Two sides of the same coin

An expert opinion by two distinguished psychiatrists- Prof. Andrew J. Cutler, MD, SUNY Upstate Medical University, Florida, USA and Dr. Kalyanasundaram Seshadri, Richmond Fellowship Society, Bangalore, Karnataka, India

Professor Andrew Cutler and Dr. Kalyanasundaram state,Poorer outcomes following early discontinuation of maintenance treatment in patients in stable remission could still be observed at a 10-year follow-up

“Treating Depression is a fine balance between what results you want to achieve as a psychiatrist and what your patients expect from the treatment, which is akin to viewing different sides of the same coin, where you see the heads and patient sees the tail of the same coin.”

Dr. Kalyanasundaram. S

“Depression speaks to us psychiatrists through the patients whom we meet”, provided we can tune in to their frequency, says Dr. Kalyanasundaram and further adds that it was a great learning experience from one of the patients who presented with major depression. It is an interesting case about Miss SG, who is a very articulate woman and a corporate trainer. She had a traumatic childhood and a broken marriage and came to me with moderate to severe depression, unwilling to carry the burden of life. In addition to showing clear signs of depression, she also narrated that she wasn’t feeling as before and there was a lack of clarity in her mind, she had been indecisive lately and very ill-tempered with her colleagues and would snap at them for trivial reasons. Clearly, she was in a bad shape both personally and professionally which was making her quite dysfunctional. This could lead to undermining her reputation and career, if left untreated.

I discussed with her about her depression and the need for medications for her to overcome this problem. Initially she was reluctant to taking pills and said she could overcome it without this. I gently persuaded her to try the new antidepressant in the market and convinced to try it for a couple of weeks and said that we will review it later.

In the next visit, I was pleased to see some change in her for the better. She was a lot more confident this time around and thanked me for persuading her to undergo treatment. She said, “gone is the irritability and I have a newfound calmness and I do not fight the past anymore but have made peace with it”. She further added that this has clearly positively impacted her at the workplace and she has resumed her work and is able to function well too. She understood the need to continue her medication and was soon back at her peak functioning, after being on the full dose of medication, in about 8 weeks. She started conducting several corporate training programmes with great deal of confidence.  I had explained to her at one of the sessions that “Depression speaks to us”, and we professionals need to tune in and understand its language. She was able to resonate with it and this made sense to her when she was on her path to recovery.

What this teaches us is that we professionals must try and understand the language they speak and not restrict ourselves to checking their symptom profile and examine the same at the follow ups too.

We must look at their functionality and recovery from their perspective, otherwise, we will lose vital information and will be unable to understand their point of view and end up working at cross purposes.

We must be willing to examine both sides of the coin, at every occasion!

Prof. Andrew Cutler

We as clinicians are trained to look at Depression very differently than how patients look at it. Case in point, we refer to depressed people as patients, however, the patient has a different take on his/her illness. We sometimes may forget that these are normal human beings with altered neurochemical balance in the brain, but they too must lead their daily life by coexisting with other people through interactions at home, society and at workplace. We can begin to understand the patient’s perspective through the lens of social media:

We are trained to look for signs and symptoms and use various scales to assess the severity of the illness and progression on treatment. Whereas for the patients, improvement has nothing to do with how many points they improved on a particular scale, but how meaningful their lives have become in their ability to maintain relationships with family, relatives and colleagues and being productive in whatever they do for living. In fact, I can draw some inspiration from the works of Dr. Mark Zimmerman from the USA and Prof. Koen Demyttenaere from Belgium on the same subject.

As per Dr.Zimmerman, patients want to feel “normal” and function normally.  They want to be in control of their emotions, they want to feel optimistic and self-confident, and they want to enjoy relationships with family and friends.

As per Prof. Demyttenaere, physicians are trained to focus especially on symptoms, while patients value things like having a meaningful and enjoyable life, personal satisfaction and being able to concentrate.

From my own experience, I can provide similar examples. I vividly remember a young mother who came to see me due to symptoms of fatigue, anhedonia, insomnia and worthlessness. But what really motivated her to seek help was that she didn’t feel like a good mother to her 2 young children. She had previously been an actress and an artist and was very creative. She used to enjoy arts and crafts with her children, but recently she had been laying on the couch and letting them watch TV and play computer games. She said she didn’t feel like herself and didn’t know what was wrong with her, implying that she was a bad person. She worried constantly that she was neglecting and possibly even damaging her children. 

What she taught me was that even though she had prominent symptoms, depression changed her sense of self and identity, of who she really was.

I am also reminded of a young woman who presented with sadness, hopelessness, intense anxiety, anorexia, and insomnia. She also had significant problems concentrating and was afraid she was going to lose her job, despite recently getting a good performance review and being offered a promotion. She reported staring at her computer all day, pretending to work, hoping her boss wouldn’t notice and fire her for being unproductive. She also worried that her boyfriend would leave her and felt guilty that he had to help with cooking and housework. Depression was affecting her function at work and at home, and she felt “like a different person, this isn’t me”. Being in the room with her, I not only collected her symptoms, but I felt her pain and despair.

I agree that patients like these and many others have taught me the importance of trying to see things from their point of view and of taking their perspectives and concerns into account as part of the goals of their treatment.  We must truly see both sides of the same coin in patients with depression!

To conclude on this very important and relevant subject, we believe that as clinicians should put a lot of emphasis on considering what is important for the patients in addition to providing remission from symptoms alone. I think the right word is ‘recovery’ or to be more precise ‘functional recovery’ and ‘reintegration with the society’. In order to achieve this, one has to look at both the sides of the coin and treat the patient as a whole not just chasing the arbitrary goals of response and remission.

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