Sunday, January 24, 2016

What Non-Depressed People Should Know About Depression

In recent decades the acceptance of depression as a treatable disease (rather than a character flaw or purely spiritual problem) has spread, along with the use of antidepressant drugs.  Everybody knows someone personally and can name celebrities or artists who take or have taken antidepressants.  This should not be mistaken for understanding depression or how one can successfully live with it.

Like pregnancy, those who cannot experience clinical depression[1] cannot fully understand it.  That's OK.  Partial understanding, enough to be supportive and sympathetic, is usually enough.  Here are a few things non-depressed people can and should know about depression, in the spirit of understanding and support.    

1. Depression is more than one thing
2. Depression comes and goes like weather
3. Depression is managed like diabetes, not cured like a bacterial infection

I have lived with depression since I was a child and it runs in my family.  On my mother's side it probably goes back to her maternal grandmother[2], maybe farther.  I have no formal mental health training but between myself, my family and my friends I have a lot of first and second-hand knowledge of depression.  


More Than One Thing

Clinicians diagnose different types of depression, but beyond that, each individual experiences depression differently, even within a given diagnosis.  For some of us the mental and emotional "weather" is triggered by the seasons, circumstances, social interactions, literal weather or physical sensations[6].  Others are jerked up and down by simple periodic cycles, unattached to anything but time.  

We also experience different symptoms[2.3].  Many of us have a diminished capacity to experience pleasure or excitement.  Others have compulsions connected to our moods that range from watching too much TV or binge eating to truly disturbing and dangerous [2.5] risk taking and self-harm.  Some of us can't sleep; some of us don't want to do anything else.  Some of us shuttle back and forth between these things.  

I have experienced a symptom I have not heard anyone else describe[3].  When very depressed my vision and hearing sometimes dull.  The visual effect is a little like the "tunnel vision" eye-strain associated with driving for long periods.  I lose my peripheral vision and can only focus on what is right in front of me.  Similarly, I have trouble hearing, as if my ears were ringing or plugged.  

It is a spot-on metaphor for one aspect of a depressed person's thinking, but that's no comfort while it's happening.  My guess is that some other people experience this dulling of the senses, but I'm not surprised I have not heard about it.  It took me many years to get around to mentioning this phenomenon to my therapist.  Conversational topics like reducing my suicidal thoughts were more pressing.  

Whether some other people with depression experience dulled senses or not, it's a safe bet that many, if not most, do not[3.5].  From the outside it is easy to assume the wrong thing when presented with such differences.  If you know one person with depression who has massive trouble sleeping and another person with depression tells you they have none, that doesn't mean either of them is a hypochondriac, misdiagnosed, lying, or anything else.  It just means they are different.


The Weather

People with bipolar disorder[4] are not the only ones whose moods shift radically and problematically.  Someone whose depression is well managed and causing little trouble can suddenly plunge, becoming belligerent, withdrawn or suicidal.  Others may struggle horribly during the winter holidays and feel relatively good most of the rest of the year.  I struggle a little more in the run-up to Presidential elections[5].  

Bipolar disorder and seasonal affective disorder are by far the most famous examples of how depression can change, but the factors of depression's variability are truly infinite.  Some people feel better and then worse cyclically, no matter what[5.5].  My depression is very sensitive to my changing circumstances but I also struggle more in the winter.  Depression comes and goes in part because it is affected by millions of different things, from how much our parents hugged us us to what we had for lunch.

The main lesson for the non-depressed is this: if someone tells you something makes their depression better or worse, or simply that it is better or worse today, just believe them. If someone says that clouds get them down, but both sunshine and rain lift their spirits, don't try to figure out how the rain cancels out the clouds.  Just take their word for it.  


Management Not Cure

It is true that most depression is episodic and that it sometimes even goes away without treatment.  The bad news is that once it has visited you there is a better than 50% chance it will come back, possibly with a vengeance.  After a recurrence or relapse, the chance of a third episode is over 80%[6].  You can probably guess where the graph goes from there.  

For someone like me who has had repeated depressive episodes for decades a "cure" isn't in the cards.  For us depression is like type 1 diabetes or alcoholism[7].  We may go for long periods of time where depression causes us no major problems (up to true remission) but we are never truly cured.

People with diabetes and recovering alcoholics actively manage their diseases because their lives depend on it.  Likewise, chronic major depression must be managed or the consequences can be grave, up to and including death.  For me, if I don't actively work at keeping depression from interfering with my relationships, career and will to live I stand to lose them.  Antidepressants are my insulin.  Talk therapy with a psychologist is my "going to a meeting."   

Although my depression is "being treated" with medication and talk therapy I usually think in terms of management, not treatment.  Management includes not just what I do with the help of professionals but everything I do to keep depression from further screwing up my life.  Exercise helps, as does spending adequate time with other people and eating foods other than refined sugar.  There are also less obvious things.  I have found that wearing a sport coat or business suit to work (not expected or required in my job) elevates my mood, so I frequently do this[8].  

This brings me back to the hypothetical depressed person whose mood is helped by sun and rain but hurt by clouds.  Imagine you share an office with this person.  You arrive one cloudy morning and he or she is sullen and teary.  If he or she believes straightening up their desk for 30 minutes will give them the necessary feeling of control to keep from breaking down sobbing intermittently for the rest of the day, it is very important that they do just that.

It will probably work.  Taking action, even something seemingly trivial, to address one's own depression can bring about immediate, if minor and temporary, relief.  For those of us who work in offices, it can be the difference between a day of productive meetings and a day of inappropriate yelling or crying.  The longer and more thoughtfully this person has been managing their depression, the more refined and effective their management techniques are likely to be.  You don't need to understand.  You just need to be supportive.




[1] AKA, Major Depressive Disorder (name in the DSM https://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders ) or unipolar depression, among others.  
[2] Why evolution has not de-selected us, I do not know.  While a little melancholy can be attractive most people would agree that full-blown depression is NOT sexy.  Still, somehow, generation after generation, we manage to meet people, get laid and reproduce.  
[2.3] https://en.wikipedia.org/wiki/Major_depressive_disorder#Symptoms_and_signs
[2.5] By "dangerous" here I mean acutely dangerous.  Overeating is dangerous, but mostly over an extended period of time.  Self-harm in the conventional sense involves immediate danger.
[3] My therapist had not heard of it either.  
[3.5] I say this for two reasons.  First, if it was truly common I might have heard about it.  Second, lots of other symptoms are not pervasive, so why would this one be?
[4] https://en.wikipedia.org/wiki/Bipolar_disorder. Please don't call it "manic-depression."  The misuse of the word "manic" has rendered that name more trouble than it's worth.
[5] 100% true.  Not a joke.
[7] ...in the AA sense, https://en.wikipedia.org/wiki/Disease_theory_of_alcoholism .  I'm also assuming the alcoholic in question is in recovery, not actively drinking or merely "dry."

[8] While my relationship with my haberdasher is not part of treating my depression, it is part of its management. :-)  He's "a professional," the third generation in his family, but not a mental health professional.  Or, as my wife, a licensed Psychologist, would say "He's not that kind of doctor."

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