Coping with Depression and Elation
By Dr Patrick McKeon - a Sheldon Press book

Certain kinds of depression and mood swings have features which set them apart from ordinary feelings of sadness and high spirits, and doctors identify them as bi-polar illness, or manic depression.

All sufferers will find this book invaluable. It describes simply and sympathetically the causes, symptoms and treatment of depressive moods, how to recognise mood swings and why it is so important that a true depressive illness should be properly diagnosed and treated. There is advice for sufferers and their families to help them cope day to day, and essential new information about the related problem of Seasonal Affective Disorder - the 'winter blues'

If you suffer from mood swings, Dr McKeon shows that there is no need to feel overwhelmed by them - most sufferers can find effective treatment and lead happy and fulfilled lives.

• Acknowledgements
• Foreword
• Preface to the second edition
• Introduction

• Recognising mood swings
• What can go wrong?
• Causes of mood swings
• Treatment of depression and elation
• Preventing recurrences
• Mood swings and the family
• Some common questions
• Appendices:

1. A summary of the do's and don'ts
2.  Lithium advice sheet
3.  Admission to hospital

• Useful addresses
• Suggestions for further reading
• Index

Preface to the second edition

Since this book was first published in 1986, a number of interesting changes have occurred in our understanding and knowledge of, and attitudes towards, depression. Possibly the foremost of these has been the increasing public acceptance that depressive illness is a major health issue, meriting attention. This long overdue and welcome shift in public opinion probably reflects the changes that twentieth century society is currently experiencing, as the technological revolution replaces the industrial age and mass unemployment traumatises individuals and whole communities, forcing them to reflect on their hurt feelings. This individual and societal awareness of hurt emotions or depression has enabled us to be more empathic and understanding. This, coupled with the realisation that depression is both common and can affect people from every stratum of society, has lessened the public perception that it is a sign of personal weakness.

In addition, when personalities like Patty Duke, Spike Milligan, Kitty Dukakis and Brenda Fricker talk unashamedly about their experiences of depression, they give a lead to others, who previously would have hidden their depression. Radio and TV chat shows and drama series have followed through with detailed and reflective interpretations of depression and how it should be managed.

The past decade has also seen significant advances in depression research. Our understanding and management of certain forms of mood swings, such as rapid cycling mood disorders, has advanced considerably, as has our knowledge of lithium and other mood stabilisers. New antidepressants are now available, and it is likely in the foreseeable future that much of the biochemical and genetic aspects of depressive and manic-depressive illnesses will be unravelled.

As with the first edition, I have written this book for people with mood disorders, their families and friends. It is based on my experience of people I have met in clinical practice, and through my involvement with members of Aware, a depression self-help organisation.

Introduction

This story is about people, people we all know. We meet them in the street, buy our newspaper from them, they preach to us on Sundays and care for us when we are sick, they design our homes and govern our country. They are people like you and me, with real feelings and aspirations. Their mood swings set them apart; for some these are mild and innocuous, for others they are grossly incapacitating and are referred to as manic-depressive moods.

Depression and elation are probably the oldest recorded mental illnesses and have been described in the Old Testament and in the works of Homer and Hippocrates. Over the centuries, from the pens of educated sufferers came accounts of inexplicable moods ranging from utter despair to periods of prolonged joy or ecstasy. The few who recognised their distress as an illness seem to have accepted it as part of the human condition while others went unrecognised or misdiagnosed.

Although graphic descriptions of individual mood swings have existed from the earliest days of civilisation, the association between the opposite extremes of mood was not widely accepted by doctors until the nineteenth century. In 1854. Jean Falret, a French psychiatrist, published a description of cyclical mental illness, calling it 'La folie circulaire'. Throughout Europe at that time other psychiatrists were reporting similar observations. The eminent German psychiatrist, Emil Kraepelin, impressed by these studies, proposed the name 'manic depressive illness' in 1896 to characterise recurrent episodes of depression and elation and went on to propose a classification to distinguish mood disorders from other mental illnesses. This classification has been the cornerstone of twentieth-century psychiatry, and his astute observations have been confirmed by present-day researchers who now recognise three patterns of mood swings: recurrent depression; recurrent depression alternating with bouts of elation; and recurrent elation.

Once mood disorders were characterised as a distinct illness, the quest for a cure started in earnest. In the early decades of the twentieth century the dramatic advances in medicine and the interest aroused by the Freudian view of emotional disturbances created an optimistic outlook for disorders of the mind. Expectations of major therapeutic advances, however, went unfulfilled and had to take their place behind the slow march of history. Treatments such as hydrotherapy and non specific sedatives were all that were available and sufferers had to wait patiently for a spontaneous break in the illness.

Dramatic breakthroughs occurred in the 1950s with the discovery of anti-depressant pills and a range of treatments for controlling elation or mania. For the first time individual episodes of depression and elation could be successfully treated, thus lessening the strain of human suffering. However, these drugs did little to prevent the pattern of recurrent mood swings. Lithium was to change all that. Although first used to treat elation in 1949, it took many years of intensive research before its value as a preventive of mood swings was recognised. Today it is the principal treatment for recurrent manic depression and has proved to be a safe and effective medication. This discovery has radically altered the outlook for patients all over the world and has made their wish for a normal life a reality.

Unfortunately, achieving stability is often hampered by a variety of difficulties. First among these is the failure to recognise that a mood swing is occurring. Even today a person in the midst of a mood change may be as beguiled by the experience as a fellow sufferer of centuries ago. Depression may be mistaken for fatigue or anaemia, or masquerade as insomnia or one of a legion of bodily complaints. Elation is even more deceptive; its boundless energy, and grandiose and witty manner may be what the patient is most aware of, but others, particularly family members, will know the impatience, impaired judgement and many indiscretions. Inevitably, unrecognised depressions and elations will leave their mark on many facets of the patient's life. So spotting a mood change in its early stages becomes the first step to successful treatment.

'Manic depression' is still considered a horrifying term and conjures up images of violence, unpredictability and sheer madness. Sufferers from the illness recoil when they first hear the diagnosis and their deep sense of dread often prevents them both learning about the illness and coming to terms with its reality, which ultimately leads to a rejection of treatment Many a traveller along the path of acceptance has faltered in the face of his doubts or was waylaid by well-meaning friends who assailed him on the evils of his 'drug' taking. Most are keen to know the facts and be advised about preventive measures.

A mood swing is not a private affair. By its nature it not only affects every aspect of the sufferer's emotional life but also his relatives and friends. They may be unsure of what is happening, have difficulty recognising the moods, blame themselves or others, and may despair of ever having the illness remedied. How they cope with these difficulties and adapt to the changing moods will have immense influence on the final outcome. Their understanding, support and guidance is as crucial as any other aspect of the treatment.

In 1982 I was approached by some relatives of patients with mood swings who felt little was being done to help them cope with the emotional burden imposed by the illness. They were bewildered, felt alone in their plight and many had never heard terms such as elation, mood swings and manic-depressive illness. We agreed to meet weekly to discuss their difficulties without any other aim in mind. From the start this gathering of relations began to see that they had much in common. They described the dread of elation, how depressions were much more manageable and, seeing the similarities in each other's accounts, they found support and realised that they could make sense of what had often previously been a chaotic situation. They learned to recognise a mood change in its early stages, became more supportive and encouraging, and helped the patient to limit the effect of the mood swings. It soon became obvious that the patients were just as much in need of a factual understanding of their illness and its implications if they were to achieve a durable stability. From this evolved a regular series of group meetings and lectures for patients and relatives where they could share and learn from each other, and grasp the facts about the illness. I have been encouraged by the many patients and relatives who have benefited from a realistic understanding of the illness and its treatment to give some direction to those who follow in their footsteps. The first edition of this book was a summary of the contents of the discussions and lectures that evolved over four years.

Those very same patients and relatives founded the organisation Aware, which established support group meetings, public lecture series and a Depression Awareness Campaign throughout Ireland. Since its formation in 1985 Aware has provided a 'phone line counselling service and has funded depression research. Similar movements evolved in the U.S.A. with the formation of the Manic-Depressive Association and in the U.K., with the Manic-Depression Fellowship.

Throughout the book's seven chapters the emphasis is on the practical aspects of coping with the illness. You will learn what is meant by elation and depression, how to detect them in their early stages, and how to recognise the different types of mood swing. As many who have depressive episodes also have periods of elation, which neither they nor the family recognise, an expanded account is given of the different degrees of elation. A new section on 'unpleasant elations' or dysphoric mania and rapid cycling mood disorder has been added to Chapter 5 in recognition of the importance of correctly diagnosing these aspects of mood disorder that frequently are not correctly identified. Descriptions of the complications that may arise and how they can be prevented are accompanied by some case histories. Next, the focus is on the causes of mood swings, and the effects of stress, childhood experiences, heredity and seasonal factors are considered. Here you will see how a variety of factors interact to produce mood swings and get some indication of why a treatment such as lithium works. The treatment of elation and depression is distinguished from their prevention, and the role of anti-depressant tablets, ECT, lithium, and psychotherapy is covered in detail. There is a section on the new mood stabilisers, carbamazepine and sodium valproate, with some discussion of other treatment approaches when more standard prevention techniques fail. You will find practical and constructive advice on how to spot and limit the effects of mood swings. Throughout, much emphasis is given to the important role of the family. You will find practical and constructive advice on how you can recognise and limit the consequences of mood swings. Your ability to understand and recognise depression and elation, how to come to terms with the possibility of recurrences and promptly to avail yourself of the best treatment there is for mood disorder is the central focus of this book. The final chapter answers a range of questions frequently posed by patients and relatives.

In the Appendix you will find suggestions for further reading and a list of depression support organisations available world wide.

Finally, throughout this book the patient is referred to as 'he'. This is by no means to imply that all sufferers of depression are male, and 'he or she' is to be understood throughout.

About the author
Dr Patrick McKeon is Consultant Psychiatrist at St Patrick's Hospital, Dublin. He studied at University College, Dublin, and is a Member of the Royal College of Physicians of Ireland, the Royal Irish Academy of Medicine and the Royal College of Psychiatrists. He is also a Senior Lecturer at Dublin University. Dr McKeon has published a number of articles on depression and obsessive-compulsive neurosis, and is co-author of Multiple Choice Questions in Psychiatry (Pitman, 1985). He has a special interest in the treatment of depression and elation, and runs a mood disorder therapeutic programme. He is currently researching resistant depression.