TO WRITE: Sounds and sights that heal
The poet Jane Kenyon had bipolar disorder and wrote about it beautifully and evocatively. (She died in 1995 of leukemia.) Her book Otherwise: New and Selected Poems is a favorite of mine.
In part six of her poem Having It Out with Melancholy, she wrote:

In and Out

The dog searches until he finds me
upstairs, lies down with a clatter
of elbows, puts his head on my foot.

Sometimes the sound of his breathing
saves my life -- in and out, in
and out; a pause, a long sigh....

Good poets create vivid, memorable images in the reader's mind. But these "images" need not be visual. I love the auditory details of this poem -- can't you just hear the clatter and the breaths?

Play with this...
Think of a sound you love or that soothes you, and write about it in either a poem or in regular prose form. Describe it so that a reader can "hear" it, and detail how it makes you feel.

TO READ: An Antidepressant That Works in Hours
Research at the National Institute of Mental Health recently revealed that a single intravenous dose of a medication known as ketamine relieved depressive symptoms in as little as two hours in some people with treatment-resistant depression. Most antidepressants require four to eight weeks or more to be fully effective.

Ketamine, used in higher doses as an anesthetic in humans and animals, is only being used experimentally, in hopes that it will help scientists develop other new, faster-acting medications. The drug probably won't become widely used clinically because of potential side effects, including hallucinations and euphoria, at higher doses. Ketamine is thought to act quickly because it exerts its effect late in the series of biochemical actions that regulate mood, whereas current antidepressants target earlier steps in the series.

In the study, 71% of the treatment-resistant patients (who had tried an average of six medications without relief) felt improvement within one day of the treatment, and 29% of these people became nearly symptom-free during that first day. Thirty-five percent of those receiving ketamine still felt improvement a week later. None of the patients in the study had serious side effects.
Beth

TO WRITE: What are you willing to risk?
In her book on depression You Are Not Alone, Julia Thorne writes:

"Getting better means taking risks. The first risks I took were physical, like starting ballet classes at age 37. Then, I took emotional ones. I began expressing my thoughts. I joined a support group. I made new friends. If there is something good for you that feels emotionally risky, try writing it down. Sometimes seeing it in print gives you courage."

Play with this...
Take five minutes to make a list of things you could do for yourself that feel "risky." Then choose one and write continuously for 15 minutes. Imagine clearly how you could do that thing and describe in detail how it would feel. The next day, reread what you've written and see if you've gained any courage.
Beth

TO READ: Publishing your writing
There are many ways in which writing can enrich the life of a person living with a mood disorder. Releasing one's work "into the universe" to be read by family, friends, peers and everyone else is one. But where to get started?

Today I'd like to plug a wonderful organization, The Awakenings Project, which operates out of Chicago. A link to its site is at the right. The Awakenings Project encourages, promotes and disseminates many forms of art created by people with mental illness -- visual art, theatre, music and literature among them. Its journal, Awakenings Review, is a great place for writers coping with depression or bipolar disorder to consider submitting poetry, fiction or essays -- about mental health issues or other topics. Published (usually) twice a year, the Review is attractive and well-produced, and includes black-and-white photography and drawings (you can submit these too).

The submission deadline for the next issue is December 31, so you have some time to put together your best work. To read the submission guidelines, link to their site and click on "literature." You can also order back issues there. I've published poetry in this journal, and I recommend it if you're interested in taking that next step with your writing.
Beth

TO WRITE: Recovering from emotional trauma
Published authors and my own students report a variety of helpful effects from writing about their mental health and other life situations. But did you know that there is also scientific evidence that writing can help your health?

For example, after writing for 20 minutes a day, four days in a row, about a life trauma, people tend to go to the doctor much less often than usual -- they feel healthier and, after a brief period of sadness, they usually feel happier and report having more insight. When patients with asthma or rheumatoid arthritis do this four-day exercise, they experience decreased symptoms, and the effects can be seen even four months later. This kind of "expressive writing" can lower blood pressure and heart rate, and can even lead to cellular changes that boost the immune system. And, while it hasn't been studied on depressed people per se, it has led to "decreased depressive symptoms" among a more general population. These results are amazing!

Now investigated around the world, expressive writing has been studied in cancer patients, Holocaust survivors, AIDS patients and more. Professor James Pennebaker of the University of Texas at Austin has led this field of research, and you can find a link to his website at the right of this column. It includes loads of information -- and several fun self-tests.

Play with this...
Try the four-day experiment yourself. Write continuously about a traumatic event, particularly one you've kept secret. You can write about the same one each day, or vary the topics. Make a note of how you feel before and after each 20 minute writing session, and see what results you find. Then let me know!
Beth

TO READ: Comparing bipolar disease to arteriosclerosis and diabetes
I recently attended the California conference of NAMI -- the National Alliance on Mental Illness -- the nation's largest mental health advocacy program. Between scientific sessions, legislative ones and peer support discussions, there were plenty of tables filled with brochures, information, advertising... and, of course, give-aways, including pens and post-it pads advertising your favorite psych drug.

One of the most interesting things I picked up was an information sheet put out by the California Psychiatric Association: Comparison of Three Chronic Diseases with a Clear Combination of Biology and Behavior. In three columns it contrasted bipolar disorder (a brain/central nervous system disease), arteriosclerosis (heart/circulatory system) and diabetes (pancreas/digestive system). I won't summarize all the results here, but several were especially interesting to me. "Yes," there is a clear genetic predisposition to all three. There are typical medications for all three, and all three also require behavioral changes, such as accepting the disorder and developing insight into it, exercise, compliance with medications, and appropriate therapy, such as psychotherapy or diet.

One of the most exciting part of the comparison for me was the medical treatment effectiveness: 85-90% for bipolar, 43% for arteriosclerosis, variable for diabetes. I hadn't realized that bipolar disorder was considered this treatable. Now, the details of just how stable or symptom-free one had to be for any of these illnesses was not spelled out. However, I found it encouraging.

Still, the most important point, I think, is that it is gradually becoming more obvious to more people that mental illnesses are real illnesses -- biologically based brain disorders -- and should be treated as such. This allows no room for stigma. Few physicians, lay people, insurance companies or patients themselves would discriminate against a person with heart disease or diabetes. Mental illnesses must be treated with equal levels of concern and compassion.
Beth

TO WRITE: A story from your illness
Today I'm going to ask you to write a story. It's a story you already know well. It's the story of an episode of your depression (or mania or psychosis, if those apply to you). I'm not suggesting you write your life history here, just a single period during which you had symptoms.

Research has found that writing about difficult times in story form -- that is, with a beginning, a middle and an ending -- is one technique that can be especially helpful emotionally. First, recall how this particular episode began. Then, describe in detail how it felt. Finally, explain how it resolved, whether that was in an hour or a year. Did your symptoms lessen on their own? Did you get medical help? Social or spiritual help?

Write continuously for 20 minutes to create this short story. Research has also found that sometimes people feel sad for a short while after writing about a trauma, but that this tends to pass quickly and greater happiness and satisfaction results. However, if you feel extremely upset during or after writing, make sure you get appropriate help. (And remember the "flip out" rule described earlier -- if you think a topic is just too disturbing, write on some other topic instead.) Let me know what you discover!
Beth

TO READ: Transcranial magnetic stimulation -- a new option
I've been feeling pretty down lately. You know... lousy mood, feelings of dread, hard to start anything, weird thoughts flitting around. We all know our own brand of misery when our symptoms really kick in. It's discouraging when all those pills I swallow every day aren't doing their job, but I'm fortunate I've got a secret ally these days too.

For the last year and a half or so, transcranial magnetic stimulation (TMS or rTMS for "repetitive" TMS) has worked wonders for me when depression descends. Every three or four months, my neurochemistry changes and, no matter how well my life is going, I get depressed. But these days, a five-minute-a-day treatment for four weeks, which applies a strong, pulsing magnet to the right side of my skull, breaks up the dysfunctional feelings and thoughts. For me, it's as effective as ECT, but easier -- no anesthesia, no grogginess, no driving restrictions or memory loss.

TMS is still in its investigational stage, not yet FDA approved, so it's only available to certain patients at certain research sites. I'm lucky enough to have gotten in on the ground floor at Stanford (since I'm such a good customer). The treatment is done in an office. After carefully measuring the way my thumb twitches when my head is magnetically stimulated at different sites, the proper treatment location can be mapped on my skull. The doctor holds against the side of my head a plastic "wand" device which is connected to a computer and a machine that generates a precise magnetic field. The wand clicks as it sends 60 one-second magnetic pulses to a specific area of my brain, stimulating activity in that region. After three minutes' rest, we do another 60 seconds, and I can go home. Sometimes I have a moderate, but short-lived headache.

I get plenty of driving in going to Stanford five days a week for four weeks, but it's definitely worth it to me. After two weeks, I'm usually improving; after four I'm nearly back to baseline. I'm told TMS seems to help about half of those who try it for either unipolar depression or bipolar depression. Like so much in psychiatric treatments, the detailed mechanism of action isn't known. But I'm very grateful it works for me. Hopefully it will be more widely available soon and everyone will have one more treatment option to consider.
Beth

TO WRITE: What little things help?
If someone recently diagnosed with depression were to ask you what helps you cope, what would you say? Chances are you'd mention medicines, therapy, maybe ECT. But what other "little" things help you on those tough days too?

For me, talking with friends (especially those who personally know depression) over coffee often helps. Also on my list are browsing bookstores, looking at magazines, petting my cat Onyx, chocolate (in moderation!), exercise -- even a little bit such as a walk -- and, of course, sitting down and writing.

Play with this...
Make a list of things that ease your depression. Then choose one or two and describe them in detail. What do you do? How does it really feel? Why do you think it helps? Write continuously for 15 minutes. Perhaps you'll develop new appreciation of these activities or find new ideas.
Beth

TO READ: More remarkable people with depression or bipolar disorder
Lists of well-known figures who have dealt with depression or bipolar disorder include many, many accomplished writers, poets, visual artists, musicians and composers -- both historical and contemporary. From Sylvia Plath to Hans Christian Andersen, Michelangelo to Georgia O'Keefe, Sergey Rachmaninoff to Charlie Parker, they represent diverse times and styles. (For excellent lists, discussions, and statistics, see Kay Redfield Jamison's Touched With Fire: Manic-Depressive Illness and the Artistic Temperament.)

Indeed, there is some degree of correlation between mood disorders and creativity of these sorts. In one major retrospective study Jamison cites, which covers the years 1960-1990, individuals in the arts showed two to three times the rate of psychosis, suicide attempts, mood disorders and substance abuse than people in other professions. Poets fared worst of all: an amazing 18% of poets studied had committed suicide.

People have noticed these correlations for centuries, and this has led to a certain degree of romanticizing of "mad artists." That is, these traits go together, and society is the better for it. Even some of these creatives themselves feel their illness fuels their unique products. Susanna Kaysen, writing in Unholy Ghost: Writers on Depression, puts it bluntly: "I think melancholy is useful. In its aspect of pensive reflection or contemplation, it's the source of many books (even those complaining about it) and paintings...."

Others feel that, while emotion can be adaptive, depression should not -- as some have argued -- go untreated in our society merely to enable art. Psychiatrist Peter D. Kramer, in his book Against Depression, imagines a time when depression could be medically eradicated. "If we could treat depression reliably, we would have different artists, different subjects, different stories, different needs, different tastes," he writes. But he goes on to consider a whole new scenario without depression's existence. "I mean mainly to ask why we would not let go of melancholy, and trust ourselves with responsive minds and resilient brains."

All the books mentioned here offer elaborate, detailed considerations of these issues and more. Still, even with these few paragraphs of information, I wonder what you think. Do you feel our society romanticizes mood disorders? Do you feel your mental health situation aids your own creativity? I believe (as of this writing!) that, if I could, I would forfeit my depression for a potential loss of some degree of creative ability. What about you?
Beth

TO WRITE: When you were diagnosed
Twenty-one years ago I was diagnosed with clinical depression. While my memories of many things have evaporated since then, that moment remains quite clear. I felt a tornado of thoughts and emotions and questions sweeping around me. I was stunned -- how could this happen to me? And I was afraid that this meant I was now on a slippery slope to crazy, whatever that is. I -- the biologist, remember -- was dumbfounded about how these pills I'd been given could actually change my moods and thoughts. But finally, I felt some relief. Maybe all my disturbing symptoms, both physical and mental, were treatable; maybe I'd get well now.

To try to get my mind around this new diagnosis, I stopped a little way from the doctor's office and sat before a big sculpture with a fountain, where I wrote a letter to an old friend who lived 2,000 miles away. I told her about what had happened and explained how I felt. It was the best thing I could have done. It helped me straighten out my thoughts and express my grief on paper -- I wasn't ready to talk about it with anyone yet.

Play with this...
How did you feel when you were first diagnosed with your illness? I've known people to describe shock, anger, sadness, fear, confusion and relief, among other things. Write continuously for 15 minutes, telling the story of how you were diagnosed and what you felt and thought then.
Beth

TO READ: Lincoln's Depression and His Writing
My friend, the Rev. Barbara Meyers, who does mental health ministry through our congregation, Mission Peak Unitarian Universalist Congregation in Fremont, CA, sent me the following fascinating information and quote from the book, Lincoln's Melancholy - How Depression Challenged a President and Fueled His Greatness, by Joshua Wolf Shenk, Houghton Mifflin, 2005. (She is also responsible for all the excellent mental health resources and information at the "MPUUC" link on the right of this page.)

Barbara wrote:
The sub-title of the book tells it all. Lincoln had throughout his life bouts of depression. He learned how to handle them with a variety of coping strategies, among them writing. Here is a quote that I thought you might enjoy. It occurs at the start of the Civil War when the Union had some losses in battle.

"Not long after McClellan's calamities at the Peninsula, O.H. Browning [one of Lincoln's friends] came to the White House. The president was in his library, writing, and had left instructions that he was not to be disturbed. Browning went in anyway and found the president looking terrible - 'weary, care-worn, and troubled.' Browning wrote in his diary, 'I remarked that I felt concerned about him - regretted that troubles crowded so heavily upon him, and feared his health was suffering.' Lincoln took his friend's hand and said, with a deep cadence of sadness, 'Browning, I must die sometime.' 'He looked very sad,' Browning wrote. 'We parted I believe both of us with tears in our eyes.' A clinician reading this passage could easily identify mental pathology in a man who looked haggard and distressed and volunteered morbid thoughts. However, one crucial detail upsets such a simple picture: Browning found Lincoln writing." (page 183)

Lincoln coped by writing, especially writing poetry, and by reading poetry and the Bible and by storytelling, especially telling funny stories.

I add:
Writing has been a coping mechanism for many literary, artistic and musical, as well as historical, figures. (Interestingly, writers suffer from mood disorders at a rate 8-10 times that of the general public. Poets tend to have the highest rates.) Stay tuned... next week I'll discuss some of the authors and poets who have used writing to help cope with their depression.
Beth

"FLIP-OUT RULE"
As you delve deeper into important personal issues in these writing exercises, consider how you feel about each topic. In my creative writing class for people with mood disorders, I always tell writers that if you just can't -- or don't want to -- deal with a particular subject right now, simply skip it and write about something else. James Pennebaker, Professor of Psychology at the University of Texas - Austin, and a leader in this field, calls this the "Flip-Out Rule." If something might make you "flip-out," do something else.

TO WRITE: How does your depression look?
In Darkness Visible: A Memoir of Madness (an outstanding book!), author William Styron describes his depression in many ways. He calls it "a storm of murk," "the abyss," "the ogre," and like "being imprisoned in a fiercely overheated room."

Play with this...
What does your depression "look" like to you? What does it "feel" like? And then, how do you see or feel improvement in your health? Write continuously for 10 minutes and see what comes up for you. Sometimes naming and putting a face on these things can help people feel that they are not their depression, but instead a person who has depression. An important distinction!

TO READ: ECT Side Effects
Last week I described the ECT procedure as I've experienced it, and discussed a bit of the stigma that sometimes surrounds the treatment. But what happens after ECT? It varies tremendously from person to person, and sometimes from treatment to treatment in the same person. I'll share what I've been through, since I'm frequently asked about this topic by those considering it, and the just-curious.

Upon waking from a treatment, I was typically groggy, wobbly on my feet and, whether my mood felt better -- usually after a couple of treatments in the series -- or not, I was hungry. After a nurse slowly walked me to the waiting room, the main ECT side effect became apparent: memory difficulties. I had to scan the room for someone I knew who would drive me home, but I didn't know who had brought me in that morning... my husband, my mom (a huge support who came all the way from New Mexico), a friend? My mother- and father-in-law laughed when each morning I was surprised to see them and said, evidently in the exact same voice, "You mean you came all the way here from Wisconsin to help us out?"

After a requisit donut in the cafeteria, the drive home (You can't drive for days or weeks after ECT.), and a long nap, I'd awaken to talk with my caretaker for the day, and larger memory issues came up. I generally didn't recall much at all of the past few weeks, including the details of exactly why I went into treatment.I had no idea what books I had been reading, whether I had seen a movie someone was discussing, what the news was with family and friends. I knew, however, that if I still felt extremely depressed, I needed to continue.

Sadly, as the weeks -- and now, even years -- passed, I found gaping holes in my memory that I don't think will be filled. People still frequently tell me of things I've done that I have no inkling about. Most frustrating are the major life events, such as a trip to the Galapagos Islands, and another across Canada, that I didn't even know I'd been on until I was told. On the other hand, some things are still crystal clear, and I treasure those and use them to tie together my picture of my life.

Please bear in mind that while some memory loss is the most common side effect of ECT, it varies tremendously. Some people I know experienced nearly none. I suspect that mine was made worse by having a lot of treatments over the course of several years. And, yes, even considering those frustrating gaps, I'd get ECT again if I needed to.
Beth

bp Magazine --
Already in its second year, I just discovered bp Magazine, which offers "Hope and Harmony for People with Bipolar". It looks quite good to me -- a quarterly mix of research (written for the non-scientist), profiles and ideas. Its website is: bphope.com

FOR IMMEDIATE HELP:
Please note that one of the national suicide hotlines will stop operating soon. If you need help, you should now call:

National Suicide Prevention Lifeline

1-800-273-TALK

(1-800-273-8255)

They will connect you to the appropriate local help.
Please pass the word.

TO WRITE: What if I don't know what to say?

You're writing along, trying to keep that pen moving or those fingers typing, pouring out thoughts and feelings, and suddenly, that dreaded question arises: What do I say next? (And sometimes lots of other uncomfortable questions come with it... Can I really do this? What do other people write about? What's wrong with me?)

The good news is that there are techniques to try and guidelines to help you when freewriting about depression or any other topic. In the Stanford class, we have honed a set of "rules" adapted from books of one of my favorite writers, Natalie Goldberg. In her Writing Down the Bones and Wild Mind (both of which I highly recommend!), Natalie stresses first and foremost the importance of keeping your hand moving even when you don't know what to write. Figure out what you want to say in the actual act of writing. I tell students that it's fine to fill a whole page with, "I don't know what to write. I don't know what to write." Eventually your brain will get bored and it will think of something to write!

Another suggestion comes from James Pennebaker, Ph.D., a leader in the research on how writing about trauma can alter everything from depressive symptoms to blood pressure to immune function. He encourages writers to simply repeat what they've already said if they get stuck. My feeling is that either technique can be very helpful.

Among the other guidelines in class:

• - Don't cross out.
• - Don't worry about spelling, punctuation, grammar.
• - Lose control of that "editor voice" in your head -- just write!
• - Don't think. Don't get logical.
• - You are free to write the worst junk in America. (Thanks to several foreign students, we've changed this to "... worst junk in the world"!)

Play with this...
Write for 10 minutes on: How do you feel at this moment in time? Try to keep to this moment -- What are your emotions? Your thoughts? Your body sensations? How are you reacting to your surroundings? Are you ruminating on anything? If you come to a place where you don't know what to say, use one of the above techniques, or just start a new sentence with "I'm feeling..."

Let me know what you discover.
Beth

TO READ: Electroconvulsive therapy (ECT) experiences

"You mean they still do that?" A new writing friend stared at me the other day, mouth agape. At lunch while attending a workshop together, we had discovered our mutual experience with depression. When she asked me what had helped me back to relative stability, I mentioned medicine, acupuncture, psychotherapy, magnetic treatments... and electroconvulsive therapy (ECT) or shock treatments.

Her horrified reaction is not uncommon when I disclose this part of my healing. And people's amazement is confounded by the fact that I speak of my ECT experiences without regret or resentment. Of course, I wish I hadn't needed those treatments (more than 100 over about 10 years), but I would get them again in a minute if I were severely depressed and nothing else was helping. ECT, like writing, probably saved my life a number of times. And these days it's not like something that makes you wince while watching an old movie. No pain, no broken bones.

ECT, in fact, is frequently referred to as psychiatry's "gold standard" treatment for depression. Nothing is more effective, and ECT tends to work more quickly than medication. Most people feel better within a series of six to twelve treatments (usually given three times per week). No one knows quite why ECT works. Administration of electricity to one or both sides of the brain causes a seizure -- that is, all the brain's nerve cells "fire," or send their messages, at the same time. Somehow this seems to "reset" the brain's mood centers.

What are ECT treatments like?
In my experience, it's pretty simple. I would go to a hospital treatment room, either as an inpatient or an outpatient, where nurses put in an IV line so that I could later receive medications. They attached wires to my head and body with little sticky pads so that the doctors could monitor my heart and brain activities. Then two doctors appeared -- a psychiatrist and an anesthesiologist. After I took a few breaths of pure oxygen, I got a general anesthetic by IV. After I was asleep, I received a muscle relaxant medication, which would act for only a few minutes, keeping me from moving and potentially hurting myself during the seizure. The psychiatrist connected a machine to those wires on my head, and it delivered a carefully-determined dose of electricity (usually to just one side of my head; occassionally we opted for two sides). The electricity caused a seizure, which lasted around 30 seconds. I've been told repeatedly that the patient's body scarcely moves. The anesthesiologist ensured I got enough oxygen until I could breathe on my own again.

How do you feel afterward...?
Stay tuned for next week's "TO READ" posting!

Beth