Talking To Depression: Do Not Give Up

Warning, this article mentions suicide.

In real-world clinical practice, depression is the most common complaint.  Because of how it has entered into the mainstream, it is also the most non-specific complaint and has come to represent a catch-all term that can mean many things.  After a thorough assessment,  what comes in as, "is this depression?" can in fact be obsessive compulsive disorder, an eating disorder or even psychosis.  For this reason, when a pure depression, without any other complications or comorbidities steps into my office, it can stop me in my tracks.  Pure depression, especially when severe is a formidable foe for any clinician and is poison to a healthy mind. 

In mild to moderate depression a person can still feel like themselves and function, but most tasks, even basic ones are harder to get through.  The person will notice more effort is needed to accomplishing less and at a lower quality than they are capable of.  This can be very frustrating and leads patients to develop harsh and critical views of themselves.  They will call themselves lazy and stupid.  There may not yet be any disruption to the stability of the person's life, but it is precarious.  The person is white-knuckling it with the hopes things will get better.  Mild to moderate depression is also a lonely experience.  I had a patient describe what it was like: "you want to talk to people, but you have nothing to say, you just want the other to entertain and distract you from yourself, and you realize how unreasonable this is, so you don't reach out at all."  In these patients, though medications can help, other interventions like therapy and taking stress-leave can help too along with interventions that build in self-compassion and self-care.  When providing care for these patients I experience them as self-aware and wanting to work with me to get better.  I feel hopeful and optimistic.

Severe depression feels like a very different beast.  For starters, there is a complete breakdown in functioning.  I have seen patients catatonic, lying in bed for days unable to do anything including bathe and eat.  Patients can develop psychotic symptoms believing they are cursed or already dead.  In these cases medication or electric convulsive therapy is recommended before any therapy can help.  What is most distressing is how severe depression affects insight such that these patients simply accept their suffering and see it as something they deserve.

For this reason, it is both fascinating and infuriating to speak to a patient with severe depression.  Because though they look like themselves, loved ones will tell me how they have completely changed.  I have tried to provide therapy to these patients.  They are immovable in their belief that they cannot be forgiven or afforded any grace.  When given words of comfort, they experience them as naive platitudes and conclude nothing can be done for them, that no one understands and they are all alone. This attitude repels loved ones and allies.  It runs counter to the natural and adaptive instincts we humans have in times of suffering, which is to connect with others.  As a result, these patients come across as ungrateful, stubborn and unlikeable.

In severe depression, the mind sees the world only in the negative, and it picks information from the surroundings that confirm one's worthlessness and others' maliciousness.  In this state, a person goes through past memories and brings into focus every small error, mistake and regret. Small slights are magnified one hundred fold, insignificant blunders are unforgiveable and held onto with an iron tight grip.  Depression then presses repeat on these memories and judgements such that they play through the mind in an excruciating loop, usually at night time, making sleep, self-care and respite impossible.

Given the above, severe depression can make the idea of suicide seem like a good idea, a logical choice.  Death puts an end to the pain and monotony, while also relieving their loved ones of their burdensome existence.

Put simply, severe depression hijacks the mind completely.  I find it one of the hardest illnesses to treat, because of how it snuffs out hope and treats my attempts to help with contempt.  It can feel like I am dealing with the devil himself.

The implications of depression are far-reaching and the suffering profound.  The most telling sign is when you or a loved one notices a significant change, a personality shift, and that you are just not yourself.  It is not a personal flaw or weakness.  It is an illness.  With diagnosis there is hope, because depression is treatable.  A mental health clinician's job in these cases is to hold the candlelight to hope, even in the darkest of times, even when the patients themselves resist.  And then to trudge forward, no matter how slowly, together towards recovery.