Case Studies

Obsessive Compulsive Disorder A Clinical Illustration – Mark

Top Student Sidetracked by OCD Despite being handsome, tall, personable, and a top student at Yale, Mark was silently struggling with an intense need to count to 100 every time he had a “bad thought”. This he told himself, reduced the thoughts from taking over. What’s more, he had difficulty socializing with his friends, without unobtrusively washing his hands for fear of contamination. And the back of his head had a patchy baldness—the result of years of nervous hair pulling (a tic like behavior), so…

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Graduation man holding paperTop Student Sidetracked by OCD
Despite being handsome, tall, personable, and a top student at Yale, Mark was silently struggling with an intense need to count to 100 every time he had a “bad thought”. This he told himself, reduced the thoughts from taking over. What’s more, he had difficulty socializing with his friends, without unobtrusively washing his hands for fear of contamination. And the back of his head had a patchy baldness—the result of years of nervous hair pulling (a tic like behavior), so he always wore a large baseball cap. As his life was grinding to a halt, Mark had begun to feel depressed and hopeless. He had tried medication, but could not tolerate it. Talk therapy was of little benefit. Finally, after 4 years, Mark came to my office with his parents, desperately hoping to get some relief without the use of medication.

Troubled Physiologic Systems
After a thorough 2 and ½ hour evaluation, I immediately put Mark on a supplement (Inositol) proven to help with OCD. This would take several months to work, but along with exposure and response prevention, I thought we would have a good foundation for healing. On the history and physical exam it became clear that Mark was having trouble on other fronts. His diet was very poor, and he often had vague stomach pains, gas, and indigestion. He was usually fatigued, and complained of increasing memory problems, which he had to work around. His normally sharp ability to calculate in his head had diminished significantly. He couldn’t handle the increasing stress of school life and was considering taking a leave of absence. His sleep was generally less than 6 hours per night, and he used a great deal of caffeine to keep himself going, but was still exhausted. Mark’s muscles were weak when tested and his reflexes were sluggish. He was hoarse, and generally looked like a rag doll, with poor posture.

Family History of OCD
Not surprisingly, Mark’s family history had evidence of other OCD spectrum disorders (his mother was compulsive clean in the home and a worrier, his two of his older sisters had eating disorders, a cousin was possibly autistic, and the maternal grandfather was a compulsive gambler).

Work-up Leads to Answers
Based on the findings above, and the fact that the immune system may play a critical role in OCD, Mark agreed to a work up. The results were astounding and also hope-inducing. Mark had 4 infections (salmonella, chlamydia, candida, and bartonella), 30 food allergies, was sensitive to gluten, and had a number of markers indicating that his body was very inflamed. Additionally, Mark was deficient in several essential nutrients including essential amino acids (tryptophan and tyrosine) and amino acids involved in neuroendocrine function (l- serine, taurine, tyrosine), omega three fatty acids, vitamin D, Vitamin A and beta-carotene, and CoEnzyme Q10. Marked showed evidence of gastrointestinal malabsorption. Finally, he was demonstrating hormonal problems in the thyroid axis, melatonin production, and the adrenal hormonal axis.

Treating the Causes
Mark, with the support of his mother and father, embarked on a comprehensive program to correct his gut, clean up his diet, replace the missing nutrients, and treat the infections. Together with the Inositol, and the psychotherapy Mark’s life turned around dramatically.

Results in Healing
This program was worked on for 6 months, and by the fall, Mark’s OCD was “95% gone”, his energy and cognitive function were back, and Mark felt like a new man. His thyroid and adrenal hormones had returned to normal, although he continues to take melatonin. He has remained off medication, has developed a social life, and has a girlfriend who will graduate from Yale with him at the end of the next semester.

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Early Recognition that Panic Disorder Can Be Treated without Medication – Joanne

1985 after being in practice for just a couple of years, a patient I will call Joanne, came to me for treatment of a panic disorder. I figured it was a pretty straightforward case that the literature, my experience, and my training indicated should respond to therapy or medication. Joanne was a 50-year-old woman in a bad marriage and her youngest daughter was going off to college. I assumed that Joanne was having panic attacks because of the threatened separations both from her daughter and…

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iStock_MotherDaughter_000019778071Small1985 after being in practice for just a couple of years, a patient I will call Joanne, came to me for treatment of a panic disorder. I figured it was a pretty straightforward case that the literature, my experience, and my training indicated should respond to therapy or medication. Joanne was a 50-year-old woman in a bad marriage and her youngest daughter was going off to college. I assumed that Joanne was having panic attacks because of the threatened separations both from her daughter and the possible break up of her marriage.

Multiple Medication Approach Failed

I thought that a course of Cognitive Behavioral Therapy should do the trick. When that didn’t work, I tried medication. I prescribed Imipramine, which is great for panic disorder. I was sure that would work, but it didn’t. Then I tried another medication – Xanax, and finally a third medication – Nardil and that didn’t work.

I Was Missing Something…

About a year into the treatment, she paged me on a Saturday night, with a panic attack. I thought, “it’s a year; she should be well by now, what’s going on?” I concluded that I was missing something, because she should have been better long ago. So, Monday morning I went into the office early to go over her chart. I looked at the Complete Blood Count I had done when she first came, and I noticed that the size of her red blood cells (MCV) was slightly abnormal. The range was 80-100, and she was 101.

I had ignored this piece of information because it was just slightly out of the normal, and so, doing as I was taught, I assumed it probably wasn’t significant. But, since she wasn’t getting better, as she should have, I had to dig deeper.

Research Reveals Cause

I did some research and found that an elevated MCV could indicate a B12 deficiency, so I had Joanne do a Schillings’ test to see if that was the case. Sure enough, it was abnormal.

Cause Pointed to Cure

I put Joanne on B12 injections and her panic attacks cleared within days and never returned. I was amazed, but also disturbed, that I had put her through a year of unnecessary treatment, and I started to wonder what else I was missing with my other patients. Gradually I came to learn that the head is connected to the body by this thing called the neck. That is when I knew it was time to look at the connections between the body and the mind.

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Medication Burn Out Assumed – Brody

19 Year Old with Depression and Panic Attacks Brody had a recurrence of panic disorder after 20 symptom-free years. Brody was a funny really warm-hearted young man. When I first met him, 29 years ago, he was 19. He was sent to me after he had been hospitalized for depression and panic attacks. He was given Nardil in the hospital and I then treated him with Cognitive Behavioral Therapy [CBT] and group therapy. Stabilized When Prozac came out, in 1988, I put him on it….

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19 Year Old with Depression and Panic Attacks

Brody had a recurrence of panic disorder after 20 symptom-free years. Brody was a funny really warm-hearted young man. When I first met him, 29 years iStock_Dad and Daughter Martial Arts_000012722399XSmallago, he was 19. He was sent to me after he had been hospitalized for depression and panic attacks. He was given Nardil in the hospital and I then treated him with Cognitive Behavioral Therapy [CBT] and group therapy.

Stabilized

When Prozac came out, in 1988, I put him on it. He was stable and so soon I was seeing Brody three times a year.

Destabilized by Major Life Stressors

Eventually he married, and then his wife developed a chronic and severe rheumatologic illnesses and his father died. Brody was stressed. Soon, had to take over his father’s retail shop, which meant he had to leave his career as an artist. His mother, who was still alive, was extremely difficult to deal with. Over the course of 18 months, Brody put on 35 pounds had borderline diabetes, and metabolic syndrome. To top it off, in 2005, he developed reflux, and his internist gave him Prilosec.

Panic Attacks Resume

Brody was on the Prilosec for three years, when in 2008, his panic attacks resumed in full force. He was literally terrified he was going to end up in the hospital, and lose his mind, his income, and his family.

Prozac Burn Out Not a Diagnosis

I remember that day because he came in, with his self-diagnosis and said, “I think I have Prozac poop-out”. I explained that Prozac burn out is a reflection of an underlying process, and is not a diagnosis. When medication stops working after months or years of effectiveness, something else must be going on. Brody resisted this idea and a work up for about one year.

Root of the Problem

Finally, agreeing to get to the root of the problem, we discovered that he had become B12 deficient because Prilosec reduces B12 absorption. So, in essence, there was a chain of events, a domino effect: stresses in his life resulted in over-eating, which resulted in being medicated for reflux. The medication then caused depletion of a nutrient critical to nervous system function and he was terrified which manifested as panic attacks.

Panic Attacks and Depression Gone

I gave him B12 and the panic attacks went away. He agreed to work on metabolic syndrome. He subsequently lost 43 pounds by correcting his diet and developing a daily exercise routine—doing martial arts with his daughter.

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Obsessive Compulsive Disorder Treated without Medication – John

Severe OCD since 4th Grade John was a very bright young fellow who was heading off to an Ivy League university in the fall. He was suffering from very severe OCD since 4th grade. He had tried Cognitive Behavioral Therapy, however it didn’t help. He refused exposure and response prevention therapy. Eventually, his OCD became so severe that he refused to extend his elbow because of his belief that such an action would cause harm to someone he loved. He also refused medication. Headaches, GI…

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Severe OCD since 4th Grade

John was a very bright young fellow who was heading off to an Ivy League university in the fall. He was suffering from very severe OCD since 4th grade. He had tried Cognitive Behavioral Therapy, however it didn’t help. He refused exposure and response prevention therapy. Eventually, his OCD became so severe that he refused to extend his elbow because of his belief that such an action would cause harm to someone he loved. He also refused medication.

Headaches, GI Problems, and Weight Problems

His Yale-Brown Obsessive Compulsive scores was= 29 (obsessive=12, compulsive=17). He complained of headache, many gastrointestinal problems (nausea, diarrhea, constipation, stomach pains, flatulence, reflux, and perhaps related, and inability to gain weight, despite a well balanced and healthy diet).

Family History of OCD

John’s family history revealed OCD in his grandmother, a suicide by that grandmother’s sister, using a gun. His father was anxious, depressed and impulsive, but high functioning and successful. His father’s sister was described as very intense, persistent, and obsessive. His other grandmother was depressed and his grandfather’s father was alcoholic.

Other Health Problems

John’s physical exam revealed an obvious contracture in his right elbow, with the right hand being cyanotic and colder than the left. His skin was dry, with severe acne on his face and back. His tongue was coated white, suggestive of Candida overgrowth, and his throat was red. He had bilaterally swollen cervical lymph nodes, white spots on his nails, hyper-pigmented scars suggestive of excessive ACTH output and adrenal insufficiency. He had chronic sinusitis.

Evaluation Points to Nutrition, Digestion, Immune Systems

In summary, my initial evaluation, (a three hour history and physical and laboratory testing), suggested problems in the areas of nutrition, digestion and immune/inflammatory processes. I suspected genetic problems in his methylation.

Lab Results Show Health Issues

The laboratory evaluation showed the following:
Nutrition: Low vitamin D, L-tryptophan was low, B5, B2;  B12, folate, Kryptopyrolles were elevated at 40.6 (consistent with acne, immune system problems), iron was low normal, low red blood cell size ( 83).
Genetic: ++MTHFR
Gastrointestinal: Candidiasis, anti-gliadin antibodies, WBC’s + in stool, HLA DQ2 (Coeliac’s).
Immune/Infection:  5 infections: salmonella, Endolimax Nana, Bartonella, Babesia, Candida, plus chronic sinus infections, delayed food sensitivities (IgG mediated).
Hormones: TSH: 4.11, melatonin was 7.1, ACTH was 42 ([norm=7-50], cortisol output was low at 20 [23-42], DHEA low normal (4), cholesterol was 131.

Now Willing to Do Everything

John was now willing to implement all of the recommendations because he had an understanding of what was causing his problems. He was a model patient. At his first 1st visit to review his lab results in May of 2007 I recommended L-tryptophan, D, B-vitamins (per his test results), high dose L-methylfoalte, inositol, three antibiotics for infections, candidiasis as well as anti-parasitics, probiotics, and a medical food product to support healthy bacteria and strengthen the gut-immune barrier.

Sleep back on Track

At his 2nd Visit on June 23rd 2007 he reported that his GI problems were gone, and his sleep was “back on track”, however his anxiety was unchanged. I recommended exposure and response prevention therapy.

Headaches Gone, Sinuses Cleared

At his 3rd Visit on July 19th 2007 he had had exposure and response prevention therapy and he reported his anxiety was “way down”. His headaches—which he had not told me about earlier—were gone. His sinuses had cleared completely.

By August 21st of 2007, John was still on his antibiotics, and he reported that the OCD was “ a million times better”, and no longer interfering with his activities”. He later was able to do cognitive behavioral therapy with exposure and response prevention.

Free of OCD without Medication

At follow up 3 ½ years (after his father’s death) he continued to be free of OCD, however at that time he was having some anxiety, which a short course of CBT was able to address. No medications were used in his treatment.

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Journey from Postpartum Depression and Panic Disorder to Wellness

High Functioning Businesswoman When Janine first came to see me she was 35 years old, and had just delivered her third child. As a former businesswoman, her transition to full time mom had been very rocky. One of the first things she said to me was, “I was high functioning until 3 years ago.” I was glad she told me this, for it gave me a baseline sense of who Janine was as a person in this regard. Pregnancy Complications, Depression, and Panic Attack She went…

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iStock_Woman Tennis Rear view_000016161625XSmallHigh Functioning Businesswoman
When Janine first came to see me she was 35 years old, and had just delivered her third child. As a former businesswoman, her transition to full time mom had been very rocky. One of the first things she said to me was, “I was high functioning until 3 years ago.” I was glad she told me this, for it gave me a baseline sense of who Janine was as a person in this regard.

Pregnancy Complications, Depression, and Panic Attack
She went on to detail her medical history: “During my pregnancy with my son, my third child, I was hospitalized with both pre-eclampsia and dehydration. Shortly after the delivery of Scotty, I developed depression, and after 18 months without any treatment—I didn’t know what I was suffering from. I had my first panic attack…”

Hospitalized for Depression and Panic Attacks
Janine was hospitalized 4 times for depression and panic attacks before her visit to me, and had two courses of shock therapy (ECT) with minimal benefit. She was on four medications: Clozaril, Depakote, Lorazepam and Wellbutrin.

Came to Whole Psychiatry
During the extended evaluation I conduct with patients, (history and physical) Janine complained of: migraines, deadening of emotion, extreme sedation, a 50-lb. weight gain since being on medication, trouble falling asleep despite her medications, Constipation/diarrhea, dry skin, peripheral edema and impaired concentration. Her Beck Depression Inventory (BDI) was 29, indicating a depression of high-moderate severity.

History Reveals Hormonal Problems
A very careful history and charting reveled severe PMS (premenstrual syndrome): She was “agitated and hyper” in late luteal phase (end of the menstrual cycle), and repeatedly experienced mild to moderate depression in early follicular phase of her menstrual cycle (day 1-7). This was misinterpreted by her previous doctors as rapid cycling, and so they put her on valproic acid (often thought to help rapid cycling bipolar disorder).

Adrenal and Thyroid Problems
The history and physical strongly indicated adrenal output problems (salt craving, hyperpigmentation, orthostatic hypotension by history, low blood pressure in the office (110/70105/70) without orthostasis, hypoglycemia (weakness, headache, irritability all relieved by food). The physical exam also suggested hypothyroidism (decreased relaxation phase of her deep tendon reflexes). The adrenal gland and thyroid gland work closely together so this was not surprising.

Family History Reveals…
In reviewing Janine’s family psychiatric history, it was clear that her
maternal grandmother had alcoholism and was diagnosed as bipolar. Her grandmother had one depression which was severe enough tor require shock treatments (ECT), and she was later maintained on lithium. Janine’s mother was described as impulsive and emotional. On the father’s side, Janine’s grandfather suffered form depression and alcoholism, as did her father and two uncles.

Testing Indicates…
As a result of timed hormonal testing we decided to use progesterone supplementation as a way to deal with the female hormone component of the mood and anxiety problems.

Result of Progesterone supplementation:
Janine reports: “On the Progesterone I avoided the down [in the follicular phase]. I felt more normal than in five years.”

Hormones Pinpointed as Necessary to Stabilize Mood
From her response to the progesterone it was immediately clear that stabilization of affective disorder quite difficult in the absence of hormonal intervention, and that her repeated late luteal phase, and early follicular phase mood disturbance appeared as rapid cycling. Studies indicate that such monthly mood cycling may increase the risk of *kindling further episodes and breakthrough mood episodes, which would require, if untreated, additional medication/hospitalization.

Testing Reveals More…
Further testing revealed that the mood cycling occurred in the context of numerous hormonal problems including:
a) Impaired glycemic control (secondary to medication and poor diet, lack of exercise)
b) Hypothyroidism (This was noted in her hospital chart but deemed “mild hypothyroidism not requiring treatment”.)
c) Adrenal insufficiency
d) Low levels of melatonin
e) Ovarian dysfunction

Nutritional Deficiencies Increase Mood Problems
In addition, we found that Janine had multiple nutrient deficiencies (e.g., L-tryptohan, B6, phenylalanine, eicosopentaenoic acid), which increased mood instability.

Psychological Effects…
From a psychological point of view, it was clear that Janine’s self-esteem was severely effected by how bad she felt physically, since she had always been health and had vibrant health. Her repetitive uncontrollable monthly mood cycling, medication side effects, the transition to motherhood, and her identification with grandmother, who had mental illness negatively effected her sense of self. Janine was really terrified that she too would be mentally ill.

Reduction of Medication
The treatment course consisted of correction of all of the above factors and Janine was able to come off three medications: Clozaril, depakote and lorazepam. She remained on her anti-depressant and required thyroid hormone. She engaged in ongoing therapy to help her with the motherhood role and her fear of being like her grandmother.

10 Years Later…Janine Functions Quite Well
With a 10 year follow up, Janine has had some episodes of depression, but has never been hospitalized and has been able to function quite well both during and between episodes. Over the course of time, it became apparent that there was a seasonal component to her depression, and because she had the means, she is intending to spend a substantial part of the winters in the south, once her children are out of the home. For now, she uses a dawn simulator, exercises, takes her hormones, supplements, medications, and therapy and is pleased that she is not following in her grandmother’s footsteps.

Take Away Lesson: Get Caring Support

I encourage child-bearing women to thoroughly discuss any mood disturbances with their physicians and their partner. Your emotional well-being is essential to your health, the health of your child, and the stability of your family. Toughing it out is not the way to go. Ask for help and understand that it is not a personal failing or a reflection about how you feel about your child. Caring professional support is available.

*Kindling is a hypothesized process that is relevent to a number of mental health disorders which can return after an inital episode. It has been shown that the occurence of one episode may make another more likely.

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Depression and Marital Problems A Clinical Illustration – “Jenny”

The Importance of Context and the Limits of Medication Every health care provider has had experiences that were so powerful that they have forever transformed his or her thinking and approach to patients. The following was such a case. It demonstrated a number of things to me, including the importance of context, the limitations of medication, and the failure of psychiatrists – myself included – to educate their nonmedically trained therapist colleagues in the rapidly progressing biological realm. At a time when the secrets of…

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iStock_Deprsd Man w Cell Ph_000011131712XSmallThe Importance of Context and the Limits of Medication

Every health care provider has had experiences that were so powerful that they have forever transformed his or her thinking and approach to patients. The following was such a case. It demonstrated a number of things to me, including the importance of context, the limitations of medication, and the failure of psychiatrists – myself included – to educate their nonmedically trained therapist colleagues in the rapidly progressing biological realm. At a time when the secrets of the brain are being unraveled, and research in the brain sciences is burgeoning like few other medical fields, we as psychiatrists are not spreading the news to our colleagues.

I Went Against My Training

Some time ago, when the concepts of sensitization and kindling were first being published in the psychiatric literature, I began to look at clinical cases from an additional, broader perspective. What I saw – and what I knew I needed to do – went against all of my psychotherapeutic training.

Relapse and Medication Changes with No Success

Jenny was a 40-year-old attorney and a divorced and remarried mother. She was referred by her therapist of two years, Ms. Troy, for psychiatric evaluation and consideration of medication to treat her worsening depression. At the initial interview, Jenny’s husband, Frank, an accountant, was present in order to provide some history. He was quite cooperative yet strangely detached. He answered all queries in a genuine manner – as he worked on his paperwork! After ruling out any medical causes of Jenny’s depression, I prescribed Cymbalta for her depression, and encouraged her to continue her therapy with Ms. Troy. Jenny responded nicely to the medication but soon relapsed. Over the course of one year she relapsed four times, each time requiring a change in medication, first Zoloft, then Wellbutrin, then Lexapro, and finally Effexor, all with limited success and a variety of annoying (at the least) side effects.

Context of Bad Marriage Triggers Depression

It gradually became clear that the source of Jenny’s unrelenting depression was her husband’s lack of accountability and responsibility regarding the marriage. While Frank said all the right things, he would frequently and unpredictably be late for couples’ sessions, not follow through on promises, etc. Jenny was helpless to achieve her dream of a satisfying marriage. This context (an uncooperative spouse, combined with a desire to make the marriage work) was powerful enough that Jenny’s depressions were recurring repeatedly, but, as may occur in a poorly managed split – treatment setting, I as her psychopharmacologist had only peripheral awareness of these dynamics. This changed, however, when I was paged to a long distance number at 11:30 p.m. on a Saturday night.

Suicide Seen as the Only Way Out

Jenny was in a hotel 2000 miles from home, threatening suicide. After arranging for her safety, I made sure that she was escorted to a friend’s home the next morning. When Jenny came in my office she looked haggard. As she filled me in on the details of the episode, I realized that the episode was again triggered by the ongoing helplessness within the marriage. Her husband, it turned out, had discontinued couples’ therapy several weeks earlier and was clearly not engaged in her attempt to improve the marriage. Jenny felt trapped between failure in a second marriage and helplessness about improving the relationship. That Saturday night she saw suicide as the only way out.

Medications Can’t Overcome Depression-Inducing Context

Now, at the crucial moment, she wanted me to tell her whether she should stay out of the house or go back to her husband. Based on the sensitization and kindling models, as well as the learned helplessness and other models of depression, I advised Jenny that a change in her context was medically indicated, and that was my firm recommendation. Her husband was creating a depressogenic [depression-inducing] context that attitude change and/or medication could not counterbalance. Continued depression caused by this context – a context in which her level of control over the outcome was negligible, a context that was in conflict with her deep need to love and be loved – led to more severe, frequent depression (sensitization, which could lead to kindling), and of course, suicidal ideation. I advised her to stay out of the home; if she and her husband chose to, they could continue in couples’ psychotherapy.

No More Depression

Jenny followed my advice, and one – and two-year follow-ups revealed that she did not relapse into depression. Jenny’s therapist was surprised by the advice I had given Jenny; she, too, had been taught that therapy was not about giving advice.

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Bipolar Disorder and Seasonal Affective Disorder A Clinical Illustration: “Bill”

Bill is a 27-year-old physicist with bipolar SAD, type A. He agreed to take lithium, which eliminated his springtime hypomania, but only partially alleviated his winter depression. Light therapy was added with good results. After three years, Bill married, and two years later he and his wife decided to move to a farm, which is at the same latitude, essentially, as his home of origin (the frequency of SAD goes down as one moves toward the equator and sunlight increases, and vice versa). I will…

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Sunrise on the farmBill is a 27-year-old physicist with bipolar SAD, type A. He agreed to take lithium, which eliminated his springtime hypomania, but only partially alleviated his winter depression. Light therapy was added with good results. After three years, Bill married, and two years later he and his wife decided to move to a farm, which is at the same latitude, essentially, as his home of origin (the frequency of SAD goes down as one moves toward the equator and sunlight increases, and vice versa). I will never forget the conversation Bill and I had after his second year on the farm, because the transformation was so remarkable.

“Doc, I gotta tell you, I finally felt like I was ready for this fall!”

“What do you mean?” I inquired.

“Well, I worked all spring and summer—from dawn till after dark in the fields. It was really hard, but I was out there all day. When fall came, I was really ready for it! I’m really in synch with the seasons now! I’m looking forward to the winter for the first time in my life. I need the rest and relaxation, the short days and long nights. I’m looking forward to it!”

I have followed Bill over four years since that phone conversation, and he has not had one depressive episode since, despite the death of his mother two years ago.

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