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Dear Dr. Saltzman,

I just read your interesting and informative reply to a question posed to you about depression, and I wonder if you could elucidate me about the case of my mother, who has been going through several depressions--or relapses into the same depression --during the last 5 years or so. I am reasonably acquainted with the problem of depression (though I am not a psychologist nor a psychiatrist), but my mother's case seems to have its peculiarities.

She is 66 and has divorced my father almost 6 years ago; she didn't like him nor the life he gave her, and according to her and to most people around her this was the best she could have done. She lives alone in Portugal, has her own house and a reasonable pension for Portuguese standards. She has a son (that's me) and two daughters; I live in The Netherlands, talk to her on the phone once or twice a week, visit her at least once a year in Portugal, and she comes to stay with my wife and I for two or three weeks every year; my sisters live about an hour away from her and have busy lives but have always kept contact with her, visiting her regularly (once a week at least in the case of my elder sister, about once a month in the case of my other sister), inviting her out occasionally, etc.

We love her very much and have supported her in many ways--emotionally as well as financially--but have also been somewhat tough with her in some respects. This is especially true of my two sisters, who are becoming increasingly fed up with her because of her general "attitude" (which I will describe below); during the last month their relationship with my mother has become particularly strained, and my elder sister has even threatened to sever relations (she hasn't called my mother for two weeks and has made clear that she doesn't want to see her nor hear from her in the near future); the other one, however, in spite of an increased harshness in her dealings with her, has actually visited my mother more often - at least every weekend -, took her to the doctor, cooked and shopped for her.

My mother has had breast cancer about 8 years ago (no mastectomy, only partial removal of tissues) and recovered well. Her sight is quite poor, but until very recently she could watch TV, go to the cinema, and even read with a special projecting apparatus my elder sister bought her. I should perhaps add at this point that my mother is reasonably well educated, likes to read, and has lucidly (as I could judge from our conversations on the phone) read several books during last Summer, for example.

Her mother died four months ago; although this was not exactly unexpected, for my mother it was yet another blow, and I think she feels remorse for not having visited and phoned my grandmother (who was in an elderly home) as often as she was supposed to. In recent years she has had a more or less active relationship with a married man, a childhood friend who I think was one of the few persons with whom she socialized, going out for dinner, etc. Recently, however, their relationship has been strained, probably due to my mother's illness, and I think they do not see each other very much (though they still keep contact).

My mother has a sensitive and somewhat whimsical and fussy character (with respect to people, food, household rituals of cleaning, eating, etc.), suffers from what I would call a spiritual addiction to medicines, vitamins, food supplements, teas and all sorts of potions which promise a happy and healthy life(almost running her own pharmacy and medicating herself), and is rather indolent and cowardly when it comes to facing up problems (since my sisters and I can remember, she has always tended to deal with problems by hiding from them or else by turning to others for help, which explains the long, unhappy marriage she endured before finally - spurred and helped by us - divorcing my father); but she has good qualities as well, which - however blurred they seem to us from the perspective of the recent events - my sisters and I still acknowledge and appreciate.

My mother has been on and off antidepressants for the last 5 years or so. She has been to several doctors (psychiatrists and neurologists), and has taken a variety of medicines, none of which had any lasting effect, and very few of which had any positive effect (Prozac, I think, was one of the best, but only up to some point). On the basis of a purported knowledge of antidepressants, she has several times decided to discontinue, or simply never actually started taking, some of the medication prescribed by some of the doctors. She is, however, aware of the danger of abruptly stopping the medication, and in fact seems to dread it.

Now to the symptoms: She complains constantly about her life, her health, her financial situation, etc., and she drains everyone's energy while doing so. She exaggerates to the extent of turning her existence into an absurdly hopeless and painful predicament. She is self-centered, showing no empathy towards other people nor interest in anything else besides her misery; in particular, she is far from being gleeful with the fact that she is going to be a grandmother soon - my elder sister is pregnant and the birth is due in April, but on the other hand she is constantly worried about going to the hairdresser, about the way she looks, etc. She is insecure and afraid of going out, she says, and in the last two months or so she practically stopped going out and has her shopping made by a maidservant who comes once a week. When I last saw her I noticed she had a general lack of interest, less appetite than usual, and lack of concentration, but on the other hand that she still couldn’t help meddling with what was going on in the kitchen, with the way we cooked, washed, etc. I should add that she seems quite lucid to me, that she can memorize things (e.g. the date of the elections in Portugal), and that she acknowledges her mental condition - it seems to me that her brain is simply tired and/or functioning at a lower rate.

We think she takes pleasure in worrying us, and that she uses all sorts of stratagems to get our and other people's attention, which is why we have been recently very hard on her. She says she doesn't eat because she lacks appetite or because she has no food at home; but the fact is that she has several people (the maid, my younger sister and my uncle) at her beck and call who have bought her food - and can buy her food whenever she needs it. She often says she would like to die, and the other day she told me she tried to open her wrists but didn't succeed because she has "no more blood in her veins" (a nonsensical expression I don't know to interpret - as the onset of madness or another token of childish, attention-seeking behavior). These are examples of what we would call a form of, or attempt at, 'manipulation'. In a word, she seems willfully intent on putting herself in a helpless, unsustainable situation.

She has recently got into the habit of calling an ambulance and going to the hospital where she is seen by doctors, invariably prescribed new medication, and then sent home. I spent two hours on the phone with her last week, trying to encourage her and to find out what her symptoms were; she said she felt she was going mad, expressed again her usual preoccupations, but this time talked very little and seemed desperately in need of having someone around to talk to and listen to, which I found quite unusual (she is not really the kind of person who likes to hang on the phone for hours). Last Saturday she called an ambulance and went to the hospital once more, and this time she was admitted (not to psychiatry though). Yesterday I talked to one of the doctors on the phone who told me she is lucid but a "bit confused", and that it is too early for diagnostics. I am aware that my mother may be suffering from a severe form of depression. However, my sisters and I cannot help thinking that her problem may lie more in her character than in any illness proper, and consequently blame and accuse her of being a selfish and mean - and indeed rather monstrous, if depression were really excluded - human being. In all the descriptions of depression I have read, I have never counted this form of 'meanness' and 'selfishness' among the symptoms, so I wonder if you could say something about it. Another thing I ask myself (the doctors we have talked to were very evasive on this point) is whether a treatment with antidepressants is really something desirable in her case, since such medication seems to do more harm than good to her. I really think that antidepressants can actually make things worse in certain cases because they essentially work by diminishing mental activity (or at least some part of it), while mental activity is sometimes crucial for the maintenance of an active and reasonably exciting life.

I would be most grateful if you could provide us with any information, and if possible give us some advice on how to act.



dr-robert: Thank you for writing. Your question is complex, but seems to simplify itself into two different basic questions: first, what is going on with your mother? And second, what are the ethics of dealing with a mean-acting older person, particularly a parent, when one is not certain whether the mean actions are part of a mental illness or simply selfishness and lack of concern for others.

I will try to help with both questions, but first, I would like to correct one misapprehension which you expressed in your letter. You wrote that, "antidepressants can actually make things worse in certain cases because they essentially work by diminishing mental activity." Although the exact reason that antidepressants like Prozac work is still not known, it is certainly not by diminishing mental activity. If anything, Prozac and other SSRIs (selective serotonin reuptake inhibitors) stimulate mental activity since they allow the neurotransmitter serotonin to remain longer in the synapses (the junction points) between nerve fibers in the brain, which tends to allow more information to travel along the neural pathways. The SSRI class of antidepressant medications have side-effects which can be unwelcome, but diminishing mental activity is not one of them so far as I know.

Now, naturally, without personally interviewing your mother, I cannot properly diagnose her condition, so all that follows is based only on what you have written, and may or may not correctly apply to your mother. That said, and, again, based on what you say, she seems to be suffering from at least a moderately severe depression, possibly a very severe one, which has persisted over time. This kind of depression certainly requires treatment, and it does not seem that your mother has received adequate treatment. This kind of case usually is best treated with a combination of antidepressant medication properly prescribed and managed as to dosage, side effects, and beneficial effects, along with at least weekly counseling. If your mother cannot afford private psychotherapy, I wonder if there are local resources that can provide it at low or no cost. In any case, she should be in the hands of a competent counselor of some kind, be it social worker trained in psychology, a psychologist, or a psychiatrist.

As for your mother's strange behaviors and words, such as, for example, the suicide attempt and her subsequent explanation that it failed due to a lack of blood in her veins: some kinds of depression can be accompanied by mental confusion or even thought processes disordered to the point of psychosis. At a distance, I cannot make that determination, but it is possible that she has difficulty with what sometimes is called "reality testing." Her statement that she felt that she was going mad needs to be taken seriously and investigated carefully, particularly when suicide is a possibility. Often suicide occurs when someone feels madness approaching and cannot stand the idea of "losing it," or when some voice in the madness suggests suicide as a solution to the disordered thinking. These features of her situation also need the attention of a competent psychotherapist who will understand what kind of treatment is required.

So far as I know, "meanness and selfishness" are not normally considered features of depression, but rather--when they are pronounced--may be considered features of certain character disorders, as, for example, narcissistic personality disorder. If your mother was also mean and selfish earlier in life as she is now, she may be suffering from a personality disorder in addition to depression. Or, she may be under such strain from the depression that she has become totally self-involved and impatient in ways which were not present in her earlier days. Once again, a diagnosis from a distance is not feasible. But this kind of behavior calls for a competent professional opinion as to options for treatment.

Now, as to the ethical question: If I read and understood your letter correctly, you seem to be feeling that if your mother's hurtful behaviors towards you and your sisters really are symptoms of mental illness, you would be prepared and able to suffer them, and to forgive them, but that if those behaviors are simply character flaws, then you and your sisters would feel justified in your reproaching of her. In a certain way this makes sense. As I understand what you are saying, if she is really ill, and if the meanness and selfishness are symptoms of the illness, you will treat her as a person who is not responsible for her symptoms, and will try support her as best you can, but if she is simply a selfish, ill-mannered shrew, then you will confront her with her behaviors. The problem is that there really is no bright line between these two categories, that is, one category (ill) seems to run into the other (nasty) with no clear way to tease them apart.

How much to put up with from your mother is the kind of question which cannot be answered by advice from an expert. The best I can do is to suggest that you open your heart to the fullest extent possible, and try to give your mother whatever you can without compromising your own feelings of integrity and self-worth. Sometimes in cases such as this it is helpful to see the task of withstanding bad behavior and insults as a kind of spiritual practice in which, remembering and understanding that the behaviors and remarks cannot really apply to you (since if your mother saw who you really are, she would treat you with more respect), you withhold criticism and simply let the troublesome actions roll off your back as water rolls off a duck's back. This may seem difficult at first, but may become easier as one feels less enmeshed emotionally with the person in question.

A propos: you might consider some short-term counseling for yourself just on this theme of possible excessive emotional enmeshment (which is not love, but prolonged, unresolved attachment) with your mother.

I hope this will help to clarify your situation.

Be well.

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