For years, I’ve suffered with extremely low mood in the mornings – even if I go to bed happy. What could be causing these overnight changes and is there anything I can do to avoid them? I’m 91.
Brian Pfeiffer, Kent.
Dr Martin Scurr replies: This is a problem I’ve seen many times. Essentially, it’s a form of depression. Symptoms can rise and fall throughout the day; we call this diurnal mood variation.
Some people’s mood slumps in the afternoon or in the evening. But the most common pattern is for symptoms to be worse in the morning, just as you describe. Some of my medical colleagues call this ‘morning melancholia’.
Typically, those affected wake very early – often around 3am – feeling low, guilty and hopeless. In some patients the symptoms are almost unbearable and yet, once the day begins, their mood improves and by late morning it’s almost unnoticeable.
It’s possible it is a sign of an underlying condition such as sleep apnoea (when you stop and start breathing in the night), which causes poor sleep: not getting enough quality sleep is linked to depression. However, while symptoms overlap with classic depression, it’s important to note that morning melancholia is not a reaction to life circumstances (in your longer letter, you say you spent six months in a psychiatric unit with depression in the 1970s, due to personal and work-related matters – I’m glad to hear you recovered).
Instead, morning depression is to do with changes in body chemistry, principally the natural ‘spike’ in levels of the stress hormone cortisol that we experience in the morning to get us going. In some people the body overreacts to this cortisol flood, causing psychological ‘heaviness’ or anxiety.
The good news is there are effective treatments and I’d urge you to ask your GP for a referral to a psychiatrist experienced in this type of disorder. You may be prescribed antidepressants.
Some people’s mood slumps in the afternoon or in the evening. But the most common pattern is for symptoms to be worse in the morning, writes Dr Martin Scurr
Bear in mind it may take several weeks on these before you notice an improvement. It may also take a little time to get the right dose and to find the most effective one for you (and if sleep apnoea is involved, that will be addressed separately).
This is where experience is so important, and why I suggest the involvement of a consultant psychiatrist.
I recently had what felt like a heart attack (with chest pain, dizziness, vision loss, sweating) while sitting playing sudoku. I had a heart attack in 2009 (so I know what it feels like) and have been on drugs for angina ever since. This time, blood tests and an ECG at hospital appeared normal. Should I be worried?
Carole Goodman, East Grinstead.
Dr Martin Scurr replies: This must have been alarming and I understand why you are still concerned.
After your heart attack you would have been prescribed nitrate spray (e.g. GTN or nitroglycerin) to relieve angina (chest pain), which is an ‘after effect’ due to impaired blood flow to the heart muscle.
However, angina usually occurs on exertion, when blood supply to the heart muscle is less than the muscle requires, starving it of the oxygen it needs. While it is possible this is what you experienced, what’s puzzling is that some of your other symptoms are not typical of angina. And as you were merely sitting quietly, your heart was not under a greater load – so angina pain wouldn’t normally be expected.
When it does happen in these circumstances, it’s usually described as ‘unstable’ angina – often due to reduced blood flow to the heart because of arteries narrowed by fatty deposits. This requires medical attention.
In your longer letter you refer to ‘near fainting’ during the episode and I wonder if you may have had some type of abnormal cardiac rhythm, a different aspect of the heart muscle being impaired by a restriction in blood supply.
My advice is to have your cardiac status reinvestigated. I recommend getting in touch with your GP to ask for an urgent referral to a cardiologist.
In my view… Let students dissect bodies
I am disturbed to hear there is growing momentum to end the practice of student doctors dissecting human bodies as part of their training – the argument is that modern technology can replace practical experience, via 3D computer models and other teaching aids.
Dissection was one of the most valuable learning experiences of my medical career: it helps students not only understand the workings of the human body better, but we also learned to respect the individual in front of us.
Of course, cadaver laboratories are expensive to maintain and donated bodies are in short supply. But I fear those who do not experience this training will not be the same doctors that those of my generation have been if it is abandoned for ever.
I have no hesitation in committing my body for dissection when I die – it will be an honour if I am accepted and I plan to register with my old medical school, University College London. When I next enter the anatomy department at UCL the circle will be complete.
