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Psychiatric - Anxiety / Depression

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - Hi, I had a diving incident with a friend who I was guiding nearly ten months ago. The incident involved him having a buoyant ascent from 15m in a dry suit. Upon reaching the surface he then (having by this time dumped all the air from his suit) dropped back to a depth of 20m. I went after him fearing he was unconscious, on reaching him he gave me the out of air signal. Using my octopus we made an emergency controlled ascent and straight away sought medical attention, and were put on oxygen.

Since the incident we have felt no physical effects and have continued to dive, however for me since the accident I haven't been able to enjoy my diving. I seem to have built up some sort of mental block about diving deep and can't bring myself to go beyond 20m. I am a PADI Divemaster and have over two hundred dives, some to 50 plus metres so I am very concerned about what is going on in my head about this? If I can't be comfortable with myself how can I look after students?

I don't allow myself to feel completely comfortable anymore. In fact, I seem to ‘spook' myself out my comfort zone when I'm too relaxed and become ‘super aware' of everything going on around me. I love diving and it's really knocked me for six, as I am normally a very confident person. A year ago I was happily sitting on the bottom at 36m playing with reef sharks, talking about tech diving. Now I'm only diving in 10m of water and saying to myself ‘there's no point in going down there!'

Could you tell me if you think it's wise to speak to a sports psychologist? If so, is it a service that you offer or could you recommend someone?

A - There’s only one guy I know who can fix this shit. You need a dive doc with a leaning toward psychology. They are few and far between as most dive docs come from GP or anaesthesia-land. Email us here at the magazine for their details.

But in a coneshell – here’s the deal. It’s my first rule of diving. ‘They who go with the bolter get the symptoms. They who bolt, don’t’. So, you are part of this law I’m afraid. You will be fine. You need to take it easy. Five metres at a time down deeper. Distractions work. Take a new camera with you. Turn your depth gauge round so you can’t see it and just look at fish ‘n’ stuff. Not up. Not down. And you will be fine.

Q - As a latecomer to diving I've become pretty obsessed with the sport. Having mastered air diving I feel restricted by the 40m depth limit, and would like to take up technical diving so I can get to 40m+, use Trimix, and try wreck and cave diving. But I'm concerned that my medications will hinder my progress. Currently I'm taking Bupropion, which I read can increase seizure risk. I'm also taking Epilim and have just started Olanzapine. Do you think it's safe for me to pursue my ambitions whilst taking these? Please say yes!

A - Er, this is going to disappoint you, but the answer is most likely no. We need a little more information here on why you are taking what you’re taking. Bupropion (aka Zyban) is most widely known as a smoking cessation pill, but was actually developed as an antidepressant. It does potentially increase seizure risk, but actually no more than many other antidepressants. The other two drugs you’re on lead me to believe you have bipolar disorder, a condition where moods cycle between manic highs and depressive lows (hence its previous label “manic depression”). This puts us in a quandary. Drug companies aren’t really interested in what happens to drugs under pressure, so there is usually precious little evidence of their safety in divers. We do know from animal studies that the blood brain barrier becomes more permeable to drugs with depth, so it’s not a big leap to imagine this might occur in humans too. This mix of medications in unpredictable doses, nitrogen narcosis and the inevitable heightened anxiety of a new diving environment could easily tip a previously stable brain into all sorts of bizarre activity. In my view the risk of a potentially fatal accident is too high here.

Q - My girlfriend had a recent family bereavement and she's started to get panic attacks at random times. She starts hyperventilating and gets palpitations. The attacks last a few minutes and she's getting better at controlling them with breathing exercises (I never believed that old paper bag trick would work but it does!) We're supposed to be going on a dive trip soon and I'm worried about what might happen if she gets one underwater. Can you enlighten me: is it safe?

A - Overbreathing can occur in a variety of situations – the out of shape diver frantically finning against a current, the malfunctioning regulator causing excessive breaths in a panicked diver, or the hyperventilation provoked by unpredictable anxiety (as in your girlfriend’s case). Rapid breathing blows off carbon dioxide, and makes the blood less acidic and more alkaline. These conditions cause calcium in the blood to bind to a protein called albumin, lowering the free calcium level and causing “tetany” - where muscles start spasming involuntarily. Not surprisingly, this causes further panic, more rapid breathing, and a vicious circle develops. The brown paper bag trick (yes, it does have to be brown) works by making you rebreathe your exhaled air, which is high in carbon dioxide, so raising the calcium level and restoring normal muscle function. Sadly there’s no waterproof equivalent as yet, so a diver has to be able to slow their breathing and keep the panic at bay whilst making a controlled ascent to the surface – easier said than done. And there’s the conundrum: if there’s no obvious cause for the hyperventilation (fatigue, a hangover, equipment failure etc.) then you need to be certain that you could cope with the sudden onset of panic underwater. A bit of honest self-assessment required, and in my view, any uncertainty necessitates a delay to diving until the issue is resolved.

Q - My doctor has recently put me on some treatment for depression. It's something I've suffered with over the years and normally I can get through it without needing medication. This time round it's been accompanied by (or perhaps resulted from) stress at work and financial concerns so I've caved into pressure from my GP and started taking Venlafaxine. Does this mean I can't dive?

A - The “black dog” of melancholia is part of the human condition, so much so that depression could be considered as a normal facet of being alive. It is certainly a very common issue that often goes unrecognised. Severity varies enormously, from a general vague feeling of the “blues” to a life-threatening illness. And so each case needs careful individualised assessment from a dive doc. We should remember that diving has plenty of positive benefits on the mind and represents a lifeline for many people, so solid reasons need to be provided for cutting it. However it can also be a very effective method of suicide. Where medications are required to treat depression, we also have to consider side effects and the consequences of pressure on the effective drug dose delivered to the brain. My rules of thumb: only one antidepressant, which should have been taken for a good few months to allow the brain to get used to it, no worrying side effects, and no significant mood swings. I always suggest fairly conservative diving (a maximum depth of 30m), and the diver’s buddy should be fully aware of the condition too.

Q - I have a mild form of Seasonal Affective Disorder (SAD). Basically I get pretty miserable between November and March, which makes me clam up in my shell and interferes with my social life. Diving through this period keeps me going but I prefer solo trips. We were discussing this at my dive club recently and they suggested contacting you for some advice on safety aspects and possible treatments. Any comments?

A - Most people get the winter blues to some extent but SAD takes this to a slightly more intense level. It can be experienced in summer, spring and autumn as well as winter. Sufferers complain of lack of energy, mood swings, poor concentration, unhappiness, and cravings for sweets or starchy foods, accompanied by withdrawal from family, friends and social activities. One interesting theory is that SAD is a mild remnant form of hibernation, and these features basically result from a reduced need for calories. Confusingly there is also a condition called reverse SAD which manifests as insomnia, anxiety, irritability, decreased appetite and increased sex drive. Diagnosis can be difficult! Bright lights, ionised air, cognitive behavioural therapy and timed supplements of melatonin can be effective as treatments. I wouldn’t ever recommend a sufferer diving alone, but with a trusted buddy looking out for you I don’t see why you shouldn’t carry on diving, particularly if you find it an antidote to the dull winter gloom.

Q - As a latecomer to diving I've become pretty obsessed with the sport. Having mastered air diving I feel restricted by the 40m depth limit, and would like to take up technical diving so I can get to 40m+, use Trimix, and try wreck and cave diving. But I'm concerned that my medications will hinder my progress. Currently I'm taking Bupropion, which I read can increase seizure risk. I'm also taking Epilim and have just started Olanzapine. Do you think it's safe for me to pursue my ambitions whilst taking these? Please say yes!

A - Er, this is going to disappoint you, but the answer is most likely no. We need a little more information here on why you are taking what you’re taking. Bupropion (aka Zyban) is most widely known as a smoking cessation pill, but was actually developed as an antidepressant. It does potentially increase seizure risk, but actually no more than many other antidepressants. The other two drugs you’re on lead me to believe you have bipolar disorder, a condition where moods cycle between manic highs and depressive lows (hence its previous label “manic depression”). This puts us in a quandary. Drug companies aren’t really interested in what happens to drugs under pressure, so there is usually precious little evidence of their safety in divers. We do know from animal studies that the blood brain barrier becomes more permeable to drugs with depth, so it’s not a big leap to imagine this might occur in humans too. This mix of medications in unpredictable doses, nitrogen narcosis and the inevitable heightened anxiety of a new diving environment could easily tip a previously stable brain into all sorts of bizarre activity. In my view the risk of a potentially fatal accident is too high here.

Q - I have been diving for around five years. I took Cipramil for depression for two years and continued to dive regularly during that time - I never experienced any problems with this whilst diving. I first took 20mg per day then 10mg and I finished taking it around 9 months ago.

I think it's probably true to say that the benefit I get from diving feels as though it does me every bit as much good as taking Cipramil did. In fact, the thought of not being able to dive makes me feel really quite down.

At the moment, I feel that the depression is returning (although I've never had panic attacks and I've never felt suicidal). I think I'd probably benefit from the support of taking medication again for a while, but I do feel a bit reluctant to start up the drugs again.

I've heard good reports from a friend of how much better he felt after taking St John's Wort, so, after reading about it as well, I have been considering trying it myself. I'm in good health generally and I'm not taking any other medication of any sort.

Would it be OK to take St John's Wort and carry on diving?

A - Sorry to hear you are on a bit of a low, but here’s some good news. The newer SSRI type antidepressives are a whole lot safer than the old ones. So it is accepted, that as long as your condition is stable – no one wants a suicidal buddy after all- and there are no odd side effects then most divers will be OK on cipramil. You will need a dive doctor to sign you off for this though, not your local GP.

As for St Johns wort, this is a fairly active compound, more in line with the old style meds, so I would think it better that if you wanted to dive, to go back to the cipramil, as at least this drug had been researched far better and we know its full side effect profile.

Or how about nature’s own prozac…..dolphins. From what I have heard, a quick dip with Flipper and Mr Gipper [his stunt double, yes really] and your serotonin will be leaking out of your ears.

Q - My brother who is a diving instructor is taking me to do the pool work of an open water course on Saturday. He said that as I had intussusceptions (sorry for the spelling which is probably incorrect) when I was a baby that there might be a chance that I would need a medical before I could do the course. I had the operation when I was 6 months old and I am now 28. I have not had any intestinal problems since caused by the operation or otherwise.

I also have suffered from panic attacks after I had glandular fever when I was 18 and also 2 years ago whilst working in a very stressful job which I left. I have not suffered from anxiety or panic attacks for the last 2 years though. Do you think I need to have medical.

A - The PADI medical has a real catch all statement on the form. “Do you have or have you ever had….” And one of the questions is about psychological problems. So you will have to answer YES to that. When you present the form to any dive shop after your bro’ has trained you, it may cause concern. So best to get your “Get out of jail free” card, otherwise known as the Fit to Dive cert. As all has been OK for a while, I am sure the anxiety will not be an issue. Unless of course, you are a total bag of nerves, and normal for you is half way between Norman Wisdom and a man about to be electrocuted.

The other issue, intussusceptions is not a problem now, but an interesting medical problem. That’s where your bowel slides into itself, like those odd water filled toys. The bowel then gets its’ blood supply cut off resulting in agonising pain, gangrene and death. Mainly babies get it and the classic sign is redcurrant jelly-like goo from the anus. A Munchausen’s-by-proxy favourite for parents with nothing to do after their lamb roast.

Q - Been diving for 3 years, AOWD, around 60 dives. Basically after a bad year at work, off-shoring, redundancies, pressure at work, I've been signed off work since 5th Dec, some 5 weeks ago. From elsewhere on you site probably was in the 'morbid depression' as a classification. Was referred to and am seeing a Dr in local hospital mental health unit weekly. Perhaps mid life crises, work-career etc. Currently feeling better than I was, generally less depressed, other wise in good physical health. Due to go diving mid March, how will I fair for diving medical regarding the prescription and 'depression', (I may hopefully be off the prescription before March)?

A - I know how you feel mate, bad years and all. But well done for getting through the worst of it, so some good-ish news for you. I assume you are on the newer SSRI style anti-depressives. These are OK for diving but only after an assessment by a dive doctor. One of the things they will look for is how bad your depression is. Morbid depression and weekly visits to the doctor is very significant. You could be a risk to yourself and buddy if things went pear shaped at depth. So you need the problem to lighten a bit, which is often due to the removal of the causative factors. Bad boss/relationship/pay etc. If these are resolved, the depression kind of normal and no side effects from the meds, then you could well be fine to dive.

Oh happy days. C’mon sing. Remember that scene in Con Air.

Q - I am a qualified PADI diver and my fiancée would like to learn to dive, however when she went to a try dive session she was advised that she probably wouldn't be able to get a medical signed off because of the medication she takes.

She is taking Stelazine 5mg and Procyclidine Hydrochloride 5mg once per day. This is to counteract a dopamine deficiency. She is aged 42, otherwise in good health and does not smoke. The type of diving we would do would be warm water, Red Sea, Caribbean, and possibly some summer UK (when hot!) and not exceeding 18m depth, mostly a lot less as nearly all the pretty stuff can be found in the first 10m. We are both fairly cautious in nature so we would not intend to 'push the envelope' in taking any risks or intensive diving, tight surface intervals etc.

I would be very grateful if you could advise me whether it would be safe for her to dive as described above and whether it would be possible to obtain a diving medical certificate when taking this medication.

A - I think its going to be difficult to get her signed off to be fit for diving on this drug combination and also for what it is used to treat.

Stelazine is a powerful tranquillizing drug used for treating severe anxious, psychotic and depressive episodes. It also has side effects similar to Parkinson's Disease, for which the procyclidine is given to counteract.

Stelazines tranquillizing action will inhibit her ability to respond in critical situations endangering both herself and her buddy, and if this were added to any narcosis then a fatality could happen.

As she is on this treatment for a major psychiatric episode, then this in itself would bar her from diving too.

I suggest she sees her psychiatrist to find out how long they think she needs to take this treatment, and if ever she is off it then a diving doctor would need a clear letter from her psychiatrist that she has fully recovered before passing her as fit to dive.

(other dive medical questions)



   


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