Thursday, July 16, 2009

Suicidal Ideation and SSRI's

In this letter the writer expresses concern regarding her sister's welfare. She worries that the SSRI antidepressant she is taking is putting her sister at risk for self-harm or otherwise interfering with her quality of life. Some concerns are raised here and some myths are dispelled.


Back when I was in the worst part of my depression/anxiety/panic disorder, I was prescribed heavy doses of Zoloft and Buspar (maximum allowable amounts). While on the meds I felt nothing, I mean literally nothing-not happy, not sad, not anything. Which I suppose was better than the depression/panic/anxiety. However, there was a feeling I had--and my sister who recently began going through the end stages of menopause (at only 46 years old) and who was also prescribed Zoloft for at least a year has also recently experienced. That is something I call "passive suicidal feelings". Not wanting to actually take action to end your life, not actively looking for ways to do it either, just a feeling of "well if a bus hit me and killed me, that would be okay" (but again, not looking for that bus, just hoping a random act would happen).

Is that normal or is it something that the medical field has heard of? I thought I was unique/unusual many years ago but my sister recently reported those same feelings and happened to be taking the same meds so it made me think there's got to be a connection (either medically or by family?)



According to the DSM-IV, passive suicidal ideation is the lowest form and least lethal of suicidal conditions on a wide spectrum of intent. Although there is no immediate compulsion to act out these self-destructive feelings, it is reason for concern because it could easily advance into more active forms of suicide and interfere with her overall happiness and satisfaction.

There is valid widespread study supporting the association between SSRI (e.g Zoloft) class medications and suicidal preoccupation. In referencing the Journal of Family Medicine, this risk is greatest in the 1st 9 days of trial. The cause is thought to be from general agitation and akethesia, a general feeling of internal turmoil and unrest. This side effect is more generally found in typical antipsychotic medications, less in atypical antipsychotic medications and to a much lesser extent in SSRI's. But it does rarely occur. Despite this phenomena, a study by Kahn (2000), reveals less risk of suicide for subjects on SSRI's than those taking a placebo or no medication at all.

A common characteristic of depression is inhibition, the repression of uncomfortable thought and a reluctance to take action. When this symptom is lifted due to the change in brain chemistry at the beginning of an SSRI trial, thoughts of self-harm and worthlessness that were once repressed may surface into conscious thought. So varying forms of SI sometimes arise early in the trial of the medication. When the veil of depression is temporarily lifted, a reassessment of self generally occurs and if negative thoughts of self are allowed to flourish, they may not subside as the medication trial continues.

During the trial of the SSRI, the full efficacy of the drug can be realized in 10-14 days. This is a time of great opportunity for the client. With a general lessening of the feelings of psychogenic pain and dread, comes an opportunity to step back from the shroud of depression and identify the root cause of the thoughts and feelings that have contributed to the depression.

This is why it is so important to engage in talk therapy at this point. Several studies point to the importance of combination therapy in treating depression (for instance see Glass, JAMA. 2004;292:807-820, 861-863). The combination of cognitive-behavioral talk therapy and an SSRI medication have been consistently found to be more effective than the sole use of either intervention. The therapist can identify long held negative schema and thinking errors the client has held and assist in challenging and refuting them and help the client replace them with more measured, healthier and positive thought.

In the case of your sister, the onset of menopause may be of minor consideration. Doctors frequently prescribe antidepressants as an off-label treatment for menopause. The more recently developed SNRI's (serotonin and norepinephrine reuptake inhibitors) have got allot of attention in treating menopausal symptoms. Along with serotonin, norepinephrine reuptake is also inhibited. Norepinephrine is a neurotransmitter and stress hormone that also effects the way the body responds to and regulates temperature. It has been found helpful in regulating both mood and minimizing "hot flashes."

So perhaps a reevaluation of the prescribed antidepressant is necessary. More so, the question to be asked is has your sister ever received CB talk therapy in conjunction with the medication? If so, did she connect with the therapist and follow through with the treatment? The opportunity to examine her inner thoughts that were initially the cause for the depression and eliminate them still exist. She should seek out a therapist, one that fits her personality and disposition.

Wednesday, July 15, 2009

A Comment About Letters and Comments

I have been writing this blog for about 9 months now. I have received some interesting letters. Many are concise and right to the point. Some are a bit rambling and I have to sift through and glean information in order to give a relevant answer. Others are so brief I have to be somewhat hypothetical in my stance and opinion.

I have promised to publish or answer all the letters written and up to this point I have kept that pledge. I have published them as written as I find this to be the most helpful and honest method in which to respond to these inquiries. However, if a letter contains vulgarity I retain the right not to publish it on my page and if it is rude or condescending I reserve the right not to answer or publish it.

The same goes for comments. I have received a few that are constructive in their criticism and I appreciate that. Some have recognized my unique approach to a topic and I humbly and graciously accept the recognition. Others have used the comments as a forum to be vile, obscene and insulting. Disparaging remarks have been made about everything from my writing style to my profile pic. Nothing constructive mind you, just rude and acidic. It is easy to make these comments from afar, assuming the person lacks the courage to make them face to face or with even a return address to be held responsible for what they said. I have no editing function with the comments, so I either publish them or I don't. If they are rude, vulgar or intentionally insulting I have to delete them in their entirety.

Some commenters appear to have difficulty knowing the difference between opinion and fact. When I state something as fact, it is generally backed by overall conventional wisdom or it is well documented by study. One of the intentions of this blog is to create controversy and stimulate dialogue via the comments section. This way people can respond with their opinion in hopefully a mutually respectful way. In doing so, it is helpful to appreciate when I am being subjective and relating my opinion to the overall advice and discourse of the writing.

For instance, a few have stated that I view relationships in a rigid and archaic way. On the contrary, I have stated several times on this blog that people can mutually define a relationship however they want to. So when I state an opinion as regards parameters in a relationship, this relates to my own personal beliefs as to how I behave and act in a relationship. It is not intended to be a dictate or written in stone. So the pretense that their should be fairness and justice in a relationship, that what is good for one is good for the other, is based on conventional wisdom. The declaration that one should not give out a phone number to an available member of the opposite sex because it would risk hurting their partner is opinion. I would invite an intelligent reader to know the difference and digest that comment in the context of the entire article and blog.

Other nasty comments and emails have revolved around the use of the title "doctor," in this blog when I lack that qualification. There is a disclaimer in this thread wherein I state "I am not a real doctor, but I do have a Master's Degree......" In the 80's and 90's there was a popular show on NPR called Ask Dr. Science, in which an almost identical disclaimer was used. If this method of disclosure was good enough for an entity as prestigious as National Public Radio, it is good enough for me.

This blog, for me serves several purposes. One is to create a quick reference for my psychotherapy clients as regards common treatment techniques for their review. Some articles are also dually published on one of my contract employer's website. Another purpose is to try to stimulate a dialogue as regards maintaining a healthy romantic relationship and a well-adjusted self. And I readily accept opinions about these issues that are submitted in a civil and mature manner. The truly obnoxious and belligerent reader can just move on (its the left click on your mouse).

Wednesday, July 8, 2009

Reunited? A look at Unalienable Maternal Rights

I enjoyed receiving this email because it broaches a topic most of us can identify with. The writer yearns to reconnect with children she birthed, then during a troubled time in her life, relinquished parental rights. I do appreciated her concise writing and I will also try to get right on topic. The correspondence is printed as written, excepting the name which was changed to guarantee confidentiality.

I Have a question and I will try to make it the short version.

Back in 1995 my ex-husband, well we were married at the time, turned our two daughters over to the state claiming he could not take car of them. When he did this I was in jail for a bounced check. He had no reason for doing this as the kids were not in his care at the time, a friend of mine had them. After fighting with the state of Tennessee for over a year, I lost and my rights were terminated and they were adopted out.

Recently i have found out where they are and who adopted them. They are 15 and 14. I'm at a loss at what I should do now. I fear them rejecting me. Should I contact their adoptive parents and talk to them to see if they were ever told that they were adopted? I don't want to disrupt their lives but at the same time I long to be reunited with my girls, there has never been a day that has gone by that I haven't missed them. I need for them to know that. What should I do? Any advice would be greatly appreciated.

Thank you


There is this blood tie at issue here. It is greater than any law on the books. Karin's desire to be a part of the life of her children in some way is understandable. At some point in her life, during her troubled young adulthood, she vowed to try to loose her emotional investment of these children. Now she has found that is an impossible thing to do.

So in considering reuniting with the children, the 1st consideration is their welfare. We must weigh the benefits of being exposed to their past versus the simple family life they enjoy at this moment. They are of an age, however, when the discussion of their past may not be detrimental. It is my experience that adopted children should at some point know the truth about their blood ties. The timing becomes important as to when the information is exposed to them, at a time when they are emotionally and intellectually ready to handle the complexities of this issue.

So when are they ready to be exposed to this juggernaut from their past? I would say simply when they begin asking well-formulated questions about their birth rights and family linage. As they reach adolescence and begin to self-actuate, they will at some point see some inconsistencies in the notion that their adopted parents are biological parents. Differences in appearance, physical constitution and inconsistencies between the marital history of the adopted parents and their births are a few examples. So when the children are ready to ask concise and elaborate questions about their past, they are usually emotionally prepared to get honest answers.

Another reason it is important for them to eventually know who their biological parents are is it is a viable part of their medical history. The family genotype has become more and more important information in terms of medical treatment and prevention. Illnesses that are passed on from generation to generation can be addressed proactively and are a vital resource in keeping these children healthy.

So contacting the adoptive parents is a harmless first step in your attempt to be in some way a part of these children's lives. Approach this contact with humility and respect, as you realize the AP hold all the cards legally. If they think it is too early for you to have contact, you must respect this. But the communication will hopefully give you some insight into their development and at worst you will have greater knowledge of how they have reached milestones and the piece of mind that they are well taken care of and provided for and are moving through developmental milestones toward adulthood.

Keep in mind that knowledge of their adoption opens a Pandora's Box. For instance, they will also want to know about their paternal father and if alive his circumstances may not be as good as yours. If they are unable to find or contact him to get answers, this will be cause for anxiety and stress. There are many other issues about their past they will be curious about and you may be uncomfortable revealing this information to them or not be informed yourself of the answers.

So once again, the emphasis is on the emotional and physical well being of these children. If you and the AP can reach a mutual agreement with this in mind and set aside all selfish motives, a beneficial outcome is guaranteed.