When it comes to depression, it can be more common than not to have multiple conditions going on at the same time. Depression can be a co-morbid condition of many chronic medical diseases such as diabetes,Multiple Sclerosis,and Rheumatoid Arthritis. One can also be dually diagnosed with more than one mental or neurological disorder. Depression can be a problem for those who suffer from anxiety, Bipolar Disorder, or ADHD.
Today we are going to talk about depression and schizophrenia.
I have had the honor to get an interview with Christina Bruni who is the community leader and lead writer for Health Central’s SchizophreniaConnection. I visit the schizophrenia site regularly as my mother has this mental disorder. Christina had recently interviewed me about my experience with having a parent who has schizophrenia. I was eager to ask for Christina’s firsthand expertise in how one copes with having both schizophrenia and depression. In my experience in living with my mother, it seemed that her schizophrenia diagnosis took precedence over any depression symptoms, which largely went unrecognized or treated. I am hoping that this interview will help to increase awareness of the signs of depression for those who are also diagnosed with schizophrenia.
Can depression be a co-morbid condition of schizophrenia? Are the signs and symptoms of depression often missed because an individual has schizophrenia?
Christina Bruni: Depression can co-occur with the symptoms of schizophrenia. One debate is whether the person who experiences the negative symptoms of schizophrenia is actually depressed. A psychiatrist I interviewed about three years ago suggested adding an anti-depressant to the mix to see if the person would perk up. A negative symptom of schizophrenia-so-called negative because it takes away from ordinary experience or reduces it-can be a lack of motivation. So it can be tricky to know whether the person is depressed or simply exhibiting a negative symptom.
The doctor I spoke with said sometimes it's worth it to try an anti-depressant in this case. One thing is that there exists a diagnosis of schizoaffective: a combination of schizophrenia with a clear-cut mood disorder that could be mania or depression co-existing with the SZ. Or a person can have depression with psychotic features. So the psychiatrist has to carefully assess what might be going on.
I know other people with schizophrenia-and one person with bipolar-who take anti-depressants so it is possible for the psychiatrist to pick up on it. However like I said depression can be mistaken for a negative symptom.
What is the experience like to have both depression and schizophrenia?
Christina Bruni: Okay: for close to 10 years I had seasonal affective disorder. Starting in the late fall and lasting miraculously and exactly up until the first day of spring I was in tears at night for two hours straight every night. Only I didn't really connect the two-SAD and SZ-and felt I was just a crying mess and who would want to marry me if he had to deal with a crybaby all the time?
Schizophrenia itself is an interesting diagnosis because of its manifestation with multiple symptoms: voices and delusions that are the classic symptoms, depression, negative symptoms and also anxiety. So it's a mix of all these things going on. Luckily as soon as my psychiatrist raised the Stelazine from 5 mg to 10 mg I stopped having SAD. Right now when I'm feeling low I'm able to pick myself up. I also go to the gym.
What is most likely overlooked is the socioeconomic burden of people with schizophrenia who get depressed because of their life experiences: living on a government disability check and having to watch their money because they get so little of it. Also dealing with stigma and feeling like they are alone and nobody understands them could cause someone with SZ to be depressed. These are environmental factors that can't be ignored. Also there is the real problem that families often turn away from their loved ones who are diagnosed with schizophrenia so there is no family support which could ease the burden of coping with your schizophrenia symptoms.
Is there any overlap of schizophrenia symptoms and depression symptoms?
Christina Bruni: Yes like I said it can be tricky to differentiate between negative symptoms and depression symptoms. Also because some people with schizophrenia lack the capability to be engaged and motivated in the world outside their apartments because they stay inside and watch TV. So their SZ symptoms can cause them to isolate in their room which is also not healthy because the loneliness reinforces the feeling of alienation and of being different, so the depression could set in.
Are there certain times when someone having schizophrenia is more prone to feeling the symptoms of depression?
Christina Bruni: Of course like I said in the late fall and through the winter. Another interesting dynamic would be [as it was in my life] the person with SZ who chooses to risk finding full-time work instead of collecting a government disability check. In 1990 when I found my first job as an administrative assistant it was unheard of for people with schizophrenia to be employed. No peer support group existed and I did everything on my own to cope with working in an office and meeting the demands of having a professional job. It was early in my recovery and I was so depressed at having the schizophrenia that I cried all the time and polished off a tub of Ben-and-Jerry's every week.
So sometimes you get depressed when you hear the diagnosis and you're not depressed because you're sad: you're sad because the diagnosis is a heartbreak and you think your life is over and that SZ is a dead-end or a life sentence. So at the earliest moment of your diagnosis you could get depressed.
I also, because I was doing so well and had recovered quickly, risked going off the medication and had a fateful relapse within three months and had to be hospitalized again and placed back on the drug. So at the moment when a person is no longer in denial about the truth of having SZ, that can also cause depression.
I've written about the stages of emotional response to trauma at SchizophreniaConnection because the diagnosis of schizophrenia is often a trauma and how a person responds can mirror the stages of grief. Depression is one of the five stages along with bargaining, anger, denial and ultimately acceptance.
Also: a person could get depressed when the schizophrenia symptoms are in full bloom if they haven't developed coping techniques for managing their SZ.
Do any of the medications used to treat schizophrenia cause depression-like symptoms?
Christina Bruni: The SZ drugs because they are thought to act on the neurotransmitter dopamine have a depressive effect in that they calm the brain. So the person taking these meds might feel drowsy or have no energy. It's often a simple matter of changing the dosing time.
My psychiatrist switched my extra dose of Geodon from the morning to at night and I immediately went from falling asleep in the afternoon to being wide awake all day. On the other hand a drug like Geodon which I do take for the schizophrenia has a mood-enhancing effect and is thought to regulate mood. That is why certain drugs to treat schizophrenia are often prescribed, sometimes off-label, to treat bipolar and mood disorders.
One thing I must tell you is that any drug you take when you have SZ, bipolar or another mental illness should be researched carefully to see if it causes depression. A good friend of mine went on two drugs [Norvasc and Lopressor] to treat high blood pressure and it had as a side effect that not only did it cause depression it caused suicidal ideation. My friend has bipolar and took the drugs and felt like jumping in front of a train so told the internist and my friend immediately stopped taking the drugs. He felt his MD should've known better than to prescribe this high blood pressure drug to someone with a history of depression.Only about 5 percent of the people taking that drug become depressed and he was one of this unlucky minority. So an astute psychiatrist would do well to ask what other drugs a person is taking when they arrive in the office presenting symptoms of depression.
Some reports show that the rate of suicide among individuals with schizophrenia is about 10 percent. In your experience, are there any warning signs to look for, to indicate that a person with schizophrenia is contemplating suicide?
Christina Bruni: Most people who are suicidal make their intentions known so take action when someone makes a direct statement. For a person with SZ: you need to be sensitive to whether they're isolating more, stockpiling pills, not taking their medication or acting reckless or impulsive. The purchase of firearms is also a clue.
Jane Pauley, who has bipolar, alluded in a talk to the fact that suicide can be an impulsive act. If a person seems more depressed, wants to give away their possessions these are also two things to be concerned about.
It can be hard to know who's at risk of committing suicide after developing schizophrenia. Everyone in the world should be well-versed in suicide prevention efforts to begin with. The American Foundation for Suicide Prevention (AFSP) web sit and the other suicide prevention web site are good places to start.
Any hint, however vague, or comment made about wanting to end it all, even if couched in other terms and not directly stated as "I want to commit suicide" should be taken seriously.
The information about warning signs and the response to take is too detailed to transcribe here so I urge you to read the following links to the AFSP pages on these topics:
It's not always easy to recognize when a person with SZ is at risk because they're not going to tell you what's on their mind necessarily. The number-one warning sign might be hearing command voices. The presence of command voices-those voices that tell a person to harm themselves-warrants immediate treatment yet sometimes the person doesn't have the insight to seek help. I once was able to pick up on a person's cry for help and immediately recommended the suicide hotline numbers (800) 273-TALK (8255) or (800) SUI-CIDE (784-2433).
If your instinct or intuition or gut tells you a person is considering suicide you should not ignore your own signals telling you this, you should talk to the person. The web sites I mentioned are good resources for how to start communicating with a person who is at risk. Sometimes you can even call the suicide hotlines yourself to get advice on how to help someone who you think wants to end their life.
The overlooked preventive measure as opposed to remedy is that if you know someone with schizophrenia, communicate with them regularly: talk to them often, support them, encourage them in their life goals, listen to them. Too often people diagnosed with SZ are ignored, forgotten, abandoned, stigmatized, left to their own devices to cope with this illness that is frightening, confusing and difficult to cope with when they have no support.
Again: for everyone in the world to be aware of the warning signs of suicide and to do what any compassionate person would do to give the person with SZ comfort and support.
What can be done to prevent both depression and suicide for people having schizophrenia?
Christina Bruni: The short answer is that more drugs need to be developed that work with minimal side effects to treat schizophrenia so that more people can find relief from their symptoms. I know people who want to commit suicide and some have tried it [having SZ] not because they want to die only because the voices and hallucinations or other symptoms are so severe that they can't take it and want an end to their pain. So their rationale is that if they commit suicide the voices will go away. This happened to someone I know and it's not a logical conclusion to jump to yet faced with non-stop voices a person might feel they have no other choice.
Also because a lot of people with schizophrenia hear command voices telling them to commit suicide or to hurt themselves that they must die they are worthless: this is where having better drug options that halt these kinds of symptoms would also help. For a significant number of people with SZ the drug doesn't relieve all of their symptoms and at times in their recovery they have breakthrough or residual symptoms that are hard to deal with. So it is trickier too if the person believes what the voices are saying and is prone to act on what the voices are telling them to do as opposed to seeing through this and understanding it's just a symptom and they have control over it. This is where cognitive therapy comes in to help a person find effective coping skills to reduce the impact of their symptoms. I keep telling people who write in at SchizophreniaConnection over and over to consider cognitive therapy in addition to medication and I wonder how many people actually take me up on this.
To prevent depression it could seem like what I'm going to say is circular logic as well. To be able to lift a person out of depression before it has the chance to start would be the ultimate solution. For this to happen I'm going to repeat something I wrote at SchizophreniaConnection: when a person has a paid job that brings in extra income to supplant the SSD check, or does volunteer work that makes them feel good. Studies have shown that doing volunteer work boosts the endorphins and you get a "helper's high" that elevates your mood in the long-term as well. So the trick is to get a person active in the world which might not be possible if they become depressed and can't get out of bed.
In my life I was lucky because as soon as I got out of the hospital the first time I started attending a day program within three weeks. So I had art therapy and group therapy every day and activities like cooking once a week and ceramics with other people who also had recently gotten out of a hospital and had been diagnosed with a mental illness. So I didn't have time to wallow in pity at having gotten sick and I had an enforced routine every day that accounted for my time while I wasn't working.
Parents whose adult children live at home after a diagnosis of schizophrenia need to set house rules: that their son or daughter find something productive to do with their time as opposed to lying on the couch watching TV. For some people it could be as simple as going to the library and reading a free newspaper or using the library computer to log on to MyDepressionConnection or SchizophreniaConnection to have an outlet in their recovery to meet other people.
I've also numerous times suggested that online communities are a good introduction to peer support for a person who is geographically isolated from a regular support group or who is so depressed they can't get out of the house. For this reason I recommend a short-term day program or volunteer work in the long-term if someone diagnosed with SZ cannot work at paid employment at that time in their life.
As for preventing suicide… be in that person's life and show you care about them. Praise them for the efforts they make in their recovery. If the risk is clear that they are going to harm themselves right away: do what you have to do even if that means calling an ambulance or at least getting help to get them to a hospital.
It may not be uncommon for caregivers and loved ones of the individual with schizophrenia to be at risk for depression. Do you have any suggestions or advice for caregivers who are battling a mood disorder and also trying to help their family member?
Christina Bruni: This is going to sound counter-intuitive however at the point where the caregiver or loved one is in danger themselves because of their own depression they should put their needs first so that they have the strength to carry on. The classic example is that of a mother on an airplane putting the oxygen mask on herself [before putting one on her kid] as the plane is going down. They should have their own therapist-and therapeutic outlets like a weekly yoga session or trips to the gym or to a museum or a lighthearted movie.
In Staten Island where I lived for many years NAMI-Staten Island offered a Respite Service for caregivers: a peer with a mental illness would come to the house to spend time with the son or daughter with SZ or another mental illness. This allowed the mother or father to go outside to dinner at a restaurant or take part in any of those activities I mentioned or even just carve out this time to do whatever they wanted away on their own for a few hours.
Last thoughts or anything extra you wish to add on this topic?
Christina Bruni: It helps when you are depressed because of the schizophrenia or because of your loved one's illness to stay active and eat healthfully and take care of yourself physically as well as mentally and emotionally, and spiritually too. I'm a zealot in my own life now about going to the gym on a regular basis because I find that when I like how my body feels I feel better about myself. Exercise in combination with an anti-depressant and sometimes on its own is perpetually touted as a mood-booster.
The last thing I can tell you [and a woman I interviewed for SZ magazine also believed this] is that when you do public service like volunteer work it takes the focus away from your problems and distracts you from your pain. Research studies prove that there are actual health benefits associated with doing volunteer work. One of these benefits is that a person who has suffered a tragedy can find comfort and reconcile what has happened to them and it speeds the way to their healing.
Thank you so much for this interview Christina. I know your suggestions and advice will help a lot of people.
For more information, resources, and support about schizophrenia please visit SchizophreniaConnection.
Published On: December 13, 2010