Category: Depression

How can spiritual, life – wellness – health coaching, and holistic and integrative therapies help?

Generally, severe depression first hit people with acquired disabilities compared with people with hereditary disabilities. Acquired disability, whether from a chronic disease, acute disease, severe injury, or the late and full expression of a genetic syndrome, creates extreme, sudden life-changing conditions with plenty of challenges in the future of everyday life. People are adjusting and challenged to acquired disability conditions. Suddenly, either way, disability can generate very adverse conditions, such as depression, that involve persistent feelings of sadness, uselessness, and hopelessness.

Disabled people are still heavily dependent on primary caregivers

Disabled people are getting heavily reliant on their primary caregiver, either a spouse/husband, partner or friend, for transportation, paying medical and other bills, providing housing and food, etc. Interestingly, the saving account for the majority of disabled people is getting “dry” very quickly because, in the first two years of the disability, the person is not eligible for Medicare or Medicaid (with some exemptions), so the saving account is getting dry very quickly paying individual health insurance premium and medical bills for two years until they get eligible for Medicare or Medicaid. Independent living movement works probably well in a big city metro area where public transportation is available, and automatically paratransit transportation is possible because of compliance with the ADA-AA. However, suppose a disabled person lives outside a big city metro area. In that case, they become heavily dependent on their primary caregiver regarding transportation. In addition, disabled people live in health disparities. Some healthcare providers do not accept Medicare or Medicaid, so predominantly disabled people have insufficient access to health care, either preventive or curative.

A homebound lifestyle is one additional contributor to severe depression, feeling fatigued, pain with or no apparent cause, loss of appetite, and a person becoming easily irritable and forgetful; the altered sleeping pattern is pervasive as well. Life is getting significant stress full of challenges and barriers! Unfortunately, the primary caregiver for a disabled person plays the central role in the presence of a person with a disability providing the crucial resources for a decent life and advocating for the disabled person daily. Still, there are no specific help or support resources to make the primary caregiver’s life easier, less demanding, and more stressful.

Depression as a co-morbidity in the population of people with disability

If we observe better already, a person with a disability is getting co-morbidity, and that is depression. According to the Social Security Administration, depression is listed as a disability as well. Thus, already disabled person is getting more disabled with the other co-morbidity major depressive disorder. Depression, isolated by itself, is the second most common medical condition listed on Social Security disability applications and, worldwide, is the leading cause of disability. Being comfortable in new social circumstances, such as lack of transportation, employment, and an isolated and homebound lifestyle, lead to dysthymia and severe anhedonia.

Why disability leads to depression

One of the problems most disabled people stated is a loss of a life direction or purpose. This devastating loss could quickly open the door to severe depression. Unfortunately, the lack of appropriate vocational rehabilitation services significantly contributes to this condition. It is a primary factor that the majority of people with disability is losing a life direction and cannot see the explicit purpose of their life in the future. Most state vocational rehabilitation services operate by approximately 76% of the federal fund; 18% is a state contribution, and the rest is from Social Security Administration for the program “Ticket to Work” and other donations. Life is getting so complicated and stressful.

Over time a person with a disability will express the first signs of decreased self-esteem; lack of confidence is a new phenomenon that we can observe. Furthermore, the loss of autonomy is a devastating factor significantly contributing to reduced self-esteem and severe depression. Moreover, sadness, grievance, and frustration because of career loss are devastating and challenging for disabled people, either with an acquired or hereditary disability. Sometimes depression is an “isolated entity,” hidden for a long time, and disability simply triggers a full expression of depression (mainly in the population where depression has a solid genetic background).

The homebound lifestyle that most disabled people face is an additional contributor to the development of severe depression. Quality of life often decreases; losing independence is evident with a homebound lifestyle and heavy dependence on a primary caregiver. In addition, most disabilities leave people homebound with few opportunities to interact with others. Sometimes disabled persons are at home alone all day while the primary caregiver, either spouse, husband, the living partner, is at work, or in another scenario, the person with a disability is confined to an assisted living center where community activities do not match either age or interests and a person with a disability is getting more depressed.

Why disability raises depression risk?

Depression induced by disability can make the disability even worse. Mostly, depressed, disabled people find it challenging to take care of their health and preventive health care, mostly missing intentionally or unintentionally essential physician appointments and annual checkups with a primary care physician. Additionally, people with disability and depression as their co-morbidity do not take their medications as directed and on time. Untreated or unproperly treated depression in the population of disabled people will eventually lead to the first suicidal thoughts. Some evidence suggests that if the first episode of depression goes untreated, a person with disability and depression as co-morbidity has a 50% chance of experiencing a recurrence. In an untreated scenario, an episode of severe depression can probably last six months to a year.

Indeed, disability is a challenging and life-altering condition enough to cope with. Developing related depression as co-morbidity to disability will make the life of a disabled person even more complex and challenging. Psychotherapy is also available and sometimes can be very successful and helpful, sometimes even worse. According to the standards, most people are placed into the chronic treatment of CBT (cognitive behavioral therapy) instead of 6 -16 sessions. However, there is one problem, and that is who will pay for the long-term treatment. Mostly, primary caregivers are paying for psychotherapy sessions, or if the psychotherapist accepts Medicare or any other health insurance, that would be a perfect option.

“A substantial body of research shows that family members who provide care to individuals with chronic or disabling conditions are themselves at risk. Emotional, mental, and physical health problems can arise from complex caregiving situations and the strains of caring for frail or disabled relatives” (National Center on Caregiving, 2017).

Some research data are available regarding suicide in the population of disabled people. Depressive symptoms frequently occur in people with multiple sclerosis, and their rates of suicidal thoughts are higher than in the general population. Also, the presence of depressive symptoms directly influences the risk of suicide (1 – 6). Generally, physically ill health, disability, and feeling of heavy dependence lead to depression (7 – 9), and long-term work disability and absenteeism significantly contribute to depression (10). There is evidence for a direct association between disability and depression, disability and suicidal thoughts or ideation, and depression and suicide ideation (11, 12). There is some scientific evidence on how sight loss has an emotional impact and how readjustment may not occur, and suicide may result from depression and disability (13, 14). Suicidality in the population of people with intellectual disabilities has been the focus of several investigators (15, 16). Disability affects health-related quality of life and dysphoria symptoms such as helplessness, hopelessness, worthless, dissatisfaction with life, depression, and suicidal ideation. Generally, research data exhibited that physical disability is associated with a higher risk of lifetime suicidal ideation (17 – 20).

Additionally, there is fascinating research performed by Fishbain D.A., and colleagues in 2012, preferences for death over disability are associated with passive and active suicidal ideation and actual suicidality in patients with chronic pain (21). Generally, chronic pain is associated with an elevated risk of suicide (22). Holley J.M. and colleagues in 2014 stated that chronic pain might facilitate the development of a critical risk factor for suicide, fearlessness about death (22).

Depression alone is a disability even without a primary cause of disability, and it is a leading cause of disability globally (23). Coshal S. and colleagues 2017 stated in their article that one-half of the patients with depression do not receive adequate treatment (23). Klonsky E.D. and colleagues 2016 published an article explaining that suicidal behavior is a leading cause of death and disability. Very clearly, they describe the process of development of suicide attempts. They talked about three distinct steps: the development of suicidal ideation and the progression of ideation to suicide attempts. They are separate entities or distinct phenomena with different explanations and predictors (24). As they explained in their research, depression, hopelessness, most mental diseases, and even impulsivity predict ideation. However, these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide generally; depression, even episodic, result in lasting disability, distress, and burden (25).

How can life, wellness, health coaching, and holistic and integrative therapies help?

In the last blog related to disability, I discussed several phases of disability, “the beginning,” “hitting the wall,” “turning around,” “letting go,” “opening up,” “letting in,” and “the gift of “healing.” Certainly, in the phase “the beginning” we cannot expect from the disabled person to be cooperative and open for any kind of the treatments for improvements of life, wellness, health. Still, the person is in the state of “shock,” grief, anger, depression, mourning…However, how time passes the person will start to live life with multiple questions such as “what is the purpose and meaning of my life in this condition”, “there are no resources to help me, and they promised to me”, “this is a fake hope, nothing happened after several months”, “I am getting heavily dependent on you, I am so sorry, I am a burden”, “I feel hopeless, worthless, helpless” and many more.

In this condition, it is essential to approach the disabled person with the question, “what do you feel and think you can work? What would you like to work?” Finding skills and pulling them out “on the surface” is vital in this condition. Even gaining some new skills is an excellent solution. Taking the courses and continuing education courses, certifications, etc.. would be an ideal solution. This will open the “magical door” to the disabled person. Getting out of the house is essential, breaking a homebound lifestyle and heavy dependence on a primary caregiver. Taking yoga sessions with mindfulness meditation is extremely helpful (which is very well documented in peer review medical journals). Do not worry; even if you cannot do regular yoga, there is yoga in the sitting position, so there is no excuse for such a thing. Tai Chi and Qi Gong are extremely helpful for balancing body-mind-soul. Many mental health professionals are trained in life coaching. Sessions with a life coach can help find a new meaning and purpose in life, even a new career, pull out skills and talents that potentially could be a new job or profession, taking actions that eventually will result in motivation and focus.

Regular physician office visits are crucial. Lack of transportation in your area is not a good excuse. Most undetected co-morbidity is a potential trigger for additional disability and chronic illnesses. Integrative Psychiatry will provide you with more comprehensive and targeted therapeutic approaches and treatments. Importantly you will not be treated “treatment as usual – TAU.” Integrative Psychiatry considers your genetic background, biology/physiology/pathophysiology, family history, previous treatments, socioeconomic status, spiritual life, and many more.

The most important thing is finding a reasonable plan to spend every day productively. It does not have to be physical work such as gardening, cleaning the house, or cooking. It could be arts and crafts, creative writing, writing blogs and articles, advocacy work, voluntary contributions to local hospitals, religious and spiritual organizations, churches, etc. Feeling productive is extremely important. A job search should be everyday work for at least one hour.

The team at Holistic Healthful can provide you with a non-medical, spiritual consultation, finding your hidden skills and talents that potentially could be a new career or job in disability, job search, and job readiness in disability / chronic illness. In addition, Dr. Miroslav Sarac is conducting sessions with disabled people, their families, and primary caregivers. Importantly, we can explain and help you with disability from the spiritual point of view! Helping is healing!

Respectfully,

Holistic Healthful

References:

1. Tauil CB, Grippe TC, Dias RM, Dias-Carneiro RPC, Carneiro NM, Aguilar ACR, Silva FMD, Bezerra F, Almeida LK, Massarente VL, Giovannelli EC, Tilbery CP, Brandão CO, Santos LMB, Santos-Neto LD. Suicidal ideation, anxiety, and depression in patients with multiple sclerosis. Arq Neuropsiquiatr. 2018 May;76(5):296-301.

2. Lewis VM, Williams K, KoKo C, Woolmore J, Jones C, Powell T. Disability, depression and suicide ideation in people with multiple sclerosis. J Affect Disord. 2017 Jan 15;208:662-669.

3. Moore P, Hirst C, Harding KE, Clarkson H, Pickersgill TP, Robertson NP. Multiple sclerosis relapses and depression. J Psychosom Res. 2012 Oct;73(4):272-6.

4. Pompili M, Forte A, Palermo M, Stefani H, Lamis DA, Serafini G, Amore M, Girardi P. Suicide risk in multiple sclerosis: a systematic review of current literature. J Psychosom Res. 2012 Dec;73(6):411-7.

5. Moore S. Major depression and multiple sclerosis – a case report. J Med Life. 2013 Sep 15;6(3):290-1.

6. Chwastiak L, Ehde DM, Gibbons LE, Sullivan M, Bowen JD, Kraft GH. Depressive symptoms and severity of illness in multiple sclerosis: an epidemiologic study of a large community sample. Am J Psychiatry. 2002 Nov;159(11):1862-8.

7. Meltzer H, Bebbington P, Brugha T, McManus S, Rai D, Dennis MS, Jenkins R. Physical ill health, disability, dependence, and depression: results from the 2007 national survey of psychiatric morbidity among adults in England. Disabil Health J. 2012 Apr;5(2):102-10.

8. Meltzer H, Brugha T, Dennis MS, Hassiotis A, Jenkis R, McManus S, Rai D, Bebbington. The influence of disability on suicidal behavior. European Journal of Disability Research. 2012. 6: 1, 1 -12.

9. Lecrubier Y. Depressive illness and disability. Eur Neuropsychopharmacol. 2000 Dec;10 Suppl 4: S439-43.

10. Hendriks SM, Spijker J, Licht CM, Hardeveld F, de Graaf R, Batelaan NM, Penninx BW, Beekman AT. Long-term work disability and absenteeism in anxiety and depressive disorders. J Affect Disord. 2015 Jun 1;178:121-30.

11. Stensman R, Sundqvist-Stensman UB. Physical disease and disability among 416 suicide cases in Sweden. Scand J Soc Med. 1988;16(3):149-53.

12. Walsh SM, Sage RA. Depression and chronic diabetic foot disability. A case report of a suicide. Clin Podiatr Med Surg. 2002 Oct;19(4):493-508.

13. De Leo D, Hickey PA, Meneghel G, Cantor CH. Blindness, fear of sight loss, and suicide. Psychosomatics. 1999 Jul-Aug;40(4):339-44.

14. Hine TJ, Pitchford NJ, Kingdom FA, Koenekoop R. Blindness and high suicide risk? Psychosomatics. 2000 Jul-Aug;41(4):370-1. 

15. Dodd P, Doherty A, Guerin S. A Systematic Review of Suicidality in People with Intellectual Disabilities. Harv Rev Psychiatry. 2016 May-Jun;24(3):202-13.

16. Lunsky Y, Raina P, Burge P. Suicidality among adults with intellectual disability. J Affect Disord. 2012 Nov;140(3):292-5.

17. Båtstad HS, Rudmin FW. Suicidal tendencies as correlates of disability measures. J Health Psychol. 2016 Dec;21(12):3037-3047.

18. Russell D, Turner RJ, Joiner TE. Physical disability and suicidal ideation: a community-based study of risk/protective factors for suicidal thoughts. Suicide Life Threat Behav. 2009 Aug;39(4):440-51.

19. Le Strat Y, Le Foll B, Dubertret C. Major depression and suicide attempts in patients with liver disease in the United States. Liver Int. 2015 Jul;35(7):1910-6.

20.  Kerkhof A. Calculating the burden of disease of suicide, attempted suicide, and suicide ideation by estimating disability weights. Crisis. 2012 Jan 1;33(2):63-5.

21. Fishbain DA, Bruns D, Meyer LJ, Lewis JE, Gao J, Disorbio JM. Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain. Pain Med. 2012 Apr;13(4):552-61.

22. Hooley JM, Franklin JC, Nock MK. Chronic pain and suicide: Understanding the association. Curr Pain Headache Rep. 2014;18(8):435.

23. Coshal S, Saunders J, Matorin AA, Shah AA. Evaluation of Depression and Suicidal Patients in the Emergency Room. Psychiatr Clin North Am. 2017 Sep;40(3):363-377. 

24. Klonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30.

25. Deshpande SS, Kalmegh B, Patil PN, Ghate MR, Sarmukaddam S, Paralikar VP. Stresses and Disability in Depression across Gender. Depress Res

Treat. 2014;2014:735307.

Disability, either acquired or hereditary, is the leading health and social problem in many countries, including well-developed countries. It represents the significant health-social challenges of this era. As of now, as is, the healthcare system and social system are very oppressive, inadequate, and inappropriate to meet the needs and challenges of the people living with disabilities. What is desperately needed is a fundamental shift in perspective approach with the application of complementary, alternative, holistic, integrative, and functional treatments where the subjective experience of the disabled person is of central concern. Yes, subjective and personal experience!

Life, wellness, and health coaching for disabled people are necessary and of urgent need. Some disabled people are with vocational rehabilitation services for years, not months, as they should be. Actually, the primary goal of their existence, primary function, and mission are to prepare and find employment for disabled people (funded for their operation predominantly from federal resources, about 75%).

It looks like each disabled person is getting stuck in one of the phases, either in “the very beginning,” “hitting the wall,” “turning around,” “letting go,” “opening up,” “letting in,” and “the end of “healing” process” (1). The phase “hitting the wall” is where most disabled people give up all services and so-called “independent living,” where they realize that they are, in reality, heavily dependent on their family or primary caregiver for the rest of their life. This is because all care and everyday living are on the primary caregiver’s shoulder, family, and friends.

Finally, we reached the point that life, wellness, and health coaching specifically designed for disabled people is “a must.” Most disabled people are chronically placed in psychotherapeutic sessions with CBT (cognitive behavioral therapy), yes, chronically for years, instead of as CBT standards proposed 6 – 16 sessions, and that’s it. No achievements, and no improvements, then a psychotherapist should take another way of therapy. CBT strictly focuses on challenging and changing unhelpful cognitive distortions and behaviors, improving emotional regulation, and developing personal coping strategies to solve current problems. Well, it sounds good, but after a short period, another challenge is coming.

Severe depression is a common comorbidity of disabled people that is “coming” silently but persistently, staying as a shadow following the disabled person who desperately wants to find a new way of life, meaning, and purpose of life as a disabled person, employment, lost dignity… coming poverty, a new monster. Not a problem; here are antidepressant therapeutics widely available and readily prescribed even by primary care physicians. After changing six or more different forms of antidepressant therapeutics, there are no expected improvements or so few with frequent relapses. Some disabled people also do not know they have treatment-resistant depression; social factors are not improved, a home-bound lifestyle is still in existence and persistent, and the disabled person is falling into a severe episode of depression.

The integrative, functional approach in the treatment of disabled people is promising, including holistic, alternative, or complementary therapy in the form of applied intensive life, wellness, health coaching, finding a new way of life, meaning, and purpose of life, objectively approaching a job search, employment, getting back lost dignity, fighting depression and anxiety and symptoms of post-traumatic stress disorder getting disabled. Indeed, disabled people also deserve to find and feel the greatest love of all in their lives, as all others do.

What is a disability?

Millions of people live with a visible or invisible disability, acquired or hereditary disability, physical, mental, intellectual, cognitive, developmental or sensory disability, disability with comorbidity and without comorbidity; nearly one in five people, currently almost 49 million people have a disability in the U.S.A. According to the data from the World Bank, “one billion people or 15% of the world’s population experience some form of disability, and disability prevalence is higher for developing countries. One-fifth of the estimated global total, or between 110 million and 190 million people, experience significant disabilities” (2).

Disability is not a disease category; it is a condition caused by physical, sensory, cognitive, and mental disorders that cause significant limitations in one or more major life activities. According to the Americans with Disability Act, “major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating and working (Americans with Disability Act).” Probably, a much better statement about disability we can find in the World Report on Disability World Health Organization (WHO) stated: “Many people with disabilities do not have equal access to health care, education, and employment opportunities, do not receive the disability-related services that they require, and experience exclusion from everyday life activities. Following the entry into force of the United Nations Convention on the Rights of Persons with Disabilities (CRPD), disability is increasingly understood as a human rights issue. Disability is also an important development issue with an increasing body of evidence showing that persons with disabilities experience worse socioeconomic outcomes and poverty than persons without disabilities.” (3).

It is imperative to understand disability as a phenomenon fully. Yes, I would say the phenomenon. Unfortunately, defining disability is exceptionally complicated. For a long time, I have been searching for one good definition of disability. Probably, one of the best descriptions of disability is from the World Health Organization; it states: “Disability is complex, dynamic, multidimensional, and contested. Over recent decades, the disabled people’s movement and numerous social and health sciences researchers have identified the role of social and physical barriers in disability. The transition from an individual, medical perspective to a structural, social perspective has been described as the shift from a “medical model” to a “social model” in which people are viewed as being disabled by society rather than by their bodies” (3 – 8). Indeed, this statement provides a much better description of what disability is and how disability is transforming from a medical model into a social model. However, I did not stop searching for a better explanation and definition of disability.

Leonardi M. and colleagues, in 2006, in their article published in the Lancet, stated: “Disability promoted as a “bio-psycho-social model,” it represents a workable compromise between medical and social models. Disability is the umbrella term for impairments, activity limitations, and participation restrictions, referring to the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors)” (9). Generalization about “disability” or “people with disabilities” can mislead and any form of generalization should be avoided seriously. Persons with disabilities have diverse personal factors with differences in gender, age, socioeconomic status, sexuality, ethnicity, or cultural heritage; a unique culture. Each has their preferences and subjective responses to disability (10). A broad range of international documents has highlighted that limitation is a human rights issue, including the World Program of Action Concerning Disabled People (1982), the Convention on the Rights of the Child (1989), and the Standard Rules on the Equalization of Opportunities for People with Disabilities (1993). Over 40 nations adopted disability discrimination legislation during the 1990s (11). According to Harris J. and the article published in 2015, the Americans with Disability Act, the marquee civil rights legislation for people with disabilities, expresses a national approach to disability that recognizes the role of society in its construction, maintenance, and potential remedy. But its mission is incomplete, and it has not generated the types of interactions between people with disabilities and nondisabled people empirically shown to deconstruct deeply entrenched social stigma (12).

Disability as a phenomenon is very complicated from a biological, medical, social, and psychological point of view. As Sen A. 2009 stated in his book: “Disability is a development issue because of its bi-directional link to poverty: disability may increase the risk of poverty, and poverty may increase the risk of disability” (13). It looks like the definition of disability is not been entirely reached. Still, the question of how disability should be defined is fraught with political, ethical, and philosophical complexities (14).

How disabled people get even more impaired than they actually are?

Predominantly, disability is associated with some comorbidities, and one of them is severe depression. Depression, by itself, a separate entity, is a form of disability. So, people with a disability who developed depression as a comorbidity are more disabled. Some previous research exhibited co-morbid depression and chronic physical conditions associated with disability (15). Unfortunately, there is a substantial lack of data on disability and suicide in the U.S.A. There is a small number of national data on studies related to this topic. Some studies reaffirmed that disability is the risk factor for depression by using longitudinal data (16). Certainly, home-bound lifestyle, lack of employment, lack of transportation, services by vocational rehabilitation and social services, and heavy dependence on a primary caregiver, most disabled people will, over a specified period, develop the first signs and symptoms of depression and even suicidal ideation. Overall, significant indicators for increased suicidal risk in the population of disabled people are unemployed for an extended period, profound social isolation due to the home-bound lifestyle and lack of transportation, and significant change in health status because most disabled people require frequent medical attention and treatments.

Progressively, due to a lack of proper access to a healthcare provider, lack of mental health support and help either because they cannot afford due to overly expensive treatments and office visits or lack of mental health care providers locally, severe depression will be accompanied by suicidal thoughts or ideation in disability. Unproperly treated or untreated depression eventually, in combination with the unbearable social status and life under the limit of poverty of disabled people, will convert into a devastating condition of major depressive disorder with frequent suicidal thoughts. The majority of disabled people are oppressed by ableism, too; living as disabled people in a society that hates disability, or a society, the community suffers from significant stigma and taboo regarding disability. Overall, disability and its functional limitation in daily living activities have been associated with suicide in the population of disabled people (17). Still, there is a substantial lack of research on what category of disabled people are more prone to develop severe depression, people with acquired disability or hereditary, and people with a visible or invisible disability. Disabled people who suffer from suicidal ideation deserve to be seen by a therapist who “speaks” their language and understand their experience; thus, cultural competency related to disability is a “must” for all healthcare professionals, including pharmacists in the retail setting, social workers, psychologist and psychotherapists, rehabilitation counselors and our primary caregivers. Unfortunately, there is a lack of research on primary caregivers’ response to a disabled person with developed depression as comorbidity and vice versa.

Unfortunately, despite a substantial lack of national data on suicide and disability in the U.S., some studies have shown a substantially higher suicide rate in the population of disabled people with certain disabilities, such as multiple sclerosis, spinal cord injuries, and intellectual disability (18). As Giannini M. and colleagues in 2010 stated: “U.S. researchers and policymakers must address the substantial gaps in knowledge that remain to help create a clear understanding of suicide in the disability population, especially targeting children and youth ages 10 to 24 and other at-risk age cohorts”. It sounds like a “wake up call” but still, since 2010 we do not have some significant contribution regarding research in this field. One of the possible reasons for such a condition is that suicidologists cannot find the data regarding the suicide rate in the population of disabled people, the data are hidden, or there is a lack of proper evidence regarding this particular issue.

As one disabled person said: “Happy spring, I am “celebrating.” What? Six years of unsuccessful services, still no job for me; with all my higher education in the vocational evaluation process, they made me an office clerk that even GED would be challenging for me, a home-bound lifestyle, severe disability, and heavy dependence on a primary caregiver…for them, I am “a low expectation and high liability.” Or another one, “I am five years in CBT (cognitive behavioral therapy). My potentially successful suicide was prevented by my primary caregiver, not a psychiatrist, psychotherapist, or rehabilitation counselor…but holistic therapy helped me balance my body-mind-soul and find a “healthier” myself.”

This blog is the first blog in a series of three blogs dedicated to disability and disabled people and how holistic therapy, life, wellness, and health coaching can help disabled people to live productive life finding “the greatest love of all.”

Respectfully,

Holistic Healthful

References:

1. Lindsey E. The gift of healing in chronic illness/disability. J Holist Nurs. 1995 Dec;13(4):287-305.

2. http://www.worldbank.org/en/topic/disability

3. WHO Library Cataloguing-in-Publication Data World report on disability 2011.

4. Charlton J. Nothing about us without us: disability, oppression, and empowerment. Berkeley, University of California Press, 1998.

5. Driedger D. The last civil rights movement. London, Hurst, 1989.

6. Barnes C. Disabled people in Britain and discrimination. London, Hurst, 1991.

7. McConachie H et al. Participation of disabled children: how should it be characterized and measured? Disability and Rehabilitation, 2006,28:1157-1164.

8. Oliver M. The politics of disablement. Basingstoke, Macmillan and St Martin’s Press, 1990.

9. Leonardi M et al. MHADIE Consortium. The definition of disability: what is in a name? Lancet, 2006,368:1219-1221.

10. Learning lessons: defining, representing and measuring disability. London, Disability Rights Commission, 2007.

11. Quinn G et al. The current use and future potential of United Nations human rights instruments in the context of disability. New York and Geneva, United Nations, 2002b (http://www.icrpd.net/ratification/documents/en/Extras/Quinn%20 Degener%20study%20for%20OHCHR.pdf, accessed 21 Sept 2010).

12. Harris J. Processing disability. Am Univ Law Rev, 2015; 64 (3), 457-533.

13. Sen A. The idea of justice. Cambridge, The Belknap Press of Harvard University Press, 2009.

14. Sisti D.A. Naturalism and the social model of disability: allied or antithetical? J Med Ethics 2015, 41 (7): 553-556.

https://www.dol.gov/ofccp/regs/compliance/faqs/ADAfaqs.htm

15. Deschenes SS, Burns RJ, Schmitz N. Associations between depression, chronic physical conditions and disability in a community sample: a focus on the persistence of depression. J Affect Disord. 2015; 179: 6-13.

16. Noh JW, Kwon Y.D, Park J, Oh IH, Kim J. Relationship between physical disability and depression by gender: A panel regression model. PLoS ONE 11 (11): e0166238.

17. Kaplan MS, McFarland BH, Huguet N, Newsom JT. Physical illness, functional limitations, and suicide risk: A population-based study. Am J Orthopsychiatry. 2007; 77 (1): 56-60.

18. Giannini MJ, Kreshover S, Elias E, Bergmark BA, Plummer C, O’Keefe E. Understanding suicide and disability through three major disabling conditions: Intellectual disability, spinal cord injury, and multiple sclerosis. Disabil Health J. 2010 Apr;3(2):74-8.

“One day you will tell your story of how you overcame what you went through, and it will be someone else’s survival guide.” – Brené Brown

We dedicate this calendar to all people who suffer from depression to help them take action, find the meaning of this life and their purpose and learn how to self-reward themselves even for seemingly insignificant little improvements daily. Step by step, day by day! Indeed, it is a process; however, it is not just about us who suffer from depression but also about our family members and friends taking care of us and loving us.

Motivation and focus in depression come and go, don’t rely on them too much. Motivation might be helpful, no doubt, but please rely on discipline, action, and self-reward as much as possible on your healing journey. Motivation will come from your small actions and self-rewards in everyday life, gradually, step by step, day by day. All your healthcare practitioners should meet you at the stage where you are, not higher, not lower. Indeed, psychiatrists and psychotherapists are a good start in your healing journey; however, life couches and spiritual practitioners could be outstanding adjuncts in addition to your healing journey. It is essential to state that integrative psychiatrists will approach you uniquely and more comprehensively and will not treat you “as usual.” Each of us has a different genetic structure, etiology, and causes of depression.

Depression is probably the most complex disease affecting your mind, ego, emotions, soul, body…; it is multifactorial in its etiology, where we need to consider genetics, biology/physiology, past/present life traumas, past/current social and economic conditions and status, spirituality and many more! Depression is not just about your “brain chemistry” being messed up.

This calendar – 52 weeks is written from many years of experience dealing with depression, experiences of many people who suffer from depression, slight spiral ups, challenging downs, and even vicious circles when ”the snake eats its own tail” when everything looks hopeless and “total apocalypse.” But you are not worthless or useless…, you are just ill! Remember it! So, commit to working on yourself, for yourself, and for your loved ones. Healing has to start with you!

We are sure some things will resonate with you and others will not. It is expected, each person suffering from depression is different. Take one of the 52 “messages” for you every week and try to think how it might help you and how it resonates with you. Journaling is one of the sacred arts; it might help you to gain actions and self-rewarding. Helping is healing!

Glenn Close wrote the beautiful quote:

“What mental health needs is more sunlight, more candor, more unashamed conversation.” – Glenn Close

1. If you are depressed, please seek help! Talk to someone. Start with your family members or a good friend, then try to find a good therapist (please, do not get discouraged, you will find the perfect match, it takes time). Postponing and avoiding is not an option for those suffering from depression. Just say I need help!
2. You are not worthless or useless…, you are just ill! Remember it! So, commit to working on yourself, for yourself, and for your loved ones. Healing has to start with you! Nothing is wrong with changing therapies; eventually, you will reach one that works for you; keep going! Sometimes, depression is like an exhausting marathon, and you feel you will never reach the target.
3. Believe me; you will turn depression all around, with a slight spiral up and challenging down, left and right side, in the circle… But try to avoid a vicious circle when the “snake eats its own tail.” Help is out there!
4. Eventually, you will realize you do not know how strong you are until staying strong is your only option. Ask spiritualists about depression; they will tell you; you are an outstandingly strong soul. The Universe, the God, the Divine brought you challenges in this life, such as (for example) learning selfishness vs. selflessness, ego dissolution, gratefulness, gratitude, unconditional love, and spiritual awakening after the dark night of the soul.
5. Motivation and focus in depression come and go; we know that; don’t rely on them too much because they do not exist objectively in depression. Motivation is helpful, no doubt, but please rely on discipline, action, and self-reward as much as possible. Motivation will appear after your initial small actions and self-rewards in your everyday life.
6. Depression is not called being weak, not at all; it is called staying strong for too long or far too long than any other person will ever experience. Remember, you are a strong soul.
7. My best coping mechanism is keeping “busy” as much as possible and having a consistent schedule as much as possible. Some days it works, and some days it does not work. I keep my mind, soul, and body “occupied.” I tire myself out from the moment I get up in the morning until the moment I go to sleep in the evening. Well, it doesn’t cure anything, believe me. Sometimes, it just helps me cope with depression day by day.
8. Depression will beat you down only if you succumb to unprecedented high pressure. It is a pressure pot; thus, resistance and avoidance of this high pressure are welcome. Be ready to find a strategy to checkmate depression. Your therapist will help you set up a suitable treatment and probably do pharmacogenetic tests, which can tremendously benefit your treatment (from personal experience). That would be a checkmate to depression.
9. Be honest with everyone in your life, express your feelings, and share how your pain is unbearable; someone will find a way to help you, but some people will go away, which is fine, do not worry. In depression, there is nothing to hide!
10. By making small positive steps every day that get you somewhere, you can improve your well-being. Be proud of the minimal positive efforts you have made every single day. Reward yourself even for minor accomplishments!
11. You have to permit yourself to do a little, very little, and apply shortcuts for all your activities, including laundry, personal hygiene, cleaning…every possible everyday errand. It is not cheating; it is an action you will be able to reward yourself with after all. Even a small self-reward after an activity will positively impact your depression. Living with depression day by day includes even learning how to do laundry in a totally new way. It is nothing to be ashamed of!
12. Asking depressed people to live an everyday life is like asking people with broken legs to participate in a race. Each day is substantially different, with our ups and downs…
13. I know you feel unhappy, isolated, hopeless; you feel worthless and useless…even you think it is immoral to like the Sun or look at yourself in the mirror, but please do one simple, beautiful thing for yourself every day, just for yourself! Do not forget to reward yourself! By rewarding yourself at the moment and each day, your brain evokes strong positive emotions, leading to the realization that your efforts result in a positive reward. It is a really healing effect.
14. The most challenging thing about depression is when people expect you always to be OK. You are so used to pretending to be happy and OK all the time, but you are so broken and damaged inside, and no one notices. It is so cruel that you feel forced to keep going when you are hopeless and have nothing going for you. Stop doing that!
15. Living with depression day by day is tough, but getting through it and healing is even more challenging. So please share it with someone! Many healthcare professionals specialize in mental health; sometimes, a good psychotherapist can help you, or a life coach and a social worker, with more practical insight into finding resources for support and your healing journey. From the spiritual point of view, many psychiatrists, psychotherapists, and other mental health professionals are souls who came into this Earthly life to be healers; their souls accumulated many previous lives experiences and memories of suffering from chronic diseases, even depression, and now it is their turn to be healers; of course, if you believe in the concept of reincarnation, an immortal soul and spirituality.
16. I had not cried for a long time and broke down. Because I have been pretending for too long. I admit I need help. Stop “torturing” yourself and “be you.”
17. Each depression is unique; please do not let your therapist place you on one shelf designated for depression cases; make a mutual agreement and ensure your therapist understands all aspects of your depression. Be honest with yourself and your therapist. It is an essential part of successful therapy.
18. Those seemingly insignificant little improvements day by day have the most significant impacts on us who suffer from depression.
19. Today is a rainy day; please do not forget above the clouds is sunshine, beautiful and bright, and tomorrow the Sun will be visible to you again!
20. We need to “normalize” feelings of sadness and depression, and hopelessness. Then, we must share the tools to go through and pull ourselves out of these dark places. Take a little time and listen to music, get out and take a walk, dress nicely (pajamas are not the only clothes you have), and finally, put on your favorite perfume…do simple and nice things just for yourself! Music therapy, such as flamenco, has proven benefits for depression and many other neurological and psychiatric diseases.
21. Some days, you will only take a shower, and that’s it. Sometimes you might not even do that, and that’s absolutely OK. However, routine is so essential in depression even though it is so difficult to reach, but never give up because you are loved and precious.
22. Depression is feeling alone, like the odds are stacked against you, feeling as though things will never get better, feeling as though the world doesn’t need you, and feeling you aren’t worth the trouble! Well, it is time to find help; the support is out there. But please, do not get discouraged if your therapist and you are not a good match. Your healing journey will require multiple attempts until you find a “perfect match.” After all, it is absolutely normal and acceptable.
23. Depression is something you cannot just overcome; it is not something you can pull yourself out of; it is not something you see someone to fix! Unfortunately, there is no surgery for depression. So the only true way to live with depression (as there is no absolute cure) is to have support, not the kind of support where they try to make you feel better, but the kind of support you know they care about you.
24. You have people you can trust, but once you get hit in the heart by a family member or friend, you feel like you cannot trust them anymore. But, it is not as it looks to you. Do not think you will be alone; you have others here for you. So, do not listen to them; listen to your heart and that potential that you have yet to unlock. Do not let them take control of your life; whatever you need to do, go for it and remember that the goals you cannot achieve right now will be completed once you grow into the person you hope to be today.
25. Remember, it is OK not to be OK. You are loved. You are not alone. You will get better.
26. You do not know the meaning of pain until you look at yourself in the mirror while tears stream down, and you are just begging yourself to hold on and tell yourself that you are strong and everything will be fine… You deserve love. Yes, you deserve to be loved…
27. I know, just saying being strong is not the answer, but accepting, not resisting, breathing, and taking what life is in this moment.
28. You have to walk through darkness to appreciate the light. So do not give up when things get rough. Things will get better. The wheel of fortune is spinning.
29. After Dark Night of the Soul, it’s coming a Spiritual Awakening!
30. Remember, your soul speaks the language of your body. Depression is trying to escape from the present. Think about what is wrong in your present life. Find it, name it, work on it, and let it go! Try to learn how to forgive, release and let it go.
31. Depression sometimes looks like an inability or refusal to observe and see things as they really are, or not wanting to look at something, unable to see the whole picture. So find it, name it, work on it, and let it go…
32. Ask your body and soul what they are trying to tell you, listen for the answer, acknowledge and be thankful for the answer, take action on the information received, and enjoy your new course of action in your life.
33. Think about what you are trying to withdraw or escape; find it, name it, and let it go!
34. The biggest problem with depression, I have found, is when you go through it, you feel there is no way out. There is no other feeling but being down, really down. No matter what you hear, who you are with, or what you do, you cannot feel anything else. That’s the worst and most dangerous part. So journaling every day and expressing your gratitude might help you. I am grateful to Mr. K, Dr. P., Dr. T., Dr. B., and myself; without them, I would never reach small actions and learned self-rewarding that eventually will induce motivation and focus on my healing journey.
35. A warm hug goes out to anyone dealing with depression. It looks like fighting with windmills, telling the story of Don Quixote. Write down what you are dealing with now. It is absolutely healing.
36. Set small, objective, and manageable goals every day. Then, please write them down in your journal. Thinking and memorizing your thoughts is not a good option for people suffering from depression. But, once they are written, they have magical power.
37. Get out of bed and out of your pajamas; it is your first victory for today. But never give up; your brain processes whatever thoughts you create…
38. Congratulate yourself for every goal you complete; it does not matter how small it is.
39. Please write down your routine, stick it on the wall, refrigerator, or somewhere you will see it clearly and use check marks when you’ve completed tasks. Accomplishing daily tasks will promote well-being and inspire you to aim higher daily.
40. Helping someone in desperate need will improve your mood and motivate you to get out of bed. Choose positive and healthy relationships, let people know to socialize with you when you feel suitable for it (not easy, right), and give volunteering a chance, at least during your healing journey.
41. Take things in your everyday life one step at a time, and do not try to do more than you can.
42. Celebrate even small victories. Do your best to think positively. You are laughing now; it reminds you of psychotherapy, and you think nothing positive is in your life. But it is not true; think about how many positive things you accomplished in your past before you got depressed.
43. Reward yourself for every step forward. Hence, the lack of self-reward characterizes much of depression, which underlies your lack of motivation.
44. What did you do and accomplish when you were not so depressed? Make a list and notes of all the activities you can think you engaged in, and start planning those for the next week, little by little.
45. Choose your purpose and actions; rather than ask about your motivation, ask yourself about your purpose or your goals and then on taking actions that lead to those goals.
46. Actually, action creates motivation. So you could reverse the vicious cycle of depression into a virtuous activity cycle and more inspiration. It is really healing! I know it is not easy. Doubts will come and go like the ghosts in a haunted house, but a beacon of hope will always come unexpectedly from those who care about you.
47. You don’t need to wait for motivation actually to do something. Instead, commit yourself to small actions and values rather than hopelessly waiting for the motivation to show up to you. Motivation and focus in depression come and go, and you cannot rely on them too much. On the other hand, gradually increasing actions will bring inspiration and motivation!
48. Motivational quotes for depression sufferers are not the ones that tell you to get up and move or to be happy. Instead, the best motivational quotes for someone with depression meet you where you are. For example, “Depression is not a personal failure, not at all.”
49. “And if today all you did was hold yourself together, I’m proud of you.” – Anonymous
50. Depression is a complex disease that cannot be treated with motivational statements.
51. Try granting yourself a little self-compassion and kindness every single day.
52. “One day you will tell your story of how you overcame what you went through, and it will be someone else’s survival guide.” – Brené Brown

You are loved,

Holistic Healthful

When a king is attacked in a chess game, it is called a check. A checkmate (a.k.a. “mate”) occurs when a king is placed in check and has no legal moves to escape. When a checkmate happens, the game ends immediately, and the player who delivered the checkmate wins.

Checkmate your opponent should be your top priority. This will ensure your victory even if you have less material or a worse position throughout the game.

Unfortunately, many people have a feeling they are playing chess with depression. For decades, the game has started to be exhausting, and they cannot checkmate depression. Undoubtedly, there are numerous gene candidates and other factors for depression, but let’s explore one responsible for a poor response to antidepressant therapy and multiple drug (medication) resistance. In our following blogs, we will discuss others, such as (for example) SLC6A4, MTFHR, DRD2, CYP450 family, and many more.

A possible solution to this problem is pharmacogenomic testing for the ABCB1 gene. Then, your healthcare practitioner will have a much better option for treating your depression. In addition, he/she will approach you with personalized treatment tailored to you, including an integrative and/or holistic approach! So really, it will be checkmate for depression. In addition, there are many commercially available tests such as (for example) https://www.hmnc-brainhealth.com/about-us/our-approach or this one https://genomind.com/providers/abcb1-gene-spotlight/.

What is ABCB1?

According to the scientific literature, so-called ATP-binding cassette – sub-family B (MDR/TAP), member 1 (ABCB1), is a medication transporter protein distributed in the intestine and the blood-brain barrier (Keh-Ming Lin et al., 2011).

Many studies have revealed that P-glycoprotein is involved in the transmembrane transport of many antidepressants. Many antidepressants act as substrates for P-glycoprotein. ABCB1 gene is located on chromosome 7 (humans). As an essential component of the blood-brain barrier and gastrointestinal barrier, it is encoded 1280 amino acid – transporter P-glycoprotein can limit drug infiltration and accumulation in the brain and regulate the effectiveness and toxicity of drugs. Indeed, ABCB1 gene polymorphism may significantly affect the function of P-glycoprotein, changing the concentration of medication in the brain, and with various degrees of impact on the efficacy of antidepressant medications. According to the current research results, ABCB1 gene polymorphism has a specific correlation with the effectiveness of antidepressants. Being known as the multidrug resistance gene, the ABCB1 gene is located at 7q21 and encodes p-glycoprotein. Its primary function includes preventing drugs and foreign substances from entering body tissues, such as antidepressants, anti-tumor drugs, glucocorticoids, and amyloid proteins. Indeed, due to the exogenous effects of P-glycoprotein on exogenous substances and medications, ABCB1 gene polymorphism and different P-glycoprotein expression may lead to diverse populations or individuals with different susceptibility to some diseases, including depression. Previous clinical studies on the relationship between ABCB1 gene mutation and antidepressant efficacy are inconsistent. Through meta-analysis study further explored the relationship between ABCB1 gene polymorphism and the efficacy of antidepressants to provide an etiological basis for individualized treatment in patients suffering from depression (Xiaoying Zheng et al., 2021).

Undoubtedly, P-glycoprotein (P-gp), the gene product of ABCB1, is a drug transporter at the blood-brain barrier and could be a limiting factor for the entrance of antidepressants into the brain, the target site of antidepressant action. Animal studies showed that brain concentrations of many antidepressants depend on P-gp. In humans, ABCB1 genotyping in the treatment of depression rests on the assumption that genetic variations in ABCB1 explain individual differences in antidepressant response via their effects on P-gp expression at the blood-brain barrier. High P-gp expression is hypothesized to lead to lower and often insufficient brain concentrations of P-gp substrate antidepressants (Tanja Maria Brückl, et al., 2016).

The ABCB1 gene contains single nucleotide polymorphisms (SNPs) in the encoding regions. Therefore, variants such as C3435T (rs1045642), G2677T/A (rs2032582), and rs2032583 have been the most commonly studied by many researchers. Most studies indicate that ABCB1 haplotypes, the SNPs rs1045642, rs2032582, and rs2032583 affect the response to treatment with antidepressants (Wei-Wei Xie, et al., 2015).

Polymorphisms in ABCB1 can affect both the function and the expression of the transporter protein P-glycoprotein. Therefore, they may lead to an altered response to many drugs, including antidepressants and antipsychotics. There was a significantly higher frequency of the T allele at positions 1236, 2677, and 3435 among the suicide cases compared with the nonsuicide cases (Samuel Boiso Moreno et al., 2015).

Genetic variation in efflux transporter permeability glycoprotein (P-gp) has recently been associated with completed violent suicides and violent suicide attempts. According to the literature data, as depression is a risk factor for suicide and many antidepressants are P-gp substrates, it has been speculated that inadequate antidepressant treatment response or adverse side effects could be involved (Anna-Liina Rahikainen et al., 2018).

It is time for action, prevention, and precision treatment for depression. Therefore, finding integrative psychiatry healthcare practitioners is beneficial and could lead to more personalized medicine/treatment and finally checkmate depression.

Respectfully,

Holistic Healthful

References

1. Keh-Ming Lin, Yen-Feng Chiu, I-Ju Tsai, Chia-Hui Chen, Winston W Shen, Shu Chih Liu, Shao-Chun Lu, Chia-Yih Liu, Mei-Chun Hsiao, Hwa-Sheng Tang, Shen-Ing Liu, Liang-Huey Chang, Chi-Shin Wu, Hsiao-Hui Tsou, Ming-Hsien Tsai, Chun-Yu Chen, Su-Mei Wang, Hsiang-Wei Kuo, Ya-Ting Hsu, Yu-Li Liu. ABCB1 gene polymorphisms are associated with the severity of major depressive disorder and its response to escitalopram treatment. Pharmacogenet Genomics. 2011 Apr;21(4):163-70.

2. Xiaoying Zheng, Zejuan Fu, Xiaomei Chen, Mingxia Wang, and Rixia Zhu. Effects of ABCB1 gene polymorphism on the efficacy of antidepressant drugs. Medicine (Baltimore). 2021 Jul 16; 100(28): e26411.

3. Tanja Maria Brückl, Manfred Uhr. ABCB1 genotyping in the treatment of depression. Pharmacogenomics. 2016 Dec;17(18):2039-2069.

4. Wei-Wei Xie, Lin Zhang, Ren-Rong Wu, Yan Yu, Jing-Ping Zhao, and Le-Hua Li1. Case-control association study of ABCB1 gene and major depressive disorder in a local Chinese Han population. Neuropsychiatr Dis Treat. 2015; 11: 1967–1971.

5. Samuel Boiso Moreno, Anna-Lena Zackrisson, Ingrid Jakobsen Falk, Louise Karlsson, Björn Carlsson, Andreas Tillmar, Fredrik C Kugelberg, Johan Ahlner, Staffan Hägg, Henrik Gréen. ABCB1 gene polymorphisms are associated with suicide in forensic autopsies. Pharmacogenet Genomics. 2013 Sep;23(9):463-9.

6. Anna-Liina Rahikainen, Jukka U Palo, Jari Haukka, Antti Sajantila. Post-mortem analysis of suicide victims shows ABCB1 haplotype 1236T-2677T-3435T as a candidate predisposing factor behind adverse drug reactions in females. Pharmacogenet Genomics. 2018 Apr;28(4):99-106.

Depression is a significant human blight.¹

Globally, depression is responsible for more people with disability than any other condition. According to the World Health Organization, approximately 350 million people suffer from depression, which is one of the primary causes of disability. It takes ninth place as the origin of mortality after cardiovascular diseases, stroke, and HIV infection. Generally, depression is widely undiagnosed and not treated. One of the reasons, there is still stigma and a lack of therapies and a lack of mental health resources. Additionally, some clinical studies have shown that patients with depression do not have a satisfactory therapeutic outcome.²

Clinically, depression is present as primary morbidity or associated as co-morbidity in one of every four people with diabetes mellitus type 2,³ and patients with multimorbidity including disability.⁴ Depression is a frequent complication after stroke,⁵ cardiovascular diseases.⁶ Generally, depression is present in the population of the elderly but still stays undiagnosed and improperly treated in the clinical setting.^7-9 Indeed, depression is a prevalent and fatal disorder, and approximately one in five adults in the U.S. have at least one severe episode of major depression in their lifetime.¹⁰

Major depression is a common, disabling condition seen predominantly and treated first in primary care practices. Some severe medical conditions, including visible and invisible disability, sleep disorders, grief, and other psychiatric conditions, can co-occur and mimic the symptoms of major depressive disorder. Indeed, healthcare providers should assess these conditions when diagnosing major depressive disorder and consider co-morbid conditions to tailor management interventions.¹¹ However, in some cases, antidepressant therapy requires more attention from healthcare providers. Multiple changes of antidepressant treatment without success can suspect drug-resistant depression. Further diagnostic tests such as combinatorial pharmacogenomic tests should be considered to prevent a severe episode of depression when a patient suffers from frequent suicidal thoughts.

Personalized medicine in psychiatry hopes to escape the current standard trial-and-error approach to treatment, moving to a more advanced method that augurs a new era for patients and clinicians alike.¹²

Respectfully,

Holistic Healthful

References

1. Smith K. Mental health: A world of depression. Nature 2014; 515:180–181.

2. Cui R. A Systematic Review of Depression. Current Neuropharmacology 2015;4:480.

3. Semenkovich K, Brown ME, Svrakic DM, Lustman PJ. Depression in type 2 diabetes mellitus: prevalence, impact, and treatment. Drugs 2015; 6:577-87.

4. Stanners MN, Barton CA, Shakib S, Winefield HR. Depression diagnosis and treatment amongst multimorbid patients: a thematic analysis. BMC Fam Pract 2014;15:124.

5. Lewin-Richter A, Volz M, Jöbges M, Werheid K. Predictivity of Early Depressive Symptoms for Post-Stroke Depression. J Nutr Health Aging 2015; 7:754-758.

6. Seligman F, Nemeroff CB. The interface of depression and cardiovascular disease: therapeutic implications. Ann N Y Acad Sci 2015;1345: 25-35.

7.  Alexopoulos GS. Depression in the elderly. Lancet 2005; 9475:1961-70.

8. Allan CE, Valkanova V, Ebmeier KP. Depression in older people is underdiagnosed. Practitioner 2014;1771:19-22.

9. Forlani C, Morri M, Ferrari B, Dalmonte E, Menchetti M, De Ronchi D, Atti AR. Prevalence and gender differences in late-life depression: a population-based study. Am J Geriatr Psychiatry 2014; 4:370-80.

10. Hirschfeld RM. The epidemiology of depression and the evolution of treatment. J Clin Psychiatry 2012;1:5-9.

11. Bentley SM, Pagalilauan GL, Simpson SA. Major depression. Med Clin North Am 2014; 5:981-1005.

12. Nemeroff CB. The State of Our Understanding of the Pathophysiology and Optimal Treatment of Depression: Glass Half Full or Half Empty? Am J Psychiatry. 2020 Aug 1;177(8):671-685. doi: 10.1176/appi.ajp.2020.20060845.