Demoralization: What If Antidepressants Are Not The Final Answer?

Owl pic from Iowa Arts Festival 2013I watched a very interesting show about owls and how well adapted they are to their environment, specifically as predators. Their eyes take up a lot more space than brain in their skulls compared to humans and their hearing is aided by their satellite dish shaped head feather arrangement. Further, they can fly silently, allowing them to catch their prey unaware. You can find a a couple of YouTube videos on line about their strengths as hunters.

But it seemed virtually impossible to find YouTube videos about the single impediment to hunting that can make owls go hungry–rain. It negates the specialized coating on their feathers which enable silent flight and it interferes with hearing. It’s fascinating how nature tends to avoid giving either the hunter or the hunted an overwhelming edge.

So how does that relate to psychiatry? Well, evolution has given humans the gift of a large brain (just as it has sacrificed the space for it in the skulls of owls), in the service of conferring a slight competitive edge in the world.

However, when we’re hospitalized with medical illness, that edge tends to be eroded and the part that gets dull the fastest is the most recently evolved large frontal lobe with the executive functions. This can lead to demoralization in patients and that’s not the same problem as clinical depression. It tends not to be responsive to antidepressant yet can interfere with healing by blunting the capacity for active coping, frequently leading to food or medication refusal and lack of participation in physical therapy.

Psychiatric consultants get called when this happens, and often the expectation seems to be that a psychotropic pill be prescribed for demoralization. Antidepressants are, in general, ineffective. More often than not, restoring executive function that gets lost from suffering severe medical illness depends on another feature of human evolution–the fostering of supportive interpersonal relationships.

It can be difficult to conduct psychotherapy in the general hospital, but not impossible. One way to look at it is to remember microtherapy “techniques” described in a previous post, thanks to my colleague, Dr. Bruce Pfohl:

1. Get the patient’s buy in or “Don’t start rowing until the patient gets into the boat and… stop rowing if the patient falls out of the boat.”

2. “Normalize the ‘abnormal”, which is sensitively assuring the patient that many other people find themselves in difficult circumstances and may feel, think, and respond in similar ways. This can be applicable to suicide risk assessments in the general hospital and mention this and other similar therapeutic techniques in the book co-edited by me and Dr. Robert G. Robinson, MD and which originated from Shea’s book “The Practical Art of Suicide Assessment: a guide for mental health professionals and substance abuse counselors.”

3. Engage the patient as a scientist or “semi-detached observer” by suggesting they write down what anxiety feels like and rate it on a 1-10 scale before, during, and after an anxiety-provoking situation. Similarly, you can ask what the patient predicts will happen in an upcoming troubling situation, which may help diminish the impact if the prediction comes true or, if the prediction doesn’t come true, teach the patient about the commonly inaccurate nature of mind-reading. Trying thought experiments by setting up worst case scenarios for the patient and asking them to brainstorm about possible contingency plans for dealing with the problems.

4. “Broaden options by identifying higher order goals” roughly means helping patients reframe the “difficult conversations” they have with others so they can imagine both/and goals in maximizing the satisfaction they derive in their relationships by focusing less on the win-lose conflict model and more on the generation of win-win agreements.

5. Help patients identify, activate, and bolster their social support system

6. Listen carefully to understand what the patient’s agenda is before trying to advance your own. Synchronizing agendas is easier when the patient feels understood. This is often facilitated by trying to restate the patient’s agenda in your own words and checking for confirmation you’re on the right track.

Another strategy is to view the challenge of demoralization through the lens of existential neuroscience, Psychiatric_Times_-_Brief_Psychotherapy_at_the_Bedside_Existential_Neuroscience_to_Mobilize_Assertive_Coping_-_2014-11-28, as described by Drs. Griffith and Gaby in the November 28, 2014 issue of Psychiatric Times. The psychiatric consultant can begin with the probe question, “What is your chief concern right now in the hospital?” followed by asking “How has this illness affected you and what have you done in response?”

Finding out what the patient’s coping style has been in the past can reveal whether they typically rely on solving problems by individual effort or interpersonal networking. Asking “What kept you going when times were hardest for you?” can uncover strengths which the patient may have forgotten.

Assessing active coping style could start with questions suggested by the authors that tap into whether the patient can engage in “pathways and agency” thinking:

“When you think about your greatest concern, can you imagine what a good outcome would look like? What would you consider realistic to hope for? What would be a first step that you could take to make that outcome more likely?”

“What else should I know about you as a person apart from your medical diagnosis? What has kept you going on your hardest days? For whom, or for what, is it important that you survive this illness and return home? What does it say about you as a person that you have continued to strive to recover? In your heart of hearts, who do you know yourself to be? What does that say about the way that you face this illness?”

Mining for the strength of relational coping can proceed with questions like:

This is a difficult illness to face alone—who do you most want to be with you as you face this illness
and deal with it?
• On your most difficult days, who do you turn to?
• Who knows what you are really going through? Who do you talk with about your illness?
• In whose presence do you most feel at peace?
• For whom does it matter that you recover from this illness?
• To whom do you most want your life to make a contribution after you recover from this illness?–Griffith and Gaby

This approach to demoralization takes longer than prescribing a medication. Find a chair where you and the patient can come in out of the rain.

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