I have talked about this before, but as mental health advocacy grows in popularity there is no better time to share again. With stigma around mental health finding a bastion in the dark corners of the internet, I want you to know that it’s okay to be depressed. Despite the fear, more and more people are coming out to share their stories, and I think that is a wonderful thing.
I am a Psychiatrist, and this is my story of depression and how it taught me to see the world in a new way. There may be a bit of science along the way, and there are certain areas that deserve more work in the future, but the message is clear; Depression is common, and recovery is too.
Early changes and growing shadows.
Remembrance of things past is not necessarily the remembrance of things as they were. — Marcel Proust.
The first signs that something wasn’t right crept up on me slowly. Although I had been a lonely kid at school, I had never felt seriously unwell. In fact, as I progressed through college and university, my life turned upside down and became something more like Hollywood Fiction.
Suddenly I was popular, well liked, valued for who I was and who I wished to become. The whole thing was unfamiliar, baffling and ultimately a cacophony of confusion and emotion. I didn’t trust it, but I enjoyed it.
It was in January of my first year as a medical student that I began to notice things were not quite right. I found that my energy was decreasing. I ascribed it first to partying too hard (that old motto about medical students is true, or at least was,) and then with vague ideas about infections. I told myself lie after lie and waited for things to pass.
But things didn’t improve, and found myself exhausted every day. But I couldn’t sleep until the early hours, and would find myself waking early.
At the same time I began to feel isolated. The world was beginning to seem more grey, the hours of the day would stretch on and I would long to return to my single bed. I still pushed myself to go out, socialise and continue things, but the enjoyment wasn’t there.
After a time, a few months, things slowly improved. I put things down to exhaustion and change and tried to forget about it. I was in some level of denial, and looking back, things could have been arrested here.
Recurrence of unwelcome feelings
Cold, cold water surrounds me now, and all I’ve got is your hand.
Lord, can you hear me now? — Damien Rice
It wasn’t long after this that I began to feel the welcoming hands of the dark again. I was in a relationship with a wonderful woman, doing well in exams and enjoying my friends. But things were, for some reason or another, beginning to slip.
I would find myself tired again, but this time my mind seemed slower, the thoughts cloudier and speckled with thunder. I would feel distant from the woman I loved, consumed by some internal struggle against a dark beast of indistinct form.
Eventually this emotional absence took its toll, and a few months later things ended. I cannot blame her, as whilst my mood dropped, my anxiety rose and my connection with her faltered. She was patient, tolerant and supportive, but in the end didn’t know the true nature of what was going on. I do not blame her for choosing her happiness, or what came next.
It is fair to say that I was already sinking, and the loss of my support network was hard. I had my friends, and they were great, but I pushed them away. I wanted to be alone, and became so. I began to miss lectures, staying in bed, perpetually between twisted dreams and laboured waking. I began to lose my appetite, to become paranoid about what others would think of me.
There were times I thought I was losing my mind. And as the world turned completely to grey, and all purpose melted away, all that was left were questions of escape in the night. Things eventually came to a standstill, and one night I rang my parents and told them about how I felt.
It is odd looking back on things now, but in my abject and pressured vocalisations I was describing a panic attack perfectly.
It was after this I sought help. I went to our University Health Centre, and the GP there took the time to listen. He suggested that I take an antidepressant, Fluoxetine. I was initially reluctant, and even as a med student, the effect of years of stigma still wormed their way through my mind. Was it weak to take a medication to feel good?
But, scared of getting worse, I took the pills. And after a few weeks things began to brighten. I felt quite numb, but numb was better than low. I couldn’t sleep well, but it didn’t bother me as much. After some time things improved, and I stopped them myself. It was a mistake.
Depression is a common psychiatric illness. Many of us will get it in our lives, or know someone with it. Throughout history the epithets of its substance have been captured by artists and novelists, and now as a Psychiatrist I can hear and feel this nadir of human experience echo through the voices of those I treat. Not everything is the same, but the same ink is used to line the page.
If you read the textbooks, depression can be experienced in different ways. Terms like ‘biological depression’ and ‘melancholic’ attempt to categorise subtle differences between presentations, but as of today, core symptoms remain. A lack of interest in activities once enjoyed, a feeling of depressed mood, negative thoughts, low energy and slowness.
Other symptoms can include changes in sleep pattern, changes in appetite, ideas of suicide or self harm and feelings of guilt or worthlessness. No two illnesses are the same, nor are people.
Although people with depression may not suffer all of these symptoms, or indeed present with different constellations (for example ‘atypical depression’ presents with increased sleep and appetite,) there is a general change to a persons life. Most manuals suggest that this has to have been happening for a while to allow diagnosis, as depression has many mimics and being correct is important in designing treatment.
It’s diagnosis is not simple, and people can be misdiagnosed, or the presence of other accompanying conditions missed. The nature of the depression can similarly be missed, or the root cause left a mystery. It can appear as stark and dramatic change in someone's life, but the journey to it is often more covert.
A chronic story
“I guess when you turn off the main road, you have to be prepared to see some funny houses.” — Stephen King
As time wore on, I would go through episodes of low mood. I never really felt as if I was back to normal, but there were certainly times of improvement. My world had changed, and I busied myself in work and extracurricular activities. Things would slip back after a few months to a year or so, and I would take medication again.
But I never really let myself get better. I stopped medication too early. And I did not address the psychological and behavioural causes that led to the falls. And I let this go on far too long, waiting for the inevitable relapse without making changes to prevent it.
It was in my first year as a doctor that things really hit again. I was working on a busy surgical ward and having a hard time. I was told on the first day that the ‘consultants had already heard about me’ (they had found out about my depression apparently, and didn’t like it.) As such, I was expected to work harder and pushed myself beyond what was healthy.
I wouldn’t say I was treated particularly badly overall, but at times I was screamed at and forced to take on more than I felt reasonable. There were a few staff who I felt judged me not as a person, but an illness. I hold no grudge against them now, as I imagine this was an expression of their fear and misunderstanding. Other staff saw the problems, and raised them.
After working runs of long shifts, my mood flattening and then plummeting, it all came back. It was like being back in the bed at university, a part of my life I had worked hard to push down and away. I broke down on the ward and found myself a closet, or walked to the hospital chapel to weep in silence. I am not religious, but the calm wat soothing.
One surgeon saw what was happening and understood it. I took his advice and got help, this time taking some time away from work to recover.
I spent that time on antidepressants and went to Europe, riding on trains and visiting different cities. I felt low the entire time, but the change of scene was helpful for a while. After I got back I resumed work, and for the longest time (apart from a few blips,) was okay. I thought I had moved on.
The next year I spent time with a psychologist, and began to understand myself better. This would lay the foundations for recovery later.
The diagnosis and treatment of depression can be hard to accept. For men in particular, who find it hard to see doctors anyway, the idea of a mental health disorder is steeped in undeserved stigma. It can take a while for people to seek help, and when they do it can only be when crisis is reached. This can mean months of feeling awful before they allow themselves to ask for assistance. And this is something we need to change.
Depending on the cause of depression, treatment may differ. Most episodes of psychiatric illness are associated with a trigger event within the preceding months, but not always. Some illnesses have much more of a genetic component, others much more based on interactions and mental schemas developed in early life finding themselves at odds with the world later.
In Psychiatry we assess a patients story in three key domains. The biological, i.e is there a physical illness that has caused a change in mood (i.e hypothyroidism can lead to depression, cushings sydrome to psychosis,) the psychological (events, stories, cognitions, perceptions and experience,) and the social (living standard, relationships, use of substances and everything else.)
It is the formulation, based on this information, that guides our treatment.
Therapy can be very helpful, and in my experience, essential for helping those with depression not only see the light, but shine that same light back on themselves to understand how their experiences have formed their illness. Medication can be very useful, and some patients swear by it. And other things, like fixing sleep and diet, exercise and activities are also important.
Recovery is process. It is not instant, and it takes work not just by the doctor and the team, but ultimately the patient does most of the work. We offer a hand, but the patient grabs it, pulls themselves up and begins to walk again.
A return and a new direction
“He who hears the rippling of rivers in these degenerate days will not utterly despair.” — Henry David Thoreau
After my second year of being a doctor, I decided to take some time out. I had wanted to go travelling for a long time. After working through what was a challenging job, and spending much of it worrying about whether the depression would come back, I decided that I needed some distance to think.
At the same time, I had spent countless hours trying to find some meaning to my suffering, and thought that maybe seeing other cultures and experiencing a different world would help. I read popular books like The Chimp Paradox, The Power of Now and even delved into philosophy. I decided that maybe the answer was already written somewhere, but I would have to find it.
My parents were naturally cautious about it, but supportive. And for the most part, the trip was incredible. But ten months in things began to go south, and I found myself in bed again. This time in a hostel in Vietnam. I rented a private room, and barely left it. The panic attacks returned, the thoughts of suicide and the hopelessness.
My days turned into alternatively laying in my room, wandering the street, drinking coffee and smoking cigarettes. At the time I didn’t care about ruining by body, just feeling something good, if only for a minute.
I remember being sat on the side of a the pool, everyone else in the bar laughing, and feeling more disconnected than ever before, as if the distance between the stars was less than between me and them.
The anxiety returned in greater force, to a point where I tried to move on to the next city but walked past the bus. And I began to worry that this one might be the last one.
I messaged an old doctor friend and he said to come home. I realised that out there I had little to fall back on, so I managed to book a flight and after an overnight bus, rather dodgy motorcycle ride and what seems like too little time, I was back at Gatwick. I spent the next 6 months in bed, insomniac and purposeless. The most I could do was wander to the shop every few days to buy cigarettes.
That was until I decided to fight back, tired of suffering.
Intermission Three — Relapse
Depression can be a one time thing, or it can come back. In many cases, depending on the cause of the first depression, certain circumstances can set in motion a ticking clock. If there is a large genetic component to an illness, it can be a matter of time. This is especially true for some health conditions like Huntington’s disease, but for psychiatry it is never as clear cut. Genetics, does not by itself, make all illness inevitable.
Precipitants of relapse of depression can include stopping antidepressants too soon (we advise to stay on them for a while after you feel better,) trauma, social isolation, loss of relationships, use of addictive substances, effects of physical illness or unresolved personal issues to name a few. Even some medications can, in rare cases, trigger what was once dormant.
According to the Shorter Oxford Textbook of Psychiatry, around eighty percent of people with major depression will experience another episode, and over a twenty-five year follow up, suffer, on average, four more. Even then, around 50% do not fully recover between episodes, with the presence of some chronic symptoms that do not fit diagnostic criteria, but nonetheless exist.
That is not to say that relapse is inevitable, and with surveillance and treatment the risk is reduced. Some people will have many episodes, some will be long, others short. But making changes in your life, such as ensuring a supportive network, optimising sleep and diet and trying therapy can make a difference.
In fact, continuing medication for a longer time can cut the risk of relapse dramatically. One study over three years showed that continuing Imipramine, an antidepressant, cut relapse risk from 78% to 22%, and another from 41% to 18%. Talking therapies like CBT have also shown a reduction in risk.
Making sense and life changes
“He allowed himself to be swayed by his conviction that human beings are not born once and for all on the day their mothers give birth to them, but that life obliges them over and over again to give birth to themselves.” Gabriel García Márquez, Love in the Time of Cholera
Depression gives one lots of time to think. And one does think, often in negative ways. For me, there were moments of hope and plans made, which would burn out as the days melded together. But I knew that I had been well before, and that I could be again. I attended cognitive behavioural therapy (CBT), and found that much of my thinking geared me up for relapse.
I needed to change. And I had already begun to reach out and write about my experience, hoping that I could show others that they were not alone.
There is defence mechanism in psychology known as ‘sublimation’, where one channels negative energy toward a good purpose. I suppose this is what I was doing, and what I am doing now. It is an attempt to bring good from bad, and salvage purpose from suffering.
My suffering is not comparable to that of many of my patients, and for that I am thankful, and I am also extremely privileged to have a natural ability to understand and communicate information. I have been blessed in life because of the hard work of my parents and those who have supported me, and in many ways I feel I owe a debt to the world.
I decided, and it was a decision (if you read enough philosophy, you begin to realise that autonomy is simply an expression of subjective moral virtue,) that I would continue to be a doctor, but move into an area that not only I felt a connection to, but that I felt I could help with.
I saw a doctor, began medication and therapy again, revised in bed, took the exam, interview and somehow ended up back on the wards as the new psychiatry trainee. Suddenly my journey had led me somewhere familiar, but this time my role was different. I was no longer the protagonist, but the friend who helps to lead the wandering hero back onto their path.
I was warned in the first months that those who enter Psychiatry to find a ‘cure’ for themselves ‘won’t do well.’ I realised, somewhere along the way, be it in therapy, or halfway up a mountain, that life is about choice. And a year on, I disagree with that original warning entirely.
Maslow's ‘Hierarchy of Need’ puts ‘self-actualisation’ at the top of the pyramid, and actualising myself, as someone who connects with people and can be of value simply by being, not as a result of validation by others, working with those whose struggles I have shared, could not be further removed or better explained by the meandering hours of my lonely youth.
I realised that Mental Health problems are extremely common, complex and varied. I realised that stories are important, and that no two are the same. I find myself honoured to share in peoples lowest moments, and be there as they leave the ward. One cannot express the level of privilege and responsibility this brings, as you are not just a doctor, but a fellow traveller.
I would not say that I am the same person I was 10 years ago, and I still regret those who I have pushed away or lost, and made amends where I can. Recently I learned that the woman I used to love had gotten married, and instead of sadness, I felt happiness. I wish her well, and no longer play stories in my head of what could have been.
Depression thrives on bitterness and regret, but that same light that therapy and time shines on life can be seen to resonate from the happiness of others. The lessons I had learned not just from recovery, but in the depths of illness, had changed me for the better. They had made me more patient, understanding and empathetic.
But at the same time, they had instilled me with a purpose, not one rushing and all encompassing, but true and stoic, resilient to the waves of emotion, challenges of life, apogee of accomplishment and nadir of failure, to live for me in the best way I could, but to forgive myself for the inevitability of the distance between ideal and reality, to value connection with others and the shared experience of those on earth.
Hopefully this little tale can show you that you are not alone.
Thank you for reading. I value your comments, questions and critiques.
If you would like to read more;
Dr Janaway is a registered medical professional. Please consult your local doctor if you have any concern about your health. All information provided above is anonymised. Images sourced from Creative Commons, Pixabay or original. I have not received any financial endorsements from the copyright holders of the books mentioned.
Image courtesy of: PDpics on Pixabay. No formal attribution required.
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