage your symptoms and cope with the day to day stress of a mood disorder. This is the reason that ongoing support from your doctor and therapist is essential for management.

35. How to be well. Ten Steps to wellness.
Coping with depression or mood disorders is no easy task! It takes professional support, medication, psycho-education and experience to manage the debilitating symptoms. With the necessary supports and monitoring, persons with mood disorders can learn to:
1. Take your medication as prescribed. (Problems: contact your doctor or go to the ER)
2. Control symptoms with exercise, chores, and hobbies.
3. Remain stable by making healthy choices
4. Have a network of friends and supports
5. Maintain employment.

I have also found that it takes an average of 6 months to one year to reach these goals. In some cases, it may even take longer due to sensitivity to medication or allergic reactions. In still others it may be the first try at medication fails to control the symptoms and the doctor must switch to a different medication. Obviously, this will cause a delay in controlling symptoms. A company called Gene Sight can do genetic testing when a person has difficulty finding the right medication at the right dose. They can tell you and your doctor which medications would work best for you.

In addition, many people will need some level of support on and off for their entire lives. The essential point is you can’t do it alone! You need a psychiatrist to manage your medication and a therapist to provide ongoing support. If things don’t go well after a time I would not hesitate to get a second opinion. (See Chapter 15 for more detail on how to be well)

Ten Steps to Wellness 

1. Take the medication as prescribed by your doctor.
• “I don’t miss often; maybe once per week.”

The number one cause of relapse to symptoms is medication non-compliance. This is a tough one. For psychiatric medication to be effective, it must be taken daily as prescribed. I consider compliance to be missing no more than 5 pills per year! Many people don’t like to take medication, especially if it means daily for life. Let’s take one step at a time and see what it’s like to function to your capacity for a year or two before you make decisions about the rest of your life.

But remember, clinical depression is a lifelong illness and it’s all about a chemical imbalance. It is a biological problem first and foremost. It’s like being a diabetic: you must take the medication as prescribed in order to be well.

2. No caffeine, substance use/abuse, or alcohol.

• “It’s not the caffeine. I like coffee. It doesn’t affect me. I’ve always drank coffee.”

Whether it’s coffee, power drink, soda or tea, caffeine can interfere with sleep and create anxiety. It is the most obvious reason for poor sleep. With your doctor’s supervision to avoid anxiety and headaches, gradually reduce your daily caffeine use. Eventually, when you are caffeine free, I believe, you will feel and sleep better.

I would certainly recommend gradually reducing caffeine use before asking the doctor for a sleep aid. Caffeine may interfere with your sleep/wake cycle. As far as your mental health, I recommend keeping caffeine to a minimum and before noon.

I also don’t recommend working the night shift i.e., midnight to 8 AM. It is difficult for your body to adjust. For a person with a mood disorder, this is not recommended. The back and forth between day and night shifts and the social isolation are risky to one’s mental health. It also wreaks night havoc with the sleep/wake cycle. Lack of sleep for a client with a bipolar disorder may bring about rapid mood fluctuations and jeopardize stability. Tell your doctor or your therapist if you are not sleeping. Wouldn’t it be better to reduce the caffeine rather than take a habit-forming sleeping pill?

• “What? I can’t have a glass of wine with dinner? I don’t do it often. It’s just one glass. It’s not like I’m an alcoholic.”

The second leading cause of relapse to symptoms is alcohol and substance use. Some doctors and even therapists say that it is all right to have one or two drinks if you have no alcohol abuse or dependence issues. I still question this because alcohol and pot are depressants. Why would you take a depressant when you are depressed or taking an antidepressant under any circumstance?

Alcohol may affect your mood for days, even weeks. At least track your mood on the calendar after you have been drinking to see if it has made your symptoms worse. As far as alcohol and substance use, it is as simple as it is hard. If it interferes with your life, your daily functioning, or your relationships, don’t do it!

There is a negative correlation between the use of alcohol or drugs and a mood disorder. The increased chance of dependence and risk of relapse to the symptoms of your mood disorder are just not worth it. Connect the dots! The essential point is that for many people USE IS THE SAME AS ABUSE!

I recommend you discuss this with your doctor. If you already know you have a problem, get into Rehab. It’s never too late to turn your life around. Get professional help and go to your Alcohol or Narcotics Anonymous meetings as often as it is necessary to maintain sobriety. Even if you are not dependent, alcohol or pot may not be a healthy choice for you. Don’t deny the obvious. So, remember, the healthy use of alcohol for one person, may not be a healthy for you. Make healthy choices!

3. Take care of your physical health.
Be sure to have annual dental and physical exams. Some medications require regular blood testing. Some physical ailments can cause depression. See your doctor regularly.

4. Exercise
People with mood disorders tend to be sedentary. They need to walk and get exercise as much or more than any of us. You don’t have to join a gym; all you need to do is take a brisk walk. You don’t have to run but you do have to hustle a little bit. Studies going back thirty years or more say that cardiovascular exercise lifts one’s mood and reduces anxiety. The more recent studies show that those old studies are true but the walk needs to be at least 40 minutes to get the full benefit toward lifting your mood and reducing anxiety.

Walk at least 4 times per week. I also recommend that you pick your days, otherwise you will say, “I don’t feel like it today; I’ll do it tomorrow.” Tomorrow comes and the same thing happens. If you make a schedule and stick to it (say, Monday, Wednesday, Friday, and Sunday), the day of the week makes the decision for you. “Oh darn, today is Monday. I have to walk.” Remember, depression affects one’s motivation; if you wait until you want to do it, it may never happen.

Note: Always consult with your doctor before starting any exercise program.

5. Plan to have fun
It’s good to have fun; have fun! When my son was about four years old, I remember distinctly, it was a beautiful summer day. Our front door was open and he stood there and saw children outside playing. He said, “Dad, there are kids out there! Can I go out and play?”

My point is that when you are a child, all it takes is something as simple as finding other kids and the party is on! As an adult, it takes planning, especially if you have a mood disorder. You need to take time to plan to have fun. Join a bowling league, take a pottery class or cooking class, take ballroom dancing, or take a photography class at the local park district. Take an adult education class at your local community college or park district. It’s not about the grade so you can also skip the tests and homework. These are inexpensive and fun and a great way to meet your socialization goals!
• Do it to be more social.
• Don’t do it for a grade.
• Do it because you are interested in it.
• Do it to help manage your symptoms and to structure your free time.

6. Make time to nurture your relationship.
Line up sitters so you can have time alone with your spouse or significant other. This may feel awkward at first but keep it up anyway. Gentlemen, don’t let the wife be responsible for all the social and vacation planning. Do your share. Plan a date night. When you go to dinner, discuss your next date night, event, or do vacation planning. Don’t use the date night to discuss difficult issues. This is should be a fun time and a way to nurture your relationship. If you are going to have fun, you are going to have to plan ahead!

7. Be social
A common symptom of a mood disorder is social dysfunction or social isolation. Human beings are by nature social creatures, but unfortunately, a common symptom of mood disorders includes social isolation and/or withdrawal. Call a friend and make a lunch date. Have people over to play cards or watch a sporting event. If you don’t have a large social network, use the park district or local community college to meet people. Taking a class or joining the volleyball league at least gives you an opportunity to be with people and make a friend. While meeting strangers may seem intimidating, think of it this way: if you don’t know them to begin with, then you really have nothing to lose if things don’t work out. On the other hand, you never know when a stranger can turn into your new best friend, business partner, or love interest!

8. Hobbies
Try woodworking, paint by number, sewing, knitting, crossword puzzles, gardening, toy trains, arts and crafts, or whatever you choose! Go to a hobby shop and look around but pick something and stick to it. Work on your hobby several times per week or when you are feeling low, negative, or worrisome. It is quite possible you will enjoy the activity so much that you will forget about your symptoms for a while. Hobbies are a great way to distract yourself from troubling thoughts when one else is around.

9. Chores
Most any physical activity is a good distraction from your negative ruminating thoughts and symptoms. Chores are another way to distract yourself and give you a clean environment. When you have depression, the idea of cleaning the entire house or apartment can be overwhelming. Break your chores down into one or two chores each day. For example:
• Monday is vacuuming
• Tuesday is bathroom cleaning
• Wednesday is washing the floor
• Thursday is cleaning the kitchen
• Friday is changing the sheets and towels day
• Saturday is laundry day
• Sunday is a free day. It is your reward for doing your chores all week long.

Chores are a great way to distract yourself from your symptoms. Most any physical activity will help. Make a schedule and stick to it. Try to come up with your own list of distraction activities. The more things you try, the less likely you will be a victim of your disorder.

10. Make healthy choices
This is my generic one. This one may very well be different from person to person. A healthy choice for one person may not be healthy for you. If you have a mood disorder, poor sleep, too much caffeine, alcohol or drug use, and social isolation are mental health issues. Remember! You manage it, or it will manage you!

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.

For those in the metropolitan Chicago area, I have offices in Millennium Park on Michigan Avenue, and Westchester near 22nd St and Wolf Road .  Call 847-733-4300 Ext 638.

James E. DelGenio MS, LCPC
Senior Staff Therapist
The Family Institute at Northwestern University

http://manageyourmood.net
http://family-institute.org
http://psychologytoday.com

Disclaimer: This material is meant to be used in conjunction with psychiatric treatment, medication when necessary, and supportive therapy. Always share this material and your questions about this material with your doctor and therapist.

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