Combating Cognitive Symptoms in Depression

Yesterday I told you about some of the reading I've been doing on the cognitive symptoms of major depressive disorder (MDD). It might have been too research-oriented for some of you, sorry about that. This stuff is what makes my heart go pitter-patter, sometimes I get carried away. Today I'll be more practical and talk about what I've read about treating these cognitive symptoms.

Medication Helps

Contrary to popular belief, antidepressant therapy is not the cause of you feeling like you've got a head full of cotton. Some medications can induce similar symptoms, but it is not a common side effect. Most people improve with antidepressant therapy. Only about 20% still have trouble with concentration and decision making after remission. Serotonin and norepinephrine re-uptake inhibitors (SNRIs) are pretty good at relieving cognitive symptoms. In a study comparing the cognitive status between depressives on selective serotonin re-uptake inhibitors (SSRIs) and those on SNRIs it was found that there was more improvement in the SNRI group. Those on the SSRIs were still having difficulty with episodic memory. They still had deficits in both verbal and visual memory. Episodic memory refers to memory linked to emotion and past experience as opposed to semantic memory which is memory of knowledge. So it looks like antidepressants that target more than one neurotransmitter are more helpful in the cognitive department. Remember, serotonin is involved in motivation and norepinephrine in concentration.

Bupropion, an atypical antidepressant has also been shown to improve cognitive symptoms. The primary focus of this one is increasing dopamine circulation in the brain. It also has an effect, although weaker, on norepinephrine and acetylcholine receptors. Again, remember, dopamine is for enjoyment and norepinephrine is for concentration. What about acetylcholine you say? That's a big one. It acts on neurons throughout the whole body. I'm not going to get into it, that's a whole biology lecture, but know that this is why bupropion is sometimes prescribed to help quit smoking.

Psychotherapy Strategies

Remediation techniques aim to improve someone's situation by targeting a specific cognitive skill. This technique is highly individualized. Programs are based on you personal interests and strengths. It involves various pen and paper tasks and some psychophysical computer tasks. The problem with remediation is that it is time-intensive. Your therapist needs to get to know your strengths and problem areas, then design the training program. Since it it's based on training, you have to do it often, sometimes several times a week.

Another strategy is compensation which relies on trade-offs. You find alternate ways of performing a task you have difficulty with. For this to work, your therapist has to be familiar with your learning style. You are basically taught to alter the course of your behaviour to suit your cognitive dysfunction. It has been found that doing this does not come naturally to people with MDD. From what I've read, it sort of sounds like cognitive behaviour therapy.

Finally there's the adaptive approach. Here you change the environment rather than the individual. This may mean changing jobs and/or depending on other people. This is used as a last resort when remediation and compensation are not working.

The Answer

There is no real answer, not yet. The cognitive side of MDD is only beginning to be studied. There is a long way to go. I have tried venlafaxin (SNRI) and it did give me better clarity. I couldn't handle the side effects and the withdrawal when I missed a dose, so I eventually came off it. Also, not a pretty experience. I am currently on bupropion in combination with some others. I did notice a difference when I added bupropion. Most days are alright, but the fog still comes and goes.

I recommend fighting through it. Don't throw in the towel on those foggy days. The brain is a wondrous thing. If those who lose their vision from traumatic brain injury can regain some of it, who knows what kind of adaptations we could build by just exercising our brains.

Sources:
cogstate.com 
Office of Mental Health 
Trivedi and Greer, 2014

Misadventures with Dr. Dreamy the Psychiatrist

I'm seeing my psychiatrist today. I'm not looking forward to it. The first time I met him was years ago. My doctor sent me to him to get another opinion on anti-depressant medication. I had never been to a psychiatrist before. I was anxious, but keeping an open mind. So I went to my first appointment and it was awkward. First of all, Dr. Dreamy is very attractive and he's not much older than me. I guess I was expecting someone older and wiser, someone who wasn't a peer. The fact the he was cute and making me blush just made it that much more uncomfortable.

I had waited months and months for the appointment, so I wasn't going to bail now. I was okay talking to him about my anxiety issues. It was harder to talk to him about depression and my body image issues, but I did because I thought it was important. I had two appointments with him before I went back to my regular doctor.

It took Dr. Dreamy about two months to get back to my regular doctor about his opinion on my meds. He said the best thing for me would be Remeron. Remeron?! Are you kidding me?! Had he been listening to anything I was saying? I had basically told him I was obsessed with my weight and miserable because I was fatter than I wanted to be. I told him I was addicted to cake. Remeron is notorious for increasing appetite, especially for junk food and is one of the worst drugs for weight gain. I'm lucky I did my research ahead of time. Otherwise, I would have assumed doctor knows best and just taken what he recommended. Needless to say, I didn't go back to him.

Fast forward a few years. I passed the 25 years old marker which was disastrous. I had to stop seeing my regular doctor because I was no longer considered a youth. 25 is also the cut off for being on your parents' medical insurance, so no more private therapy. Therapy is a little expensive for a grad student. I tried the counseling services at the university, but that didn't go well. A story for another time.

So now what? I started going to a walk-in clinic to get my refills. They refused to give me more than a month's worth. So once a month I'd spend a few hours waiting at the walk-in. Yuck. I was put on a waiting list to see psychiatry (hope!). Then I found out they refer to the same practice that Dr. Dreamy was from. I made sure I requested a woman this time. Not only to avoid Dr. Dreamy, but I was hoping a women would take my body image issues more seriously. It took over 8 months to get an appointment with psych.

So I go to my appointment, feeling hopeful that I'd be able to get some real help again. I'm waiting in the waiting room and I hear my name called. I look up.....and it's Dr. Dreamy again. Doh! Apparently since I started my file with him, I have to stay with him. Unfortunately, the past few years have been good to Dr. Dreamy and he's still as cute as ever.

Since I didn't really have a choice, I gave Dr. Dreamy another chance. He seemed better this time, although talking to him is still awkward. I feel like he is actually listening now. I've gone back to him many times, with long wait times in between. Instead of telling me what medication would be best for me, he has been asking what I think would be best for me. I'm managing my own meds? Does anyone else's psychiatrist do this? At least this way I wont go on anything that causes weight gain, but I'm not a doctor, I don't really know what I'm talking about.....

Road Trip and Withdrawal

Road Trip!!

I was actually looking forward to the change in scenery. I got up early enough to get in a workout before hitting the road at 8am. The drive from Montreal to Toronto isn't that exciting. You go straight...for about 5 hours. At least there is no chance of getting lost. The major highlight making this trip as a kid was the giant apple on the side of the highway just outside of Toronto. They call it The Big Apple and sell all sorts of apple items, pies in particular. I've never stopped there, but who knows, maybe I will this time.

So I was enjoying my road trip with the husband until we got to Cornwall. Cornwall is about half an hour outside Montreal. I realized I had forgotten all my medication. When you are on anti-depressants and they tell you not to go cold turkey, it's not something to be taken lightly. So much for my little getaway. I'll be okay today and tomorrow, but after that the flood gates will open, my negative feelings and self-loathing will return. My brain just wont work right anymore. The way I think and what makes sense completely changes when I'm off medication. I've left my meds behind often enough to know that this is what happens. I know my thoughts are distorted and I shouldn't take them seriously, but its still no comfort, I still have to fight the demons. It gets harder to concentrate on things, to smile, to make conversation and normal routine tasks like brushing my teeth or taking a shower suddenly become insurmountable. Forget going to work or out with friends. That's what I was planning to do on Saturday, go out with friends from elementary school. I hope I'll still be able to handle that by Saturday.

Going cold turkey on some meds is easier than on others. It also depends on your brain chemistry. What I'll be going through in the next few days will be rough, but I'll manage. I wont be wishing I could slam my car into a tree or anything. It is like that sometimes when you suddenly stop. When I was on Effexor and I ran out it, was scary! I couldn't stop crying, I couldn't leave the house and I was wishing that I could go to sleep and never wake up. I also got a really strange withdrawal symptom.....shocks. You know when you shut the car door in the summer, sometimes you get shocked. It was like that, but happening in my head. It was really disruptive and uncomfortable. It's hard to carry on a conversation with that going on in your head. So weird.

I ran out of medication a few times while I was on Effexor. I didn't have a regular doctor and prescription refills aren't exactly top priority at the walk-ins. Because of the horrible withdrawal and all the other uncomfortable side effects (stomach upsets, dry mouth, loss of libido, tremors and excessive sweating) I ended up switching medications. Effexor was both the best and the worst medication I have been on. It gave me a lot more energy, I even lost weight, but the side effects and withdrawal were too steep a price to pay.