NIMH

Having a close friend or two to talk to---someone on whom you can depend for emotional support---can be great when little things accumulate or you temporarily feel down in the dumps. But can a friend talk you out of depression or lessen its pernicious effects? A study recently published in the British Journal of Psychiatry examined the viability of "befriending" as a tool in the treatment of emotional distress and depressive symptoms. The findings suggest that friendships, even therapeutic ones, aren't necessarily substitutes for good treatment.

Keep in mind the researchers weren't talking either about the garden variety of befriending (a term that has become common parlance among Facebook or Twitter users) or about a mild case of the blues. For the purposes of their study, the team of primary care researchers at the University of Manchester, Manchester, UK defined "befriending" as social support that was "initiated, supported and monitored by an agency" expressly for one or more parties to benefit. It was, by definition, a treatment for depression or emotional distress that was "non-judgmental, mutual and purposeful."

The meta-analysis (a systematic statistical analysis) looked at more than 24 studies that covered a wide range of depressed populations, including caregivers of individuals with dementia, adolescents, lonely widows, men with prostate cancer, and pregnant women. The frequency of befriending varied among the studies as well as the ways in which the befriending took place. Some contacts were made face-to-face, others were by telephone, and some were a combination of both. Befriending was delivered both by trained and untrained volunteers.

The researchers found that the befriending intervention was less effective than cognitive behavioral therapy (CBT) in adolescents with depression and in medication-resistant individuals with schizophrenia. It was also less effective than nurse cognitive-behavioral problem solving in caregivers of people with dementia. It was similar in effectiveness to a nurse education and self-efficacy intervention in older adults recovering from myocardial infarction, to local community support groups for new inner-city mothers, and to systemic family therapy in depressed adolescents.

Based on their data, the researchers were unable to conclude that "befriending" is an effective, evidence-based treatment. Instead, they suggested that more rigorous study was needed to compare "befriending" head-to-head with standard treatments (such as CBT and medication), and that individual preferences should be considered in determining what works, for whom, and under what circumstances. This study relied on meta-analytic techniques to look at the friendship question but it would be worthwhile for researchers to design more large studies that look closely at whether and how friendships can alter the course and outcomes of various types of depression.

The conventional wisdom is that the presence of social supports can serve as a buffer against depression. Sounds logical enough: Friendships offer an outlet for people to express their emotions, to put things into perspective, to feel less alone, to reduce stress, and to encourage someone who's feeling distressed to seek out professional help when needed. But people with severe depression often have a hard time reaching out to anyone and it is often equally difficult for friends, even very good ones, to know what to do to help them recover. There's a lot more to learn.

Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis

Nicola Mead, PhD, Helen Lester, MB, ChB, MD, FRCGP, Carolyn Chew-Graham, MB, ChB, MD, FRCGP and Linda Gask, PhD, FRCPsych, NIHR School for Primary Care Research, University of Manchester
Peter Bower, PhD, National Primary Care Research and Development Centre, University of Manchester, Manchester, UK

The British Journal of Psychiatry (2010) 196: 96-101. doi: 10.1192/bjp.bp.109.064089

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How to Help a Friend or Relative Who is Depressed (From the NIMH)

If you know someone who is depressed, it affects you too. The first and most important thing you can do to help a friend or relative who has depression is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with him or her to see the doctor. Encourage him or her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

To help a friend or relative:

• Offer emotional support, understanding, patience and encouragement.
• Engage your friend or relative in conversation, and listen carefully.
• Never disparage feelings your friend or relative expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend's or relative's therapist or doctor.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if he or she declines, but don't push him or her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind your friend or relative that with time and treatment, the depression will lift.

Facts about Major Depression

According to the National Institute of Mental Health (NIMH), major depression is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. An episode may occur only once in a person's lifetime, but more often, it recurs throughout a person's life. , It is estimated to affect 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.

Dear Dr. Levine,

I am reeling from the awareness that certain friends who meant a great deal to me have abruptly turned their back on me now that I have revealed and declared my struggle with mental illness. I was diagnosed with a form of bipolar disorder after weathering several years of depression alongside "up" periods. When it was just garden-variety depression, I believe the problem had been more acceptable to these individuals, who are mostly male.

Now, having spent almost two weeks in hospital, the tables have turned and folks have run for the hills. I mean nothing: No phone calls, no cards, unreturned e-mails. These relationships, mind you, go back almost 20 years. I've spent most of my time being the "counselor" to these folks. Still, for the most part, I gained a lot from the relationships: mentoring, laughter, contacts, learning, etc.

So I'm not sure how to proceed from here. My self-esteem is shot-to-be-damned, and I really haven't much patience right now for the childish ways of grown people. Over the years, I've observed that people who "hide" from others' adversity find some way to wheedle back in after it seems like the coast is clear. I'm pretty clear about cutting these folks off, since there's really nothing to be salvaged except my self-worth. I am angry, and I can't guarantee that I still won't be angry when they inevitably return to my world. How would you suggest I handle this?

Signed,
Alone

ANSWER

Dear Alone:

When someone has a serious medical condition, deciding whether or not to tell others is never straightforward. This is compounded when it comes to disclosing mental or emotional disorders because of the pervasive misunderstanding, stigma and discrimination commonly associated with disorders of the brain. As you found out, there is even a pecking order among mental illnesses. People are generally more understanding and accepting of depression and anxiety disorders than they are of bipolar disorder, schizophrenia, or schizoaffective disorder. This is simply because of the dismal lack of mental health literacy among the general public.

In considering whether or not to tell, it's important for someone to think through whom to tell (the answer might be different for different family members, friends, employers and acquaintances) and how much information and detail to provide (e.g. the name of the disorder, the nature of the treatment, specific vs. general information, etc.). Decisions like this are deeply personal. Ultimately, individuals need to make decisions that feel comfortable to them! There is no right or wrong.

Getting back to your specific situation: You made the decision to be candid with friends whom you trusted, hoping they would understand and rally around you. This wasn't the case so I understand your disappointment. But consider the possibility that these friends weren't ill-intentioned. They may simply have felt uncomfortable and didn't know exactly how to react or what to say---because they don't understand bipolar disorder, its course, or its treatment.

Perhaps, you could seize this as a teachable moment, focusing on one or two of the individuals with whom you feel closest, and helping them better understand your experience. After you speak, you could also direct them to online resources for information such as one of the booklets made available from the National Institute of Mental Health  or from the National Alliance on Mental Illness.

Being hospitalized for a mental disorder often feels like a setback to that individual (although it shouldn't be that way!). Admittedly, it is an unplanned disruption to work, study, and/or friendships. You say your self-confidence is shattered-so give yourself the gift of time and allow yourself to slowly get back into a normal routine. Try to hold back your anger towards your friends, which may turn out to be misplaced. You may find that some of these friendships were tenuous and aren't worth resurrecting but I sincerely hope that at least a few of them will be recoverable.

You signed your letter "lonely." Simultaneous with working on your old friendships, you may want to get involved in a support group such as those sponsored by the Depression and Bipolar Support Alliance. This will allow you to meet other people who have struggled with similar issues and who can support you as you get back on your feet. I hope you also have the benefit of a relationship with a mental health professional who can help you get over this trauma.

Remember that lifting the veil of secrecy and shame that shrouds brain disorders can only be accomplished one person at a time. I applaud your honesty as well as your posting this letter.

Warm wishes for your recovery,
Irene

P.S. In my book (co-authored with Jerome Levine, MD), Schizophrenia for Dummies (Wiley, 2009), on P. 216-222, there is an extensive section on "Breaking the News," the pros and cons of disclosing mental disorders. Since it provides far more detailed advice than I could post here, you may want to glance at the book in the library. Although my comments in the book are focused on schizophrenia, they are just as pertinent to bipolar disorder.

Think back to your days in high school. Do you remember your exaggerated concerns about your appearance—constantly worrying about your pimples or what you were wearing? Do you recall the social cliques (e.g. nerds and jocks) that embraced some of your peers and drew circles to keep others out?

Imagine what high school is like for teens with disabilities who are just coming to terms with the realization that they are different and find that their peers are rebuffing them. "It's hard enough to be a teenager," says UCLA clinical instructor of psychiatry Elizabeth Laugeson, "but it's harder still for adolescents with autism because they typically lack the ability to pick up on all the social cues most of us take for granted — things like body language, hand gestures and facial expressions, along with speech inflections like warmth, sarcasm or hostility.

Autism Spectrum Disorders (ASD), also known as Pervasive Developmental Disorders (PDDs) can range from very mild cases to more severe ones. However, according to the National Institute of Mental Health (NIMH), all children with ASD have deficits in three areas: 1) social interaction, 2) verbal and nonverbal communication, and 3) repetitive behaviors or interests. To address these deficits, Laugeson and her colleagues developed and evaluated a special training program, called the Program for the Education and Enrichment of Relational Skills (PEERS) for teenagers with autism.

Since social interaction, communication and showing an interest in others are essential building blocks in developing and maintaining friendships, the 12-week UCLA PEERS program is designed to teach teens with autism the skills they need to relate to their peers that might not come naturally: This includes: how to join a group; how to choose a group; and how to handle bullying, teasing and arguments. The teens are given the chance to learn these skills through a range of modalities, including modeling, role-playing and coaching.

"The class is very structured, and the skills are broken into small steps," says Laugeson.  "For me, the most important outcome of this research is that we're able to have a direct impact on the quality of lives for teenagers with ASD," Laugeson said. "Helping them to develop meaningful relationships and feel more comfortable within their social world — these are essential ingredients to living a happy life, and what could be more important than that?"

Source: Press Release UCLA, Teaching autistic teens to make friends, April 7, 2009

April is Autism Awareness Month. To learn more about Autism and how you can promote awareness in your own community, visit the web sites of the Autism Society of America or the National Institute of Mental Health.

QUESTION

Dear Irene,

I have a very close friend who is going through a rough time. She recently became pregnant after ongoing fertility treatments. I was extremely supportive through all of this.  Since becoming pregnant, her anxiety and panic has increased immensely.

She is an only child who depends greatly on her parents and will often choose to do things with her mom over doing something with me. I don't ask her to do much these days since she is with her mom most of the time.

With her panic issues, she has become extremely hard to be around.  I try to help as much as I can, but she will usually just tell me that I don't really understand because I haven't had her exact symptoms. She now thinks she's becoming depressed as well.

I guess my issue is that over the years I go through these stages where I feel like she expects me to be there for her whenever she needs me. But when I need her, she barely has time for me. I can call her with a problem, and she's always doing something while talking to me. I NEVER get her full attention.

I know this is a troubling time for her, but it just seems to have brought back my negative feelings about this friendship. And, to a certain extent, she is creating some of her anxiety/panic/depression.  I am just finding myself very angry about this whole friendship. Any advice?

Thanks,
Paige

ANSWER

Hi Paige:

If your friend has a true panic disorder, she may be experiencing terrifying physical and emotional symptoms that feel out of her control. Panic disorders are often associated with depression and anxiety as well. While you sound like a very empathetic and caring friend, your friend is probably correct in saying that you can’t understand exactly how she is feeling. You also can’t make her symptoms go away. But these two facts don’t make you less of a friend.

Because of your friend’s problems, the relationship has become one-sided. It’s normal that you would feel resentful because she isn’t able to be there for you in the way that you are there for her. Since you call her a “very close friend” and acknowledge that she is going through a “rough time,” it seems like your friendship once had a more reciprocal basis, where there was more give and take, so I wouldn’t give up on the friendship just yet.

The signs and symptoms of a panic disorder tend to flare up during difficult life transitions, and coping with infertility would be high on such a list. In fact, some research suggests that coping with infertility can be as stressful to a woman as dealing with a serious physical illness like cancer or HIV/AIDS. Although getting pregnant after having fertility problems should be uplifting, it can be another source of stress.

You didn’t mention whether or not your friend is being treated for her symptoms. If she is, she may need some more time. If not, you may want to suggest that she get diagnosed and treated. Perhaps, her mother is worried about her daughter’s problems and that’s why she and her mom are spending so much time together. If you have a comfortable relationship with her mom, you can mention that you are concerned about your friend.

In any case, it sounds like you are burned out and may need to step back a bit until your friend is more together. You could have a frank discussion with her and tell her that you are a bit overwhelmed by her neediness but still cherish your friendship. In the meantime, take a break. Spend more time with other friends you enjoy, create a bit more distance between you and this friend, and see how things evolve over time. Just keep in mind that it is unlikely that her emotions are under her control at this point and she’s probably suffering more than you. Above all, be kind because she’s your friend.

I know this isn’t an easy situation but I hope this gives you some food for thought.

Best,
Irene

About Panic Disorder (from the National Institute of Mental Health)

Panic disorder is an anxiety disorder. It causes panic attacks, which are sudden feelings of terror for no reason. You may also feel physical symptoms, such as

* Fast heartbeat
* Chest pain
* Breathing difficulty
* Dizziness

Panic attacks can happen anytime, anywhere and without warning. You may live in fear of another attack and may avoid places where you have had an attack. For some people, fear takes over their lives and they cannot leave their homes.

Panic disorder is more common in women than men. It usually starts when people are young adults. Sometimes it starts when a person is under a lot of stress. Most people get better with treatment. Therapy can show you how to recognize and change your thinking patterns before they lead to panic. Medicines can also help.

Have a friendship dilemma? Perhaps I can help. Write to me at irene@fracturedfriendships.com/

Hi Irene,

It's almost funny that I found your site and am now writing to you---as I don't have ANY female friends. I can't keep a friend to save my life. If I hit it off with someone, I end up sabotaging the friendship. I say "yes' to plans and then start panicking about what to do, say, wear, and ultimately end up thinking of an excuse so that I won't have to go.

I don't like the phone so I don't call people back. I suffer from severe anxiety and it really cripples my ability to trust. I don't trust girls because I've always been disappointed with them. I should probably also mention that I am in a very happy and fulfilling relationship and am getting married in September...My energy is always focused on my fiancé and I know that in doing so, I relinquish the ability to "give" myself to potential friends. I don't think that is wrong, but then why do I get sad when I don't have a Girls' Night Out to go to?

Finally, one other key piece - I have a twin sister who, while we email/speak every day, I am too much for her. She constantly pushes me away and always holds me at arms length. It's really sad, and I do wish for more. This email seems too disjointed to even send, but I might as well put it out there anyway.

All the best,
Fran

ANSWER:

Hi Fran:

It sounds like as much as you would like to have female friends---you just don't feel comfortable making friendships or being around people you don't know very well.

One possible explanation is that you are suffering from a condition called social anxiety (also called social phobia). People with social anxiety feel like they are constantly being evaluated by other people and even may become viscerally uncomfortable in the presence of others. Given these uncomfortable feelings, it's understandable that the person would try to avoid or escape from social situations, even ones they would really to participate in, like parties or other social events.

The National Institute of Mental Health has an excellent online publication that describes some of the hallmark symptoms of social anxiety. People with social anxiety:

• are very anxious about being with other people
• are very self-conscious in front of other people; that is, they are very worried about how they themselves will act
• are very afraid of being embarrassed in front of other people.
• are very afraid that other people will judge them
• worry for days or weeks before an event where other people will be
• stay away from places where there are other people
• have a hard time making friends and keeping friends
• may have body symptoms when they are with other people, such as blushing, heavy sweating, trembling, nausea, and having a hard time talking

You seem to have remarkable insight into your predicament so it would definitely be worthwhile for you to discuss this problem with a mental health professional. There are a range of medications and behavioral approaches that make social anxiety eminently treatable. While you may never be the life of the party, when treated, you may find that you have no problem making friends and enjoying their company.

It's great that you have a good relationship with your fiancé but you are missing out on other relationships that may also be rewarding. I'm not sure what the problem is between you and your twin sister---she may not understand how you're feeling or acting. Alternatively, it may be totally unrelated to this problem.

It was very brave of you to write. Interestingly, people with social anxiety often feel more comfortable with virtual friends than face-to-face ones.

I have every confidence that you will change---because you want to! Congratulations on your upcoming marriage. If you are planning a wedding, it would be great to get this problem in check before then.

My best,
Irene

It’s depressing to be with a friend who is truly depressed. You may even get weepy yourself. The black cloud of depression spreads over you too, making you feel like you want to escape and be with anyone else but her. But read this first!

I’ve blogged here repeatedly about the importance of female friendships to women’s emotional and physical well-being---and about the perils of toxic ones as well. I’ve talked about friends who are too needy, too self-centered, too angry, too demanding, or too unreliable and have pointed out that some friendships reach a tipping point when it’s time to call it quits. I still believe that relationships that are consistently draining should be ended or at least, placed on hold.

Then I received a post from a reader entitled, Toxic Friends May Be Crying Out for Help, which reminded me that there are exceptions to every rule---and that it is important to distinguish between a toxic friendship (which is pathological relationship) and depression (which is a mental disorder). Here's the post:

Dear Irene:

Thanks for pointing out that there are bad friends out there, However I want to play devil's advocate here and say that in 2006 when ALL and I do mean ALL 5 of my close friends bailed on me like a chain of dominoes I nearly died from the depression it caused. In the wake of that nightmare I found out I had a mental problem and needed HELP. Your call to DUMP Toxic Friendships would be better served by advocating INTERVENTION for people who may possibly be in serious trouble rather than leaving them behind like trash on the street corner.

Signed,

Anonymous

Yes, there are some cases when close friends need to cut a little slack. Could it be that your friendship feels burdensome and painful because your friend is depressed?

Recognizing depression

Clinical depression is extremely common, affecting nearly one out of ten people in a given year, and it’s is twice as prevalent in women as it is in men. It’s more than a case of the blues or a bad mood that passes. Depression profoundly affects a person’s ability to function. And as hard as someone tries to shake it, it recurs nearly every day, all day, for at least two weeks or longer.

According to the National Institute of Mental Health (NIMH), the symptoms of depression may include:

• Persistent sad, anxious or “empty” feelings
• Feelings of hopelessness and/or pessimism
• Irritability, restlessness, anxiety
• Feelings of guilt, worthlessness and/or helplessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, waking up during the night, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

Does this list of symptoms and signs make you think of one of your friends? Well, this is a reminder. As much as you might like to, you can’t talk a friend out of being depressed. Even a kick in the pants won’t help. Depression is a biological illness.

What you can do

• If you are a good friend, there are some ways in which you can help and possibly make a difference:
• You can listen carefully, provide support, and offer to spend some time doing things you enjoy together (taking a walk or bicycle ride, or going to a movie).
• You can offer to help her with concrete tasks she can’t accomplish on her own because she feels so overwhelmed or has no energy.
• Try to be patient---and never be pushy. Don’t dismiss her feelings. Show that you understand them but encourage her to realize that these feelings are only temporary and will eventually pass.
• Don’t pussyfoot around the issue. Remind her that depression is a treatable illness and encourage your friend to seek treatment.
• If she resists your initial suggestion, try again but don’t nag. Don’t make demands or set ultimatums. Many depressed people need time to find their way to treatment and some people just want to be left alone.
• If you worry that your friend may be harboring suicidal thoughts, you have certain ethical obligations. Be direct and ask her if she feels suicidal. If she does, remind her that she is important to you and that she needs immediate professional help. Never allow the burden of having a depressed friend be yours alone. Be sure to inform someone else (e.g. her partner or closest relative.) If you’re her partner, tell her doctor.

Recognize that you can only be a friend, not a mental health professional. There is just so much that friends can do and so much that they can give. You may need to reluctantly cut loose and be there for her when she begins to recover.

Note: This post is about friendship and isn't intended as medical advice.

This post can also be read on The Huffington Post.