Before I get to today's post, I want to wish my beloved wife and editor, Kathleen McGovern Chaffin, a joyous birthday, and I pray the gift I ordered arrives today! I have added a link to her poems below (left hand margin) from a recent feature in Mindfire (ed. Gary Blankenship), which I encourage you to read, not because it's her birthday but because she is an outstanding poet who, unfortunately, writes only rarely. She is one of the most lyrical poets I know, as her deafness affords her one outlet for her love of music: language. I would also be remiss if I did not mention that her beloved service dog, Kenyon, turned 11 on May 15.
Here's one of the many love poems I've written for Kathleen:
To Kathleen, after Neruda
As the salmon seeks its mother gravel
through the lying ions of the sea, I seek you.
Without your body my blankets are cold,
the ground hard, my joints uneasy.
Apart, I am a mold for your bronze--
halved, discarded. Do you know this hollow?
There is no shame in love. Daily
I embarrass myself, collar strangers,
weary my children. I am the ancient mariner
condemned to speak of you wherever I go.
Have you suffered this? Who am I to compare us?
You are smooth as agate, I am ripsawn wood.
My heart seeks you like a cyclone.
I would swallow your farmhouse whole.
Without you I am a one-handed magician
cheating at solitaire, hoarding coppers.
When will you come to me? It is already late
and my father has closed the drapes.
I listen for your stride; I could never
confuse it with another.
Your back is strong as a barge,
your legs were sculpted in Greece,
your hips formed in India,
your face sought by Raphael.
Your eyes threaten green lightning
from the Atlantic. You could crush me
with a word, like a mussel at low tide.
Why do I trust you so utterly?
Now back to the anxiety of depression:
I feel its cold shadow on my neck.
When I turn it’s gone. It keeps track of this.
It keeps track of everything
in a black binder with angstrom-thin sheets.
Did Mom create it by incessant hovering?
Did Dad by his necessary domination?
Did school create it by forcing comparisons,
or did I, by imagining I was important?
It feels like a huge bear behind me,
more impatient than malevolent,
sniffing the wind for the first hint of failure.
I try not to disappoint.
One of the most crippling aspects of typical clinical depression, or melancholia, as opposed to the lethargy of atypical depression, is an overwhelming sense of anxiety. It's as if every tiny decision is one terrible, fatal, final exam. Emptying a dishwasher can be a horror. Making a sandwich is like walking a tightwire without a net. Your hand shakes with the pressure of putting sugar in your coffee. You get the picture. Today's poem emphasizes that aspect of clinical depression.
I have found in treating patients that often a depression cannot be reversed unless the anxiety is first controlled, especially since early reactions to antidepressants can lead to an increase in anxiety (particularly Wellbutrin and Effexor in my experience).
This early effect of antidepressants is also the reason for a window of increased suicide; the driving energy of the antidepressant, while the mood is still black, can lead to rash actions. The physical stimulation of an antidepressant usually manifests before the patient experiences an improvement in mood, why it's very important to talk a patient through this transition.
Often a benzodiazapine, such as clonazepam, is beneficial in this transition phase to control anxiety. Antipsychotics may be needed, but remember: they can cause akisthesia, a feeling of "ants in one's pants," which can make the transition even harder. Lithium is a good adjunct in bipolars, less effective in unipolars, in acute depression, and there are many other adjunctive options, including thyroid supplementation, but to list them would be beyond the scope of this blog.
All for today,