4/24/09

360) Dealing Positively with "Post Transplant Depression"

April 23, 2009
Thurs
day

Evening: So... Bernadette calls and asks if I went to have blood drawn twice... and I say, "Well, yes... Peggy called me and asked me to come back and said she needed to re-draw... etc. etc." and Bernadette responded with an AHA!... cause my cyclosporine levels were at the top of the curve, not the bottom like she expected. I apologized for Peggy's mistake and got the impression that Bernadette accepts that these things happen cause we ARE all human... and I do have labs again next Tuesday... so, unless the Doc has a problem... we just go onward thru the fog.

And, I might not have even blogged these developments cause I am trying to report the silver linings more that the storm clouds.

However, another darkening cloud is worth mentioning at this point, based on a conversation I had yesterday with Heather T, another PKD blogger from way back (see comments on Post #359 and her post, entitled "Hey Jack"). Serendipitously, I had noticed her visit to my blog thru Feedjit and clicked on her blog and read the following:

"...don't be surprised if you become depressed after surgery. I was depressed, but not until about 3 weeks out. After my family left and my husband went back to work. At the time, I thought I was just "enjoying" my time alone and away from work. But now (months later) I realize I was depressed and avoiding most all tasks."*

These descriptions reframed some growing feelings / thoughts I had been having for the past few days (that I had framed as "tired", "lazy", "wishing I was retired (like Thomas in his PJ's)", "wishing I could be at home all the time (the crab in my shell metaphor)", and I had hallucinated that it was probably some post-surgery depression rearing it's ugly head.

Post Kidney Transplant Depression: This topic has quite a few resources on Google, but most are people's stories and complaints. I did find one study on depression 1 to 3 years post transplant and the results being related to "poor outcome", but this doesn't really relate to the issues of depression in the first year.

One study by Gill and colleagues, entitled Cognitive outcome following kidney transplantatiion, published in Nephrology Dialysis Transplantion (
2008 23(3):1032-1038) states in the discussion section:
"In summary, the current findings suggest that memory and executive functioning difficulties may be present following successful kidney transplation. Given the fact that reduced cognitive performance (memory?) has been identified in kidney TX recipients, it will be paramount to elucidate the consequences in terms of medication adherence, ability to return to work and other functional outcomes (anxiety/depression?). Such research may prove invaluable in assessing the relevance of neuro-psychological findings to everyday living, and further highlight the potential benefits of formal evaluation of cognition to develop and implement treatment strategies throughout the course of kidney disease."
Butler, et. al. found in a 2004 article on risk factors for non-adherence to immunosuppressants that "Although not related to adherence, depression was common. Depression has been associated with reduced quality of life and increased morbidity. Thus clinicians should be alert to the presence of depression post-transplantation. Therapeutic interventions and antidepressant medication to improve the emotional state of transplant recipients are important independently of affecting adherence." However, this study was completed 6 to 63 months post transplant, although it suggests that the literature finds depression as a "common" post-transplant concern. There are also other evidence-informed articles referenced in the above two for any of you who want to delve further into this topic area. Find the Nephrology, Dialysis, Transplantation Journal online and you will find other free articles you can peruse.

Another Frame from Social Constructionism: You see, over the years I have taken on a strengths-based view in which we don't really believe in "depression". When we remove the diagnostic trappings (which don't really have much of an evidence base) "depression" is just another label that therapists use to describe treatments (in the "disease model") for a certain group of people. Many psychiatric diagnoses are not always diseases and can be treated with medical regimens AND the research is present to show that the practitioners "treating" any one diagnosis use so many different treatment regimens that are effective that the whole question of the rational, medical assessment / diagnosis / treatment paradigm basically breaks down. According to the research-informed folks at the Institute for the Study of Therapeutic Change
this has been known for some time --->"The research is clear at least: psychiatric diagnosis as codified in the DSM is unreliable. In this study, researchers investigated degree of agreement among psychiatrists in an emergency service setting. Once again, they found appallingly low agreement both in terms of diagnosis and treatment recommendations. Indeed, the particular diagnosis and treatment recommendation... depended more on who was doing the diagnosing than on the particulars of the clinical situation. Isn't it time to bag the DSM?"

So, when we look from the lens of post-modernism, there are many truths... all with small "t"s rather than one Truth with a capitol "T". And, at least in the realm of depression, the symptoms do not prescribe the treatments. We counselors ask "depressed" people to DO SOMETHING. Wash your window. Take a trip. Change the scenery. Consider what you want instead of depression. In fact, how do you know you're depressed? What are you doing? What are you saying to yourself? In what tone are you saying it? Let's break it down...

Depressed behavior = "I walk around not wanting to do anything, especially chores.. I would rather listen to KUT or watch TV than DO anything. I waste time on the web or sitting on the back porch or playing with the dog (and washing my hands afterwards)"

Depressed thoughts = "I think about how my big a change my life has taken and I am tired of everything... I don't want to go back to work now... too many stresses... I wish I had stayed with the state and retired by now. I am healing well, and still don't feel Good! I've hit the Wall! I HATE washing my hands so often!"

Depressed feelings = "I feel tired... like I must have a "brain cloud", or my own word for it; fuzzy brain...

What do I want instead? "Hummmm... I want to be ready to re-enter the world without worry. I want energy back. I want to be Happy with all the blessings I already HAVE and not worry about what I don't have! I want to get back to living from my heart."

Is some of that already happening? "Yes. 1) Planning re-entry with Kimbo. 2) Doing some constructive activity [Taking a walk!] every day. 3) Commenting on my Blessings in the Present, when I notice them. 4) Giving from my heart in small ways.

If a Miracle occurred while I am asleep, and I had what I wanted, but I didn't know it cause I am asleep, how would I notice it when I woke up in the morning? "I would wake up looking forward to meds and morning procedures on my mind and go downstairs before the girls have left"

What is the first step I could take? "Set my morning alarm at night before going to bed"

What are the absolute smallest things I can do about:
Behavior?
"Take a walk"
Thoughts?
"Say to myself 'onward thru the fog!'"
Feelings?
"Remind my self 'all the blessings already are'"

So, for the formulaic folks out there, it looks kinda like this:

~~~~~~~~~~~~DIFFICULTY~~~~~~~~~~~~GOAL~~~~~~~~~~~~[TASK]

INSTEAD of depressed behavior I want INCREASED ACTIVITY [take a walk]

INSTEAD of depressed thoughts I want INCREASED + SELF TALK [encouragement]

INSTEAD of depressed feelings I want INCREASED REFLECTION [count my blessings]

There is always something we can do to improve our situation and we need to start small, measure our improvement and drop what isn't working like a hot potato, and keep doing more of what works!

6 comments:

Cheryl said...

Hey Jack! Well, it's been awhile since I've visited your blog, but NOT since I've thought about you.
Has anybody considered that the "depression" may be simply(or not so simply) "loss" issues? Here's a few examples. Even though your kidney was failing, it was, after all, YOUR kidney, and now it's gone....and you have the kidney of a man/woman who died. Leaving dialysis may be a blessing, but you have also left a group of people who held a place in your life for several years. Though your life wasn't ordered as you would have prefered during that time, it was certainly ordered - ie: you knew where you needed to be, when you needed to be there, and for how long you needed to be there. That regime and certainty are also gone. Even though receiving the new kidney is an obvious blessing, what about the anger that you HAD to get it in the first place? Couldn't some of your feelings be simple good 'ole fashion grief that needs to be recognized? Makes sense to me.....but then, I hallucinate! :) Love, Your Cheryl

Jack Nowicki said...

Ah yes... these are good thoughts Ms. Cheryll... and as I read them I remember all the grief work I've done with folks over the years. Good Job. And, however, the loss is only an addition: like my two old 61 year old, 3 pound kidneys ADOPTED a young 25 year old kidney! Part of the reason my girth has grown. Now thats grief for the loss of my old 34" waist!

I agree about the loss of my many buddies at El Milagro... good point.

My life NEVER seems "ordered to me", and I only knew where I needed to be because of copious lists and my Time Design, and my wife and my manager Kim... Oh... that was Order, wasn't it?

Anger... well... there are surely some unresolved issues in that bag... but I choose not to deal with them in this lifetime... AND btw: that PKD anger is one of the tiny ones.

So, thanks for your perceptive thoughts and for sharing them. Maybe I should come to you for healing... although there are these rules about such stuff. However, you got a lot to offer your non-friend peoples and I respect you for doing your work!

And, thanks again for your ongoing posts, my friend. JN

cheryl said...

Well, ok, so you DIDN'T lose your kidney (I forgot that point), but then you had to go and use the word "adopted"....now there's an issue close to my heart...and one "rife" with losses!!! :)

Love, YC

Clausewitz said...

Oi. Parabéns por seu excelente blog. Gostaria de lhe convidar para visitar meu blog e conhecer alguma coisa sobre o Brasil. Abração

Jack Nowicki said...

Cheryl ~ Can't get anything by you can I? Is there some similarity here, in some sort of metaphoric way? JN

Jack Nowicki said...

Mr.Clauswitz, for my English speaking readers, said:

"Oi. Congratulations on your excellent blog. I would like to invite you to visit my blog and know something about Brazil. ção"

...and I replied, "Eu olhei e não entender o Português ... Ainda não se parece muito interessante e animada!"

For Clausewitz: Eu olhei e não entender o Português ... Ainda não se parece muito interessante e animada!*

*from: http://translation2.paralink.com/