October is Depression Awareness Month

Feeling the bite of the black dog?

It's probably no coincidence that October is national Depression Awareness Month.  The days of decreasing light are paralleled with increases of calls to my office of people seeking support for anxiety and depression.

Depression is a life-threatening disruption that takes on a life of its own.  This graphic shows some of the connections.  It's not perfect, but shows some of the self-feeding flow of stress (psychological or physiological).  Wish I could cite the source.  It's been reprinted a lot and the few citations I find lead to dead ends.  

I've been in practice a long time.  In a town with a population of 50,000 and over 40 therapists, you'd think I'd run out of clients.  But I get 5-10 requests a week even with a phone recording saying my practice is full.  Most of my colleagues also are full.  And every year,  demand seems to increase.
What's up? 

I have a few ideas.  I have lots to say on each of them, but we'll start with the bullet points, and I'll talk in more detail in future posts.

1)  Complexity of life has increased geometrically, and with it, stress.
 a)  Work patterns have changed.  We work more, have fewer vacations, and work leaks into domestic life in ways unprecedented in history.
 b)  We are interrupted more:  by auditory and visual stimulation, by devices and demands.  There are constant challenges to our attention and rest.
 c)  Increased information leads to anxiety
      1)  We are fed ceaseless bad news about isolated events to the point we feel in constant threat.
      2)  We are exposed to countless choices that drown out intuition and lead us to second-guess if we
            are good enough or have made the ultimate best decision.

2)  Eating, sleeping and light exposure patterns of humans have changed dramatically.  Each of these affects our circadian and hormonal rhythms in ways our evolution has yet to accommodate.
  a)   24 hour food availability changes long-term human patterns of seeing food as sustenance into              sources of comfort or entertainment, leading to obesity and hormonal challenges.
  b)   Availability of cheap, heavily marketed and nutritionally thin foods appeals to instant
        dopamine rewards; robs us of vitamins and minerals that protect our physical and mental health.
  c)  Constant artificial light, night shifts, 24 hour stores, etc profoundly disrupt sleep cycles.

3)  Social connection and support are decreased.
   a)  Communities have lost their centers.  People go out less, and when they do, they engage less with each other and more with their devices.  Natural support communities such as   churches are weaker (see 1-- no one has time).
    b)  This generation reports having fewer friends and spending less face-time with those they have.
    c)  Multi-generational family connections are less valued.  More people live away from where they were born, and they move more often and more widely than in previous generations. 

In a nutshell:  lots of us are stressed out, overstimulated and overworked, underconnected, and not sleeping, exercising or relaxing as much as our body needs to come even close to the demands of modern day life.  We are anorexic not of food, entertainment or choice, but we are vastly underfed of love, support, rest and community.

It's no wonder we get depressed and anxious.

You know who fares well in times like these?  Sociopaths.  Through a quirk in their genetic evolution, they lack empathy and don't rise high on many other emotional scales either.  They don't get angsty about much that doesn't effect their personal and immediate bottom line.  We're getting good case presentations on this genotype with the current Middle School Machinations of the country's political parties.  They don't seem to be losing a lot of sleep over the jobs that folded overnight because they are in a pissing war with the president. 

But those of us who through religious or humanitarian ethos feel it is our job to be kind, to be just, to help those who cannot help themselves, to protect the earth for future generations, who put people before profit... we're feeling the pain big time.  As William Blake said:  "Can I see another's woe, and not be in sorrow too?"  Yes, apparently some can.  Watch out for them.  They are dangerous.

The more oyxtocin-dipped among us tend to be in sorrow.  Throw some complex stress, lousy sleep and poor support, and sorrow morphs into full-fledged depression.  The predisposition may have always been there, but the cultural nudges are throwing it right off the cliff.

There are interventions for depression.   Like cancer, it's a serious disease and the treatments aren't comfortable or easy, whether we're talking about talk therapy, CBT, mindfulness training or medicine.
Flawed as the approaches are, they beat the disease.  I'll be listing resources in each post.  Some you can do easily on your own.  Some that seem easy, aren't at all if you are really gone into the cycle.  Then it helps to have a coach, counselor, best friend, doctor, religious leader--somebody you trust-- hold you up when your backbone's slipping. 

But:  Don't give in.  Fight the cycle.  Choose one of the three areas mentioned and come up with a plan to intervene.  Improve your sleep, reach out for support or connection, simplify your obligations and reduce as much complexity as you can.  More details to follow.

For catch up reading, here's a few past blogs about depression.  Feel free to comment or to email me with questions.  We'll be talking more soon.
Jana


http://www.janasvoboda.org/2011/02/delving-into-blues.html

http://www.janasvoboda.org/2011/03/fading-blue-gene-cognitive-behavioral.html

http://www.janasvoboda.org/2012/04/rip-mike-wallace-newsman-and-depression.html

http://www.janasvoboda.org/2011/03/fading-blues-ii-understanding-and.html

http://www.janasvoboda.org/2012/04/marked-for-depression-maybe-implant.html

http://www.janasvoboda.org/2011/03/more-bytes-on-black-dog.html

Your Brain on Grins

Went to the library for the first time in a while, and binged at the new release section.  It's fun to judge a book by its cover and its first few paragraphs, and I pick up things I'd never hear of, let alone consider, otherwise.

Take this one:  The Face of Emotion:  How Botox Affects Our Moods and Relationships, by Eric Finzi, MD.  I thought it might be a condemnation on the use of botulism toxins to freeze our faces into wrinkle-less masks.  But nope, that's what this guy does for a living-- or rather, he's a dermatological surgeon, and Botox is a big chunk of his practice.  Now I'm judgy as can be, but I read the back cover, and a couple authors I like neuroscientist, an evolutionary biologist) like it, and their comments are focusing on the face and emotion part, not the botox.

Home, an hour later, I've read the first 150 pages, and put in 20 or so paper scraps to mark passages and studies.   His premise is not ridiculous:  facial expressions form a strong feedback loop to the brain.  Maybe you've heard of the pencil study.  He gets to that around page 105.  Experimenters in the early 70s found that when subjects clutched a pen between their lips, effectively forcing the same muscles used in a smile, they rated cartoons as funnier than if they held same pen with lips.  To remove bias, the subjects were doing various tasks while mouthing their pens, under the guise that the study was actually looking at how persons with limited use of limbs could adaptively use mouths to control tools or complete tasks.  Holding the pen in the lips inhibits the muscle used primarily for smiling, and it "sort of bummed them out".  No, not quite their language-- it "inhibited the experience of positive emotion" or something.  At best, it seems our thinking about why we are making the face ("I'm happy" vs "this pen shoves my mouth up") doesn't change how our brain interprets the muscle motion-- Brain is heartened to see us smile.

The book is chock full of interesting anecdotes, most of which you probably have heard elsewhere.  Dr. Finzi touches on the universality of facial expressions over cultures.  A a true smile is a smile wherever you are. and disgust looks the same in remote villages in Ecuador as in Brooklyn. He talks about micro-expressions, those very fleeting millisecond facial changes that modify or discount conscious facial changes.  You know that fake smile people give?  It's in the eyes.  It's hard to fake an eye smile.  They are using their zygomaticus muscle but inhibiting their eyes, a big give away.  (Caution:  sociopaths can fake it pretty good, and that's because they aren't fakiong it-- they are delighted with glee they are getting ready to eff you up.)

You can elicit that same true smile in some weird ways with the same sunny-after-glow.  Scientist Duchenne did it with electrodes, and his subjects full on grinned peepers to teeth  (see pic on page 64). Where there are cultural differences, it is more about circumstances in which one might be allowed to display these expression, but not their existence or meaning.  For example, Japanese youth often hide smiles behind hands and engage in more social (not Duchenne full-on) smiles.

The read is full of interesting nuggets to illustrate that much of what think is conscious about expression is not, and either way, it changes or brain, and then often or perceptions/moods and way of thinking of the situation;.  Case study of one:  I consciously practiced the Mona Lisa Half Smile (eyes slightly lifted, forehead smooth, peaceful secretive smile) through Chapter 1-5.  I feel calm and good and benevolent.  I revved up to the open mouth crinkly-eyed Duchenne smile for the next half hour and was energized-- it was cold bacon hitting a hot griddle. 

The point-- there is a point here-- is the expression makes the face, and the face makes the wo/man. and the wo/man makes a life out of that face.

We smile all alone, so it's not just a social reaction.  But we smile 6 times more in social settings.  Blind people too, so it's not just a social feedback loop.  The more we smile, the happier we'll be.  We are throwing little dopamine biscuits into our reward center, which is wired by time and experience to know a good smile at you usually benefits you at least indirectly, and a spontaneous smile is proof of happiness.  And at this point Le Sophisticate Brain gets a little mushy, because hey, why you so happy holding that pen with your teeth?  But look, you are.  OK, let's reinforce it with a speck of dopamine.  REWARD!Brain correlates both the events that bring smiles and the smiles that bring rewards as desireable; it's not so picky.  And the person, they get happier.

 In my single case study I improved my scattered anxious monkey mind's mantra (too much to do too much to do /repeat) into a state of darn nice happy contentment.  and a little giddy  excitement.  just by consciously relaxing the part of my forehead associated with distress (read: worry, sadness, frustration etc) into a friendly open field.  And I found my lips twinkly upward, and then my eyes, and they by golly I was reading and grinning like a goof and happy.

I have to say this works better for me than a meditation sit, where i endure for 20-30 minutes and come out either slightly comatose, or full of self-criticism for getting bored, chasing my thoughts, and not Getting There.  Laughing yoga and smile practices seem to achieve very good results without all the painful positions for those of us who can't sit still for more than fifteen seconds.  It's not the same as all of the benefits you'd get from years of meditation practice, but I'm sold on incorporating MORE JOY, or at least practicing its expression.  Monks and laughers are both activating similar parts of the brain.  There's many ways to skin a cat.

The Big Kabowski of the article is his noticing that as he botoxed away those worry creases from his lady patients, they reported feelings happier, for the 1-3 months after the shots wore off.  Here things get a little mushy.  The effects held true whether they were receiving botox for migraines (another indication), bell's palsy, whatever.  "When three is not tension in the frown muscles, when those muscles have been temporarily frozen with Botax, there is no negative feedback to report to the brain."  In other words, his inelegant hypothesis is that when we smile, brain says "I'm happy, things are good"  We are changing our thinking and emotions without real consciousness,  But effectively.  When we frown, same thing happens.  When we can't frown, we feel as if we aer in less distress.  To simplify it even more, Finzi believes this feedback loop is being calculated all day long on a brain score sheet.  "I'm frowning this much, fear this much, worried this much, happy this much:  total:  PA'NIC with occasional sun bursts."And we can choose to consciously manipulate that.  If we literally cannot frown, the thoughts and feelings triggered by this facial reaction aren't formed..  Studies on persons with facial paralysis echo this finding:  the sufferers say they can articulate the emotion but can't really inhabit it. 

Finzi did an interesting study.  He took people with depression and migraine and treated their migraines.  They were less depressed.  Who wouldn't be?  They had migraines before.  So he narrowed the field.  He treated people with depression.  If you know what someone looks like with true depression, you know what I mean.  Crumpled faces, worry crease, downward jowls.  Behold, they improved-- til the shot wore off 1-3 months later.

A couple of things might be happening with our subjects.  They look less depressed, so people are complimenting them, interacting with them, smiling at them more.  They are smiling back, more effectively because they can't pull that ha;f-assed smile with wrinkled forehead off anymore.  We're social smilers-- you give more, you get more.  Now they smiles look less pained, ore genuine.  It's reinforced by other's reactions, by what they see in the mirror.  Hey, maybe this botox isn't so evil after all.  It's so local, so specific-- probably less risky that a lifetime of pills that have to metabolized through your liver.  I'll be going back to the stacks to see what hard science has been publisher about this theory.

In the interim, I'm just going to do my own experiment: 20 minutes conscious smiling every day.  Maybe broken up into 5 minutes an hour.  See what happens.  Can't hurt, unless I swallow the pen :)

This practice is especially useful for those of us with TOO DARN MANY MIRROR neurons.  How do you guess we show empathy for all those stories we hear?  We lean in, get the dog eyes, wrinkle our foreheads in concern.  We are deeply intereswted in analyzing all those microexpressions and we form little movies of them on our face and brain.  And then, like actors repeating a highly emotional and dramatic role, that faucet don't turn off when the show is over.  Our brain score card has registered that we wore the unhappy/anxious/sad  face much of the day. Guess how we may feel?   For therapist, this is a real challenge.  It's also way I like to PLAY SO HARD when I am not being a therapist,, which you may have noticed if you follow this blog.  Antitoxin!  Because when I am wearing the expression of deep concern, my brain is on alert that life is difficult, sad, nasty, brutish and short.  I throw in as much lighthearted humor as is appropriate to my client's situation, for balance, but it takes a toll.  As a result, don't ask me to join you see the latest expose on Something Horrible That is Happening Right Now.  I just don't want to work after work.  But if you want to take the dress-up box to Browsville for a photoshoot  and picnic in the park, I'm in.

Homework:  try it!  Do a quick facial scan.  Check for the usual suspects:  tight jaw, set mouth, wrinkled forehead.  Imagine Mon Lisa's forehead, a vast plain of relaxed skin.  Life the corners of your mouth and eyes.  Use props if you like, but you don't need to for effects.  Hold that expression best you can for you next 5-15 of whatever you are doing--dishes, talking to a friend, shopping at the store, weeding in your garden.  What do you notice?  Let me know. 


Read this book, or hear Finzi's interview on NPR.  Witching hour has struck and I must shut up now so you are left to your own devices on that one.  And make sure to practice the eye/mouth smile at least 5 minutes a few times a day and report out here.

Feelin' Breezy--
Jana

The Incredible Heaviness of Being: Braving The Stigma of Mental Illness

Kay Redfield Jamison wears many distinguished hats.  A PhD psychologist, she is a tenured professor of Psychiatry at the prestigious John Hopkins school of medicine.  She's been honored by Time Magazine as a "Hero of Medicine", and is the author of at least two international bestsellers and over a hundred published research articles.  She's had dozens of  fellowships, lectureships, and national awards.  She's received the MacArthur "Genius" Fellowship.

She also has, and she will be the first to tell you this, a serious mental illness.

Dr. Jamison first became ill with Bipolar Disorder as a senior in high school.  In her conservative Episcopalian family, mental illness was not discussed, and if anyone noticed how she was floundering, it wasn't remarked upon.  But she noticed.  She noticed the long periods of high creativity and energy followed by the much less tolerable periods of complete, abject and suicidal depression.  The story of these, and her later complete psychotic break and serious suicide attempt, are charted in vivid and heartbreaking detail in her books "The Unquiet Mind" and "Touched with Fire:  Manic-Depressive Illness and the Artistic Sentiment". 

It's unusual for a PhD (as opposed to an MD) to be offered a professorship in psychiatry.  But that rarity pales in comparison to the level of support her employers at John Hopkins gave her for being "out" with her illness.  In an unusual display of wisdom and compassion,  her mentors allowed her to continue to pursue her work after her first major break and hospitalization.  And her direct supervisor urged her to use the experience of her illness to teach and write.  As a result, we have what has been called the classic textbook on Bipolar illness (then called Manic Depressive Disorder), countless research studies, and an example of human courage exemplified.  If she had been dismissed, marginalized-- if she had her license to practice revoked (none of these are unusual situations in our culture, when ignorance is faced with illness)-- we would have none of these great works, which have done much to encourage understanding and treatment.

But it is not only the compassion of her employer responsible.  It is her courage in saying:  "Yes, I have an illness.  It is genetic.  It is not my choice, but it is my responsibility to manage".  Her bravery has had a profound effect in showing people that "different" is not always hopeless.

Dr. Jamison would tell you, as she did the audience of several hundred at OSU tonight, that having BP  is not an easy path. In fact, (and I disagree with her, but I don't have her direct experience to effectively contradict) she says that having a mental illness is "99.5% bad".  As in my last post, I strongly believe that it was her experience of the illness and her ability to humanize and integrate it that led to some of her greatest gifts.

I don't have much to add to information about Bipolar that colleague and expert on affective disorders psychiatrist James Phelps has not already said, much more brilliantly than I could.  If you've not visited his website, I urge you to do so.  (If you or someone you love has BP, get his book as well).  I would add a bit to Dr. Jamison's speech, though.  I'd add that there are some effective management techniques other, or in addition, to medication when folks with affective disorders aren't significantly impaired or completely disabled by their affective differences.  You can read about these on Dr. Phelp's site.  I would take issue with calling those without BP "normal", because I just haven't met anyone who truly fits that description-- we ALL have our stuff.  I think her point in repeatedly saying "mental illness" was to get across that these impairments are not any more chosen, or morally suspect, than having asthma or cardiac disease.   And the outcomes of not treating this illnesses are profound:  50% of persons meeting criteria for Bipolar Disorder attempt suicide.  10% succeed.  That's a very lethal illness.

See also:  http://www.janasvoboda.org/search/label/depression

In some ways, it is easier than ever to get treatment for affective and other dis-eases of the mind.  You can google, ask your MD, look in the yellow pages.  In other ways, it is harder than ever.  There is still a lot of stigma and ignorance about illnesses and differences that affect our minds and behavior.  And even though literature reports that  lifestyle changes and therapy support are as effective or increase effectiveness over medication alone, insurance often won't pay for counseling.  Certainly not everyone has insurance.  Your local NAMI chapter can help you find resources and support.  If you are a student, contact your education counseling center to see what low-fee or free services are available.  If not, call your local mental health center (God. politicians and voters willing that you still have one).  If all else fails, call a crisis line.  There are many you can find on the web.

Here are two: 

1-800-SUICIDE 1-800-784-2433

1-800-273-TALK 1-800-273-8255

Fading Blues II: Understanding and Addressing Depression

  "I feel so ashamed."  "It's ridiculous I should be so unhappy.  Others have it so much worse." "I shouldn't be so weak".
     These are common comments in my office made by persons in the throes of depression.  Because it is a mood disorder, and because people assume moods  have causal links to what's happening in their lives, depression leaves people bewildered when they cannot link the feelings to situational events.  Even when they can, the other common depressive ruminations (guilt, hopelessness and helplessness) reinforce a very personal responsibility for the symptoms.
 "I feel like a burden."
"I should be able to handle this."
"I'm broken."

These thoughts are symptoms that arise from the disorder.

When one has a fever, one doesn't usually think "I shouldn't be so hot."  A person with Type 1 diabetes doesn't tell themselves or their doctor "I really should have my pancreas under better control."  But when our brains are screwing up, we take it really personally.  We confuse our mind/soul/personality with our brain.  And we think we are supposed to be in charge of it.

The brain is an organ; a very complicated one. It interlinks with a intricate endocrine system over which we have little conscious control.  That system tells our body such things as "wake up", "be energetic", "get drowsy".   In his Feb 2011 New Scientist article "Days of Wonder", Roger Highfield charts the mysteries of the complicated chemical factory that is our human body as it goes about an average day.  From the moment we wake up, when perifornical orexin neurons start our day by alerting the sympathetic nervous system to get going, to the time we ready for sleep and the dark triggers a chemical dose of drowsiness to quiet the system, hundreds of complex biological processes are happening.  Like Japan's nuclear power plants, there are dozens of redundant mechanisms to prevent the inevitable mishaps from collapsing us.  And like Fukushima, sometimes there are enough failures of those mechanisms that there are catastrophic results.

In depression, there is many potential failures (or more benignly, design issues) that can happen.  As psychiatrist Jim Phelps explains (buy his book already!), "A big part of depression is a single gene."
A person no more chooses to carry this particular gene than the one for say, hairy knuckles or that one that makes your pee smell funny after you eat asparagus.

Other things that can increase likelihood a person has a depressive episode are as varied as season and latitude, daylight savings time (!), hormonal changes (pregnancy and postpartum, menstrual cycles,  and menopause for women), and medication (including some you'd never think of-- even certain antibiotics, such as Cipro).  The linked list doesn't include antihistamines, which seem to cause depressive symptoms for me.  Every body is different.  If you notice you have a consistent negative response to a medication, consider reporting that to the FDA here.   These anecdotal reports add up and make a difference if there are enough of them.  I remember back in the day it was commonly thought that there was no such thing as a withdrawal syndrome for folks on antidepressants.  It wasn't until enough people complained to FDA and doctors that they were having serious issues that guidelines for slow tapering of SSRIs became common.

A more obvious causal relationship can be made for depression in a person who has been through one or a series of traumatic or stressful events.  Even then, it is likely the physical response of the body's bombardment with stress chemicals that explains the lethargy, mental fogginess and emotional reactivity of severe depression, not just the psychological effects.

How can you mediate the body's reaction to these difficulties?  There are a few straight-forward paths to wellness, whether your symptoms are aches of the physical or psyche:

1. Practice good sleep/wake habits  to support the endocrine system's ability to do its complex job.  
2. Minimize late night light and get a reasonable amount of daily fresh air and sunshine.
3. Eat well:  adequate nutrition is essential for good mental health.
4. Exercise is neurogenerative. There are dozens of studies showing its benefit to mental well-being.
5. Social connection is very predictive of happiness.   Depression encourages withdrawal.  While reflection is good to a point, don't isolate.  Find ways to increase community.  If you are too shy or depressed to go out, at least go online, and find a support group/chat where you can connect with others.
6.  Count your blessings.  Pay attention to what is going well in your life and keeping a journal of gratitudes.
7. Address the unproductive inner focus by finding ways of being in service. 
8. Find and practice ways of giving your life meaning.
9. Develop a spiritual discipline that supports compassion to self and others.
   
10. Learn to recognize depressive cognition (thoughts) as symptoms rather than reality.
11. Minimize your exposure to avoidable stresses as you would to secondary smoke. 
12. When stress is unavoidable, learn ways to decrease its impact through Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, meditation, prayer, focused distraction, creativity or other means.

As always, click on highlighted links for more information.

Fading the Blue Gene: Cognitive Behavioral Approaches to Treating Depression

PART ONE:  CHANGING YOUR FOCUS
Remember losing a tooth when you were a kid?  How you could hardly leave that hole it left alone?  How big it felt, how you couldn't stop fiddling with it and poking the space where the tooth used to be with your tongue or finger?  Maybe for a while it drove you crazy.  Maybe for a while it was all you could think about. 

And then after a while, you forgot about it.

OK, depression is not much like losing a tooth.  The link here is the idea that when you pay a lot of attention to something, it occupies a lot of space in your mind.  

You know those cartoons where someone stubs his toe so he bites his thumb?  It doesn't make much sense that adding pain could subtract from it.  But what's effective isn't the addition of a new pain, it's the distraction from the original one.  When we use a focused distraction, it's not that the pain isn't real.  It's that we are choosing to focus our minds and energies elsewhere.  This is part of the thinking behind all that complicated breathing they teach in Lamaze to control pain during childbirth.  There's some neuroscience and other physiology there too, but the simple part is:  it's hard to pay as much attention to pain when you are trying to remember all those patterns to the choo-choo breathes.

In the quirky and beautiful French film MicMacs, protagonist Bazil deals with his depression and PTSD by reciting obscure history facts to himself when triggered.  He's practicing a form of Cognitive Behavioral Therapy.  As the name implies, CBT aims to change thinking and actions from nonproductive or destructive patterns to those that support health.

When we are depressed, we ruminate-- obsessively mull over negative thoughts.  The original thoughts are spontaneous; we can't control them.  But by repeating them over and over in our mind we create neural bridges that strengthen them.  What we hear over and over (even from our own in-the-moment-distorted minds) seems believable.  At minimum, we wear a groove that we can now slide more easily down.  If you've ever studied music, think of it like chords or scales.  No one is born knowing how to play a C chord.   You learn it, and at first you have to think about it.  On the piano, C E G: white keys, each with a black between them.  If you've practiced them often enough, you can form the chord with your fingers even if the instrument is nowhere in sight.  If you now pretend to play a D chord, you know that middle finger moves up, to hit the black note in the middle of the chord.  You don't really even have to think about it.  After a while it becomes automatic.

Thoughts can be like this too.  We have a spontaneous thought, such as "Life sucks."  Let's say we don't know exactly why we are thinking it.  If we start ruminating about it, being the problem-solving and pattern seeking people we are, we can probably come up with some evidence to support the thought.  Because we are sorting for supportive evidence, we disregard or fail to look for exceptions to the thought.  After a while, the evidence we've selected comes easier to the fore.  After a longer while, it comes automatically.  And because it is so present, so pervasive...

We believe it.

One way to deal with depression is to question the thoughts and the narrative we use to support them.  As mentioned in a previous blog on Obsessive Compulsive Disorder, everyone has crazy thoughts.  The difference in folks with OCD is they pay attention to them.  Say you are driving down the street and you think, out of nowhere, "I could serve my car into that oncoming semi."  Who knows where that thought came from?  Maybe you saw a movie where it happened, or heard a news story, or maybe you just had a random "brain fart."  Most people who have that thought might be momentarily disturbed.  They think, "Where did that come from?"  But the next minute they resume thinking about the burrito they are off to get, or singing along to the radio.  People with OCD have a different reaction.  They think, "How could I think that?  What sort of monster am I?  Does that mean I want to do that?  What if I DID do that?  What if I can't control wanting to do that?"  They go over and over the scenario.  Maybe eventually they can't even drive, because they are afraid of having the thoughts or of acting on them.

In depression, minds can get sticky in a similar way.  Our task is not to control the original thought, but our responses to them.  We can do this in many ways.  Focused distraction--  intentionally turning the mind to something else-- is one.  Singing, paying attention to sensory detail, doing math-- it hardly matters what it is as long as it's a less harming thought.  See Managing the Monkey Mind for more on this. 

As AA says, it's simple, but not easy.  Just like scales, learning a new skill takes time and lots and lots of practice.  If you have depression, you've had lots of practice in negative thinking and narratives that support why you feel so crappy.  And as noted in the last post, it's not that you aren't really feeling that crappy.  The point is the way you are addressing it can change, and that change can do you good.


CBT has been found to be as effective as antidepressants in alleviating depression.  Other CBT interventions and more on how it works coming up-- stay tuned!
 Meanwhile, here's a positive thinking song from Gloria Gaynor:  dance it out.

More Bytes on the Black Dog

If you are one of the rare few that hasn't had at least a two-week case of the blues, it can be hard to fathom what it's like to be in the maw of what Churchill called his "Black Dog"-- a companion both familiar and dangerous.

Depression comes in all shapes and sizes.  There's dysthymia, a sort of a profound negativity and sour or melancholy disposition that's hung on for two years or more.  There's major depression, which can oddly enough be mild to severe, and in the latter form be accompanied by psychosis.  In kids, the chief symptom of depression can be irritability.  There's cyclothymia/bipolar two ("soft" bipolar) in which low moods alternate with normal or expanded ones.  Then there's Bipolar One-- what used to be called Manic-Depression, in which the highs can be WAY more damaging, accompanied as they often are with delusions of grandeur, paranoia, and really out of character behavior.  Read the last few days' infotainment news to see examples of a current celebrity demonstrating many of those symptoms.  (Note:  you can't diagnose based on news reports.  Said celeb may also be showing symptoms of heavy amphetamine use or even a brain/thyroid tumor.  But's he's doing a bang up job of illustrating the non-stop energy and grandiosity of someone in the throes of a manic illness).

The chief features of garden variety depression are the low moods, cognitive cloudiness, ruminations and withdrawal from activity.   Depression is a biological illness, not just a "thinking" problem.  (Don't forget-- your brain is IN your body).  Stomach issues are very common-- did you know your stomach is a second brain?  Other aches and pains increase as well.  Some of this may be strictly physiological, but some of it is an offshoot of the cognitive changes that occur when we are depressed, specifically ruminating thoughts.

Rumination means focusing too much on distress, its causes and its consequences.  Marni Jackson's book, "Pain: The Fifth Vital Sign," gives a vivid example.  The author is happily biking down a country path, enjoying the sun, the company, the ride, when she feels something hit her mouth.  Suddenly her world temporarily collapses into a very small place: she's been stung by a bee, and she's no longer thinking about the beautiful day, her family, the bike ride.  She's in pain, and that's all there is in the world for a time.

Depression is often like that.  A pain so intense, so overwhelming that it knocks the importance of everything else out.  Alternately, it can be a numbness that completely blocks the possibility of feeling joy.  In either case, the depressed mind mulls over and over the pain or numbness, searching for reasons and filling in the narrative with explanations of deservedness, hopelessness. helplessness-- the cognitive triad mentioned in the last post.

While loss and tragic circumstance can lead to depression, they aren't necessary as explanations.  Brilliant, beautiful, gifted and successful people suffer along with and sometimes as much as those who've been beset by real-life horrors.  Sometimes that can make it even harder.  "Why are you so miserable?  You have a wonderful (fill in the blank: spouse/career/job/family/life)".  Such statements are no more helpful than telling an amputee that s/he shouldn't have pain in an absent limb.  It doesn't matter whether it looks like there's a reason-- the pain is very real.  Blaming one for feeling it only makes it worse, adding guilt to the burden.

But like the amputee, the migraine sufferer or the victim of losses, intense focus on the pain does nothing helpful either.   One must find that strange balance between denial and indulgence-- acknowledging the pain, addressing it where possible, and bringing focused attention to something besides its insidious, hypnotic insistance that it is all that exists or matters.  Remembering that acceptance is not the same as approval, we can work on being a compassionate witness to our emotional state instead of consumed by it,

Next blog:  cognitive approaches to managing depression.

Diving into the Blue(s)

Depression.  The Black Dog.  The Emotional Flu.  The Blues.  
Along with anxiety, mood issues are a major source of discomfort for folks with the Troublesome Trifecta: Big Feelings, Big Radar and Big Processers. 
Depression is nothing new and, at least in its more common appearance, nothing rare.  Most people will go through periods of sadness in their lives when energy and concentration lags, thinking is cloudy, and the future looks dim.  It's normal following the loss of a loved one, illness, catastrophe or other sorts of regular life hardship. Time and emotional support will usually be enough to address these dips into dark places.  Jungians say aspects of depression can be a strange sort of gift:  the slowing down, withdrawing and going into one's thoughts can offer opportunity for rest and reflection.  Depression can be Psyche's way of expressing dissatisfaction with Ego's choices and a chance to think about what soul truly needs.

What's known in the biz as "clinical depression" is another matter.  This sort of emotional upheaval is so intrusive and persistent that the sufferer's life is affected in multiple ways. Work, relationships and physical health are disrupted.  Levels can vary from mildly incapacitating to life-threatening, and the sadness may be recurrent, with periods of remission and relapse. There appears to be a strong genetic component.  In families with histories of mood disorder there may be generations of substance abuse: perhaps markers of attempts at self-medication.

Symptoms of clinical depression as listed in the DSM-IV include sadness (you knew that one, right?), loss of interest in previously pleasurable activities, sleep disturbance (too much/little),  fatigue both physical and mental, clouded thinking and inability to make a decision, weight changes (loss of appetite is usually more significant than gain), thoughts about death and suicide, and the triple-threat-thoughts of helplessness, hopelessness and guilt.  Again, most everyone has some of these, some of the time, for a bit.  But for persons with clinical depression the symptoms persist, aren't necessarily related to anything happening in the outside world, and interrupt functioning on one or more levels.

The thinking can be the worst part.  Depressive thinking feels Very Big, Very True, and it's a liar.  It says:  You're worthless.  You've always felt this bad.  You'll always feel this bad.  You're a burden.  The worst outcome of the lies of depression is suicide.  Depression can be a fatal disease.

In Japan, the colloquialism for depression is "kokuro no kaze", which translates roughly to "when the soul has a cold."  Prior to a major marketing campaign by big pharma, depression wasn't much discussed in Japan, but the idea that one's soul could feel weak, leaky and lousy resonated with a lot of people.  Likening it to physical ailment rather than a character defect lessened the societal stigma, and inquiries to the medical profession about how one could address depressive symptoms immediately and dramatically increased, as did sales of antidepressant drugs.

In the US, antidepressants are at the top of the list for most prescribed drugs; some studies say nearly 10% of the US adult population currently take them.  Ads for antidepressant therapies are ubiquitious.  You can't flip through five pages of most pop magazines without seeing dramatic before and after pictures of hapless, then happy souls.  The symptoms described in some ads are general enough that most anyone could relate on a bad Monday.  Such campaigns have inspired numerous parodies.  Click here to see one from the satire newsmag The Onion. Reprinted as fact in a few web sources, it was apparently so close to actual ads that outraged readers couldn't tell it was in jest.   I want to be clear: antidepressants have made a significant and positive difference for many persons with depression.   There are also concerns about their overuse, effectiveness,side effects and limitations.   Medication is one approach to treatment of depression; we'll talk about that and other interventions in a future blog.

There are many authors who believe the high rate of medical intervention for depression is a result of overpathologizing these unavoidable life events.  I think it's a little more complicated than that.  Changes in American life, from technological and environmental to social, may all play a part in rising reports of depression.  Probable suspects are abundant.  Artificial light and poor wake/sleep cycles (not to mention environmental contaminants) mess with our hormonal systems.   As a nation, we eat a lot but are often poorly nourished.  We are too busy and we are much too stressed.  We don't sweat enough to work out all those fight-or-flight chemicals our brains pump out to deal with those stressors.  And we don't have nearly the social supports we had before we all moved so often, worked so much, and dropped out of networks (churches, clubs, coffee circles) where we could ask for and get support.

Psychiatrist Jim Phelps, a specialist in mood disorders, has been mentioned several times in my blog for good reason.  If you want a lot of great information on depression, its causes and treatments, check out his website or order his book Why Am I Still Depressed?.  He takes very complicated information on the genetics, neurology and treatment of mood disorders and makes it understandable and interesting.  You'll notice he talks a lot about Bipolar disorder.  Don't let that scare you.  Dr. Phelps makes a convincing argument (supported by leading researchers in the field) that most depressions are part of a spectrum of mood issues called "soft" Bipolar or Bipolar II, where periods of low mood are accompanied or interspersed with anxiety, irritability and other symptoms.  His site includes information on medical, therapy and lifestyle treatments with known positive benefits for addressing the symptoms and causes of depression. 

The most important thing to know:  depression is real.  It's a full-body illness, with physical, social, cognitive and emotional effects.  It is treatable and recovery happens.  Don't let it run you.  The WHO commissioned the video below.  Share it with others, and pass the word that the Black Dog doesn't have to have the last word.

A Troublesome Trifecta

Being an oldtimer in the field, I've picked up patterns in clients over the years that are interesting and often predictive.  I noticed the kids I saw that struggled in English and more theoretical classes but were good at kinesthetic learning tended to have cross-dominance handedness as well as temper or opposition issues.  Anecdotal, but interesting, and there's probably a good neurological basis.

A very common feature I see in clients with anxiety and depression issues is what I call the troublesome trifecta.  These folks have a combination of traits:  Big Radar (they take in everything), Big Sensitivity (they feel it bigger) and Big Brains (they want to analyze everything).   As a result they have a high signal to noise ratio and spend lots of energy trying to figure out the data they are receiving.   Since much of it is noise, life can be pretty exhausting.

As stated in a recent blog, I'm a firm believer in the great benefits of the natural variation of human experience.  In other words, let's not pathologize everything.  But I can tell you, folks with the troublesome trifecta are both burdened and blessed.  Maybe they were bathed too long in the Oxytocin waters, and now that's what runs through their veins.  They see everything through the excruciating lens of Love's Potential.  They tend towards the ruminating spirit, as actor/director Jodie Foster called it in a recent interview with the National Alliance on Mental Illness.  The blessings come in the form of increased empathy and higher highs, creativity and a deep curiosity.  The burdens, unfortunately, come from the same place: the capacity for deep wounding, heaviness, and feelings of not being up for the Call.


Some people intentionally choose not to love and feel deeply.  Deep connection can result in deep loss when the connection closes, through choice or circumstance.  Highly empathic folk don't have a real choice about their capacity to experience life deeply.  But they may try to to run interference with the effects by dimming input with  drugs and other distractions. 


Half the battle is learning to know and love ourselves for who we are.  The other half is taking responsibility, even if we don't have the choice, for our limitations/strengths.  We can find ways to tone down the noise, to sort out the signal.  It requires attention and intention.  It is easier in the short run to be self-aversive or try and become comfortably numb.  That's back to losing the baby when we throw out the bathwater.  As Tom Waits sings, "If I exorcise my devils, my angels may flee too" (and he stole that line from Oscar Wilde, I think, though I can't find it now).  But it is our job--our calling-- to be aware of our impact with its gifts and limitations and take responsibility that it doesn't harm others.

Yes, I wrangle with the troublesome three-- well, at least the big radar/big sensitivity part.  I notice a lot and I don't naturally have a big filter.  This works well in my profession, especially if I apply the analysis to the data.   As always, I'm going for door number two in addressing the effects of this predisposition.  I want to wrestle with my demons and see what they have to teach, and trust my angels to keep me in line.  I want to keep enough shadow to know both light and dark when I see it and to pay attention to what I can learn there.  I don't want to trade knowledge with its discomfort and connection and wind up with blissful ignorance, at least over the long haul.

But I know there are tasks for me if I chose the less traveled road.  I need to practice mindfulness, gentle curiosity, and deep compassion as emotions and thoughts spontaneously arrive, sometimes unwelcome.  I can stay in wise mind of not-knowing the outcome.  I can decide when I've worried enough about some difficult matter and see that indulgence is of benefit to no one.  I can engage in acts of kindness and bravery despite lack of motivation or surpluses of fear.   I can practice self-soothing, not relying on others to have been hit in the same way I might be by a recent experience,  I know there is enough suffering in the daily that I won't look for entertainment in the nightly news or latest tearjearking Oscar winner.  I can sing not in spite of suffering but because there is suffering, and hope that like me, others may need my song more than my tears.  I can cry, too, when I need to, but not take residence in my tears.  I want to be available, and that means respecting my ability to deeply feel and connect, and knowing when to go quiet and replenish.

It may be that my childhood led to my family role as a caretaker.  It may be that some sensory integration deficits led to my enormous sponge for interloping sensory information,  It could be I became awash in excess oxtocyin in the womb and am forever reacting to its urgings or chasing its replacements.  For me , I am less interested in the why of how we end up who we are.  I want to learn how to best swim this ocean I am in, with respect for myself and the paths and people I cross and impact.

It ain't easy.  And it's important, beautiful, essential we don't give it up learning how to navigate these beautiful, dangerous waters.

How so?  Come back soon for tools I have gathered on the way.

Resolution #27: Don't Feed Ethel

Most of us have a loud and annoying bully in our head who tells us Bad Scary Stuff.  I've decided to name it "Ethel".  Please forgive me if you are or have an Ethel in your life that you love.

Ethel says things like:  "You can't do it.  You're a loser.  Why try?  You don't deserve to (fill in the blank:  be happy, healthy, out of debt, in a good relationship)."  She tells lots of scary stories with an authority that is quite convincing.  Ethel gets bigger and stronger every time you listen to her.  

Today's resolution:  Don't feed Ethel.   

When that doubting voice shows up, don't even bother talking back.  It's OK to talk to yourself. Tip:  Unless you're alone, don't do it out loud.

Tell yourself: "That's just Ethel, doing her deal."  Tell yourself some facts, like "I've been scared before and done fine anyway."  Or "I don't really know how this will turn out, and I won't know anything more if I don't try."  When Ethel has no attention, she tends to wander off.

----------

Extraneous news:

Four more to go!  I can taste the relief.  Here's a couple of comments sent to me today about the 31-day challenge thus far.  I appreciate comments and conversation.  Don't be shy!

Erica, a lovely local therapist, wrote:

I read your blog this morning...  Here are a couple thoughts you engendered for me:

     When temptation is at hand...

Sometimes I think of future self as tomorrow's self (which helps that immediate gratification self latch onto something close at hand), so I ask "what will I, tomorrow, look back and thank me, today, for doing right now to get closer to that goal. 

    Sometimes, the best I can do is "damage control"--i.e. to take a hard day or down mood and at least not make it worse with dysfunctional cognitions or behaviors.  "Damage control" reminds me that not making it worse is sometimes the most positive thing I can accomplish.  Then surely the next morning I look back and thank myself for "not making it worse."  Make sense?

And my great pal Hal, who designed my pretty work website, wrote:

Miss Jana,
Hearty congrats on your sustained resolution to write January Resolutions... To ease you into February, for yer remaining 5...consider, please, if you will:
* Resolution #27: Find an Answer to All the Giraffe Ennui
* Resolution #28: Stay Away From Those Taco Bell-Bottom Trousers
* Resolution #29: Embrace Your Inner Bingo; Polka Nights
* Resolution #30: If You See That Fork in the Road, Take It
* Resolution #31: Sing the Body Electric...But Wear Rubber-Soled Shoes, Eh?
Your indentured servant,
Wally Ferblunghit

----

For more Hal and some good reads, check out his website:  http://hdklopper.net/ 

Today's musical vid:

Resolution #1: Spend more time in nature

A walk in the woods can temper a week of worries.  In Japan, the practice of "forest-bathing" (shinrin-yoku) is promoted as a healthful practice for calming and restoring the spirit.  City stimulation taxes the brain-- the constant background drone of machinery, the changing quality of light, the barrage of visual information takes its toll on us physiologically and psychologically.  The quieter pace of natural novelty encourages contemplation, relaxation and a more regular rhythm for both body and brain.  The flora increases available oxygen, and there are fewer interruptions to thought. Walking calms the parasympathetic nervous system and provides gentle exercise without the need for a gym membership or bulky equipment.

In the valley, there are numerous close-in trails where one can feel enveloped in natural beauty.  Terrains range from short 1/2 mile loops on boardwalks (Jackson-Frasier Wetlands) to McDonald Forest's more than 80 miles of trail through old growth and foothills. The Benton County public library has put a PDF of Phillip Hays' guide to Corvallis trails on-line-- find it here.

Resolve to spend a half hour or a day in the woods, and see what it brings you.
 

S.A.D.? Lighten Up!

Someone articulate said something about how we humans are caught in the crossfire of indolence and productivity.  I've crossed over to the dark side on that one, so here's an updated rerun on from two years ago, in tribute to the darkening nights and increase in phone calls we therapists get this time of year.  By the by, Costco has daylight simulators and light therapy boxes on sale this week.  Be sure to check  Dr. Jim Phelps' exceptional thorough discussion on research and information on light and depression.

 The days are darkening here in Corvallis, and it won't be long until what little slanty sun could shine will be thwarted by rain clouds. If you notice yourself getting sleepy, lethargic, or gloomy, you're in good company. Seasonal changes in light have a very real and physiologic effect on mood and energy. Our brains and bodies are set up by evolution to react to long light days with increased energy (work those fields! harvest!) and to cooler, dark days by slowing the system down (sleep! now sleep some more!). Our bodies would be perfectly happy going to bed not long after the sun sets. That probably worked well in days before widespread use of artificial light and 24/7 availability of food and things to do-- but it's unrealistic for most of us now. The result in the split between rapid societal evolution and much slower physiologic evolution can be sleep, energy and mood disorders, including the Oregon State Malady:  Seasonal Affective Disorder.

A light box can address both typical and more drastic results of the effects of waning light on the brain and body. Light boxes produce effects similar to sun exposure and can be used in the morning to assist in wakefulness and mood regulation and in the afternoon to increase energy. Exposure is typically between 15-30 minutes at a regular time each a.m. or early afternoon. To be effective, the light source should be at or above face level, with eyes open (although it is not necessary or recommended to look directly at the light)and within 15-30 inches of the light source. Specific instructions vary according to model. There is a great deal of evidence of effectiveness in the use of light boxes to treat seasonal affective disorder, a type of depression linked to low winter light.

Because they have a real--and sometimes profound-- effect, they are best used according to specific directives based on the particular mood or sleep issues one is experiencing. In some cases, use can increase hypomania (agitation, excess energy, and insomnia among other symptoms). Usually a reduction in the exposure time or moving exposure from am to afternoon  is enough to remedy that. However, I encourage persons considering light therapy to consult their physician or mental health practitioner and have some sort of system in place to track results. Because it isn't completely clear that such intense light exposure is safe over long periods for eyes, light therapy isn't for everyone and the risks as well as benefits should be explored.

I'm a chronically terrible sleeper, and an even worse waker. I noticed that the best sleep I have is when I am camping and rise and go to sleep with the summer sun. Since that time frame is typically also when I rise and wake in the winter, I have found great benefit in the use of a dusk/dawn simulator. The device I use attaches to my bedside lamp and is programmed to turn the (100 watt full spectrum) light down very gradually in the evening and then up again gradually in the morning. I use it from October to May and find I don't even need an alarm clock, as the dawning light creates a gentle alertness over time. I wake up refreshed instead of startled. Research suggests that gradual lightening stimulates a chemical cue to awakening, just as gradual darkness stimulates a chemical cue to drowsiness. I rarely use a light box since I've bought my dawn simulator. They aren't cheap-- mine was $150-- but I find it a bargain for the help it's provided me with sleep and waking.

Meanwhile, if it's a nice day, get out there!The average American is getting LESS than the 20 minutes of sun a day needed by the body to manufacture adequate vitamin D-- that's on a summer day.  In Corvallis, you'd need to be outside during 24 daylight hours to get that daily dose.  The USDA just doubled the RDA; if you are supplementing, they say go for D3 and 800 mg.  Harvard Health suggests 1000 and tells more about the importance of this vitamin, ways to get it, and effects for different populations in their newsletter here.

Resources:

The Office of Dietary Supplements/National Institute of Health FACT SHEET on D.   There's a chart on getting vitamin D from diet.  Trust me, if you aren't taking cod liver oil or drinking a half-gallon of milk a day, you probably won't get it there.

Corvallis's own Linus Pauling Research Center is doing lots of research on D and are big proponents.  Find out what they are on about HERE.

Boston University reseacher and professor Dr. Michael Holick is considered one of the foremost researchers on D; he alerted a nation to links between D deficiency and increased autoimmune diseases and cancer.  He worries our obsession with sunlight protection in the form of sunblocks and clothing is causing a national deficiency.  Remember, no need to tan-- 20 minutes on hands and face in summer is plenty to produce all the D you need.

Quote of the day:  Albert Camus
To correct a natural indifference I was placed half-way between misery and the sun. Misery kept me from believing that all was well under the sun, and the sun taught me that history wasn't everything.

Song of the day (what else):  

You are not your mood.

One day last week I woke up cranky. Might have stayed up too late, might have been the moon. Maybe I had a bad dream. Whatever the reason, I woke up irritated, and projected it on everything. A series of regular delights and irritations followed:
some things I wanted to happen, didn't, even though I did my part. I had a nice breakfast with a colleague. Someone talking on a cell phone nearly ran me over. I found a present from a stranger. Point being: things happen. Every day. Good things, bad things. But from my half-empty-glass state, my attention wanted to focus on the bad.
That morning, I noticed my mood and decided I would make a real effort to act reasonably even though I don't feel reasonable. In my therapy practice, I talk a lot about acceptance, as in the Serenity Prayer: deal with reality you can't change, change what you can, be smart enough to figure the difference. I figured I may not be in charge of my mood. Feelings aren't facts; they rise up when they want. But how we act on them-- we can take charge of that. It wasn't easy. I wanted to snap at people (and I did, time to time, before I caught it), but for the most part I was intentionally kind and patient, even though some rascally part of me wasn't motivated to that. I want to be clear that I was not denying my mood or feelings. Rather, I was choosing my behavior, on the premise the mood would pass. I thought about the economist I quoted in an earlier blog who noted our future self often would prefer we make different choices than our present self desires. I practiced, in short, being a grown up and doing the hard but right thing.
It was simple, but it was eye opening. The next day, when I inexplicably woke in a good mood, I was able to assess my choices of the day before and feel ok about them.
There's a story I sometimes tell, about a king who was terribly melancholy and searching for a cure. He hired and fired various priests, sages, doctors and wizards. Nothing worked. After a time, he was presented with a ring and told it would do the trick. Inscribed on the ring: "This too will pass."
That's the deal with moods. In his book Don't Sweat the Small Stuff , the late Richard Carlson noted that we wake up different days in completely different moods, despite the same circumstances we had the day before. No sense reworking your life-- or your reactions, or behaviors-- on something so transient.
Good stuff, bad stuff--this too, will pass.
Jana

If you're going to break, break open.

Are you starting to feel the knot of fear unravel, or grow tighter?
There's a lot of bad news out there. It's easy to react by holding on more fiercely to our divisions. I attended a beautiful talk this week on reconcilation by Rabbi Benjamin Barnett. He started with the poem at the end of this post. It beautifully addresses how fear closes our hearts.

We're all in this together. Be kind to one another.
Some seed for your journey can be found at
www.loveandforgive.org

The Place Where We Are Right

by Yehuda Amichai

From the place where we are right
Flowers will never grow
In the spring.

The place where we are right
Is hard and trampled
Like a yard.

But doubts and loves
Dig up the world
Like a mole, a plow.
And a whisper will be heard in the place
Where the ruined
House once stood.

Lighten Up

The days are darkening here in Corvallis, and it won't be long until what little slanty sun could shine will be thwarted by rain clouds. If you notice yourself getting sleepy, lethargic, or gloomy, you're in good company. Seasonal changes in light have a very real and physiologic effect on mood and energy. Our brains and bodies are set up by evolution to react to long light days with increased energy (work those fields! harvest!) and to cooler, dark days by slowing the system down (sleep! now sleep some more!). Our bodies would be perfectly happy going to bed not long after the sun sets. That probably worked well in days before widespread use of artificial light and 24/7 availability of food and things to do-- but it's unrealistic for most of us now. The result in the split between rapid societal evolution and much slower physiologic evolution can be sleep, energy and mood disorders.

A light box can address both typical and more drastic results of the effects of waning light on the brain and body. Light boxes produce effects similar to sun exposure and can be used in the morning to assist in wakefulness and mood regulation and in the afternoon to increase energy. Exposure is typically between 15-30 minutes at a regular time each a.m. or early afternoon. To be effective, the light source should be at or above face level, with eyes open (although it is not necessary or recommended to look directly at the light)and within 15-30 inches of the light source. Specific instructions vary according to model. There is a great deal of evidence of effectiveness in the use of light boxes to treat seasonal affective disorder, a type of depression linked to low winter light.

Because they have a real--and sometimes profound-- effect, they are best used according to specific directives based on the particular mood or sleep issues one is experiencing. In some cases, use can increase hypomania (agitation, excess energy, and insomnia among other symptoms). Usually a reduction in the exposure time is enough to remedy that. However, I encourage persons considering light therapy to consult their physician or mental health practitioner and have some sort of system in place to track results. Because it isn't completely clear that such intense light exposure is safe over long periods for eyes, light therapy isn't for everyone and the risks as well as benefits should be explored.

I'm a chronically terrible sleeper, and an even worse waker. I noticed that the best sleep I have is when I am camping and rise and go to sleep with the summer sun. Since that time frame is typically also when I rise and wake in the winter, I have found great benefit in the use of a dusk/dawn simulator. The device I use attaches to my bedside lamp and is programmed to turn the (100 watt full spectrum) light down very gradually in the evening and then up again gradually in the morning. I use it from October to May and find I don't even need an alarm clock, as the dawning light creates a gentle alertness over time. I wake up refreshed instead of startled. Research suggests that gradual lightening stimulates a chemical cue to awakening, just as gradual darkness stimulates a chemical cue to drowsiness. I rarely use a light box since I've bought my dawn simulator. They aren't cheap-- mine was $150-- but I find it a bargain for the help it's provided me with sleep and waking.

Meanwhile, if it's a nice day, get out there! I recently read that the average American is getting LESS than the 20 minutes of sun a day needed by the body to manufacture adequate vitamin D. My MD tells me northwesters are often deficient, and the government just doubled the recommended RDA.

For more information on light and mood, see the wonderful website of Dr. James Phelps at www.psycheducation.org. Dr. Phelps is a psychiatrist who has done extensive literature review on the subject of mood disorders and light therapy.