Exploring depression
Exploring depression

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Exploring depression

1 The experience of depression

The main forms of depression and related conditions are summarised in Box 1. Diagnostic criteria also distinguish between less severe and chronic forms of depression. Treatment-resistant depression and dysthymia are defined in Box 2. We will look at diagnostic criteria later on, but the information provided here should serve as a useful reference as you read further and engage with the activities in that follow.

Box 1 Depression and related conditions

(based on NIMH, 2015)

Major depression involves severe symptoms that interfere with the ability to work, sleep, study, eat, and enjoy life. An episode can occur only once in a person’s lifetime, but more often, a person will experience several episodes.

Persistent depressive disorder is where depressed mood lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years.

Other forms of depression include:

Psychotic depression, which occurs when a person has severe depression plus some form of psychosis, such as having disturbing false beliefs or a break with reality (delusions), or hearing or seeing upsetting things that others do not (hallucinations).

Postpartum (postnatal) depression, which occurs in around 10-15% of women after childbirth, and is more serious than the ‘baby blues’ that new mothers may experience after giving birth.

Seasonal affective disorder (SAD) is characterised by the onset of depression during the winter months, when there is less natural sunlight. The depression generally lifts during the spring and summer. SAD can be treated with light therapy, but nearly half of those with SAD do not get better with light therapy alone, and will require antidepressant medication and psychotherapy to reduce symptoms.

Bipolar disorder is also sometimes called ‘bipolar depression’, but the condition is different from other forms of depression− someone with bipolar disorder will typically experience episodes of extremes of mood (highs and lows) as well as symptoms of psychosis (delusions, hallucinations, disordered or disorganised thoughts).

Box 2 Treatment-resistant depression and dysthymia − definitions

(adapted from Bschor et al., 2014)

Treatment-resistant depression* typically refers to depression which does not immediately respond to ‘standard’ treatment with antidepressant drugs (but note that drug treatment is only one of the therapeutic options available for depression). Depression is termed ‘treatment-resistant’ if two trials of drug treatment, each at an adequate dose administered over a sufficient course (period of time), have had no beneficial effect. This definition too is partly arbitrary, however; more specific definitions grade treatment resistance according to the number of failed treatment attempts.

Dysthymia according to ICD-10, is a state consisting of a depressive syndrome, lasting for several years, with lesser severity than in depression as strictly defined (including chronic or ‘major’ depression). The once separated diagnoses of ‘dysthymia’ and ‘chronic major depression’ have been grouped together in DSM-5 on account that ‘diagnostic and therapeutic differences between the two entities’ were deemed ‘too small to warrant separate classification’ (Bschor et al., 2014).

NOTE: (*) The time at which depression becomes ‘chronic’ by definition has been set, more or less arbitrarily, at two years. Chronic and treatment-resistant depression present the same symptoms as an acute depressive episode, but the following tend to be most prominent: low affective variability, anhedonia (an inability to find pleasure in activities one would normally find pleasurable), lack of drive, social withdrawal, lack of self-esteem, hopelessness, loss of libido, sleep disturbances, cognitive impairment and chronic suicidality.

Activity 1 The experience of depression

Timing: Allow 60 minutes

Watch the video below and consider the questions that follow. You might wish to view the entire recording first and then watch the video again thinking specifically about the questions the second time around, or you can review the questions as you watch the video from the start. Choose whichever approach suits you best.

Download this video clip.Video player: TED Talk: Andrew Solomon – The Secret We Share
Skip transcript: TED Talk: Andrew Solomon – The Secret We Share

Transcript: TED Talk: Andrew Solomon – The Secret We Share

ANDREW SOLOMON: 'I felt a funeral in my brain, and mourners to and fro kept treading, treading, till I felt that sense was breaking through and when they all were seated, a service, like a drum kept beating, beating, till I felt my mind was going numb and then I heard them lift a box, and creak across my soul with those same boots of lead again. Then space began to toll, as if the heavens were a bell, and being were an ear, and I, and silence, some strange race wrecked, solitary here. Just then, a plank in reason broke, and I fell down, and down and hit a world at every plunge, and finished knowing then.'

We know depression through metaphors. Emily Dickinson was able to convey it in language. Goya, in an image. Half the purpose of art is to describe such iconic states. As for me, I had always thought myself tough. One of the people who could survive if I had been sent to a concentration camp. In 1991, I had a series of losses. My mother died. A relationship I'd been in ended. I moved back to the United States from some years abroad. And I got through all of those experiences intact. But in 1994, three years later, I found myself losing interest in almost everything. I didn't want to do any of the things I had previously wanted to do, and I didn't know why.

The opposite of depression is not happiness, but vitality, and it was vitality that seemed to seep away from me in that moment. Everything there was to do seemed like too much work. I would come home, and I would see the red light flashing on my answering machine, and instead of being thrilled to hear from my friends, I would think, what a lot of people that is to have to call back. Or I would decide I should have lunch, and then I would think that I'd have to get the food out and put it on a plate and cut it up and chew it and swallow it. And it felt to me like the stations of the cross.

And one of the things that often gets lost in discussions of depression is that you know it's ridiculous. You know it's ridiculous while you're experiencing it. You know that most people manage to listen to their messages and eat lunch and organise themselves to take a shower and go out the front door, and that it's not a big deal. And yet, you are nonetheless in its grip, and you are unable to figure out any way around it. And so, I began to feel myself doing less and thinking less and feeling less. It was a kind of nullity. And then the anxiety set in.

If you told me that I have to be depressed for the next month, I would say, as long as I know it'll be over in November, I can do it. But if you said to me, you have to have acute anxiety for the next month, I would rather slit my wrists than go through it. It was the feeling all the time like that feeling you have if you're walking and you slip or trip and the ground is rushing up at you, but instead of lasting half a second the way that does, it lasted for six months. It's the sensation of being afraid all the time, but not even knowing what it is that you are afraid of. And it was at that point that I began to think that it was just too painful to be alive, and that the only reason not to kill oneself was so as not to hurt other people.

And finally one day I woke up and I thought perhaps I'd had a stroke because I lay in bed, completely frozen, looking at the telephone, thinking something is wrong and I should call for help. And I couldn't reach out my arm and pick up the phone and dial. And finally, after four full hours of my lying and staring at it, the phone rang, and somehow I managed to pick it up. And it was my father. And I said, 'I'm in serious trouble. We need to do something.'

The next day, I started with the medications and the therapy. And I also started reckoning with this terrible question. If I'm not the tough person who could have made it through a concentration camp, then who am I? And if I have to take medication, is that medication making me more fully myself, or is it making me someone else? And how do I feel about it, if it's making me someone else?

I had two advantages as I went into the fight. The first is that I knew that, objectively speaking, I had a nice life, and that if I could only get well, there was something at the other end that was worth living for. And the other was that I had access to good treatment. But I nonetheless emerged and relapsed, and emerged and relapsed, and emerged and relapsed, and finally understood I would have to be on medication and in therapy forever. And I thought, but is it a chemical problem or a psychological problem? And does it need a chemical cure or a philosophical cure? And I couldn't figure out which it was.

And then I understood that actually, we aren't advanced enough in either area for it to explain things fully. The chemical cure and the psychological cure both have a role to play. And I also figured out that depression was something that was braided so deep into us that there was no separating it from our character and personality. I want to say that the treatments we have for depression are appalling. They're not very effective. They're extremely costly. They come with innumerable side effects. They're a disaster. But I am so grateful that I live now and not 50 years ago, when there would have been almost nothing to be done. I hope that 50 years hence, people will hear about my treatments and be appalled that anyone endured such primitive science.

Depression is the flaw in love. If you were married to someone and thought 'Well, if my wife dies, I'll find another one', it wouldn't be love as we know it. There is no such thing as love without the anticipation of loss. And that spectre of despair can be the engine of intimacy.

There are three things people tend to confuse: depression, grief and sadness. Grief is explicitly reactive. If you have a loss, and you feel incredibly unhappy, and then, six months later, you're still deeply sad, but you're functioning a little better, it's probably grief. And it will probably, ultimately, resolve itself in some measure.

If you experience a catastrophic loss, and you feel terrible and, six months later, you can barely function at all, then it's probably a depression that was triggered by the catastrophic circumstances. The trajectory tells us a great deal. People think of depression as being just sadness. It's much, much too much sadness, much too much grief at far too slight a cause.

As I set out to understand depression and to interview people who had experienced it, I found that there were people who seemed, on the surface, to have what sounded like relatively mild depression, who were nonetheless utterly disabled by it. And there were other people who had what sounded, as they described it, like terribly severe depression, who nonetheless had good lives in the interstices between their depressive episodes. And I set out to find out what it is that causes some people to be more resilient than other people. What are the mechanisms that allow people to survive? And I went out and I interviewed person after person who was suffering with depression.

One of the first people I interviewed described depression ‘as a slower way of being dead’. And that was a good thing for me to hear early on because it reminded me that that slow way of being dead can lead to actual deadness, that this is a serious business. It's the leading disability worldwide, and people die of it every day.

One of the people I talked to when I was trying to understand this was a beloved friend who I had known for many years, and who had had a psychotic episode in her freshman year of college and then plummeted into a horrific depression. She had bipolar illness, or manic depression, as it was then known. And then she did very well, for many years, on lithium. And then eventually she was taken off her lithium to see how she would do without it, and she had another psychosis and then plunged into the worst depression that I had ever seen, in which she sat in her parents' apartment more or less catatonic, essentially without moving, day after day after day.

And when I interviewed her about that experience some years later, she's a poet and psychotherapist named Maggie Robbins. When I interviewed her, she said 'I was singing "where have all the flowers gone" over and over to occupy my mind. I was singing to blot out the things my mind was saying, which were, "you are, you are nothing. You are nobody. You don't even deserve to live". And that was when I really started thinking about killing myself.'

You don't think in depression that you've put on a grey veil and are seeing the world through the haze of a bad mood. You think that the veil has been taken away, the veil of happiness, and that now you're seeing truly. It's easier to help schizophrenics who perceive that there is something foreign inside of them that needs to be exorcised. But it's difficult with depressives because we believe we are seeing the truth.

But the truth lies. I became obsessed with that sentence ‘But the truth lies’. And I discovered, as I talked to depressive people, that they have many delusional perceptions. People will say 'No one loves me'. And you say, 'I love you. Your wife loves you. Your mother loves you.' You can answer that one pretty readily, at least for most people. But people who are depressed will also say 'No matter what we do, we're all just going to die in the end'. Or they'll say 'There can be no true communion between two human beings. Each of us is trapped in his own body.' To which you have to say 'That's true, but I think we should focus right now on what to have for breakfast'.

[LAUGHING]

A lot of the time what they are expressing is not illness, but insight. And one comes to think what's really extraordinary, is that most of us know about those existential questions, and they don't distract us very much.

There was a study I particularly liked in which a group of depressed and a group of non-depressed people were asked to play a video game for an hour. And at the end of the hour, they were asked how many little monsters they thought they had killed. The depressive group was usually accurate to within about 10%. And the non-depressed people guessed between 15 and 20 times as many little monsters

[LAUGHING]

as they had actually killed.

A lot of people said, when I chose to write about my depression, that it must be very difficult to be out of that closet to have people know. They said 'Do people talk to you differently?' And I said 'Yes, people talk to me differently. They talk to me differently insofar as they start telling me about their experience, or their sister's experience, or their friend's experience.' Things are different because now I know that depression is a family secret that everyone has.

I went, a few years ago, to a conference, and, on Friday of the three-day conference, one of the participants took me aside and she said 'I suffer from depression and I'm a little embarrassed about it, but I've been taking this medication and I just wanted to ask you what you think'. And so I did my best to give her such advice as I could. And then she said 'You know, my husband would never understand this. He's really the kind of guy to whom this wouldn't make any sense, so it's just between us.' And I said 'Yes, that's fine'.

On Sunday at the same conference, her husband took me aside, and he said 'My wife wouldn't think that I was really much of a guy if she knew this, but I've been dealing with this depression, and I'm taking some medication and I wondered what you think?' They were hiding the same medication in two different places in the same bedroom. And I said that I thought communication within the marriage might be triggering some of their problems.

[LAUGHTER]

But I was also struck by the burdensome nature of such mutual secrecy. Depression is so exhausting. It takes up so much of your time and energy, and silence about it really does make the depression worse. And then I began thinking about all the ways people make themselves better. I'd started off as a medical conservative. I thought there were a few kinds of therapy that worked. It was clear what they were there. There was medication; there were certain psychotherapy; there was possibly electroconvulsive treatment and that everything else was nonsense.

But then I discovered something. If you have brain cancer, and you say that standing on your head for 20 minutes every morning makes you feel better, it may make you feel better, but you still have brain cancer and you'll still probably die from it. But if you say that you have depression and standing on your head for 20 minutes every day makes you feel better, then it's worked, because depression is an illness of how you feel. And if you feel better, then you are effectively not depressed anymore. So I became much more tolerant of the vast world of alternative treatments.

And I get letters. I get hundreds of letters from people writing to tell me about what's worked for them. Someone was asking me backstage today about meditation. My favourite of the letters that I got was the one that came from a woman who wrote and said that she had tried therapy. She had tried medication. She had tried pretty much everything, and she had found a solution and hoped I would tell the world. And that was making little things from yarn.

[LAUGHING]

She sent me some of them, and I'm not wearing them right now. I suggested to her that she also should look up obsessive compulsive disorder in the DSM.

And yet, when I went to look at alternative treatments, I also gained perspective on other treatments. I went through a tribal exorcism in Senegal that involved a great deal of ram's blood and that I am not going to detail right now. But a few years afterwards, I was in Rwanda working on a different project, and I happened to describe my experience to someone, and he said 'Well, you know, that's West Africa and we're in East Africa, and our rituals are in some ways very different, but we do have some rituals that have something in common with what you're describing'. And I said, 'Oh'. And he said 'Yes, but we've had a lot of trouble with Western mental health workers, especially the ones who came right after the genocide'. And I said 'What kind of trouble did you have?' And he said 'Well, they would do this bizarre thing. They didn't take people out in the sunshine where you begin to feel better. They didn't include drumming or music to get people's blood going. They didn't involve the whole community. They didn't externalise the depression as an invasive spirit. Instead, what they did was they took people, one at a time, into dingy little rooms and had them talk for an hour about bad things that had happened to them.'

[LAUGHING]

He said 'We had to ask them to leave the country'.

[LAUGHING]

Now, at the other end of alternative treatments, let me tell you about Frank Russakoff. Frank Russakoff had the worst depression, perhaps, that I've ever seen in a man. He was constantly depressed. He was, when I met him, at a point at which every month he would have electroshock treatment. Then he would feel sort of disoriented for a week. Then he would feel OK for a week. Then he would have a week of going downhill. And then he would have another electroshock treatment. And he said to me when I met him 'It's unbearable to go through my weeks this way. I can't go on this way. And I figured out how I'm going to end it if I don't get better.' But, he said to me 'I heard about a protocol at Mass General for a procedure called a cingulotomy, which is a brain surgery, and I think I'm going to give that a try.

And I remember being amazed at that point to think that someone who clearly had so many bad experiences with so many different treatments still had, buried in him somewhere, enough optimism to reach out for one more. And he had the cingulotomy, and it was incredibly successful. He's now a friend of mine. He has a lovely wife and two beautiful children. He wrote me a letter the Christmas after the surgery, and he said 'My father sent me two presents this year. First, a motorised CD rack from the Sharper Image that I didn't really need, but I knew he was giving it to me to celebrate the fact that I'm living on my own and have a job I seem to love. And the other present was a photo of my grandmother, who committed suicide. As I unwrapped it, I began to cry, and my mother came over and said "Are you crying because of the relatives you never knew?" And I said "She had the same disease I have". I'm crying now as I write to you. It's not that I'm so sad, but I get overwhelmed, I think, because I could have killed myself, but my parents kept me going and so did the doctors, and I had the surgery. I'm alive and grateful we live in the right time, even if it doesn't always feel like it.'

I was struck by the fact that depression is broadly perceived to be a modern, Western, middle-class thing, and I went to look at how it operated in a variety of other contexts. And one of the things I was most interested in was depression among the indigent, and so I went out to try to look at what was being done for poor people with depression. And what I discovered is that poor people are mostly not being treated for depression. Depression is the result of a genetic vulnerability, which is presumably evenly distributed in the population, and triggering circumstances, which are likely to be more severe for people who are impoverished.

And yet it turns out that if you have a really lovely life but feel miserable all the time, you think 'Why do I feel like this? I must have depression', and you set out to find treatment for it. But if you have a perfectly awful life and you feel miserable all the time, the way you feel is commensurate with your life, and it doesn't occur to you to think, maybe this is treatable.

And so we have an epidemic in this country of depression among impoverished people that's not being picked up, and it's not being treated, and it's not being addressed. And it's a tragedy of a grand order. And so I found an academic who was doing a research project in slums outside of DC, where she picked up women who had come in for other health problems and diagnosed them with depression and then provided six months of the experimental protocol.

One of them, Lolly, came in, and this is what she said the day she came in. And she was a woman, by the way, who had seven children. She said 'I used to have a job, but I had to give it up because I couldn't go out of the house. I have nothing to say to my children. In the morning, I can't wait for them to leave, and then I climb in bed and pull the covers over my head. And 3 o'clock, when they come home, it just comes so fast.' She said 'I've been taking a lot of Tylenol, anything I can take so that I can sleep more. My husband has been telling me I'm stupid. I'm ugly. I wish I could stop the pain.'

Well, she was brought into this experimental protocol, and when I interviewed her six months later, she had taken a job working in child care for the US Navy. She had left the abusive husband, and she said to me 'My kids are so much happier now'. She said, 'There's one room in my new place for the boys, and one room for the girls, but at night, they're just all up on my bed and we're doing homework all together and everything. One of them wants to be a preacher. One of them wants to be a firefighter. And one of the girls says she's going to be a lawyer. They don't cry like they used to, and they don't fight like they did. That's all I need now is my kids. Things keep on changing, the way I dress, the way I feel, the way I act. I can go outside not being afraid anymore, and I don't think those bad feelings are coming back. And if it weren't for Dr. Miranda and that, I would still be at home with the covers pulled over my head, if I were still alive at all. I asked the Lord to send me an angel, and he heard my prayers.'

I was really moved by these experiences. And I decided that I wanted to write about them not only in a book I was working on, but also in an article. And so I got a commission from The New York Times Magazine to write about depression among the indigent, and I turned in my story and my editor called me and said 'We really can't publish this'. And I said 'Why not?' And she said 'It just is too far-fetched, these people who are at the very bottom rung of society, and then they get a few months of treatment and they're virtually ready to run Morgan Stanley. It's just too implausible.' She said 'I've never even heard of anything like it'. And I said 'The fact that you've never heard of it is an indication that it is "news”'.

[LAUGHING]

[APPLAUSE]

'And you are a news magazine'. So after a certain amount of negotiation, they agreed to it. But I think a lot of what they said was connected, in some strange way, to this distaste that people still have for the idea of treatment. The notion that, somehow, if we went out and treated a lot of people in indigent communities, that would be an exploitative thing to do because we would be changing them. There's this false moral imperative that seems to be all around us that treatment of depression, the medications and so on, are an artifice, and that it's not natural. And I think that's very misguided. It would be natural for people's teeth to fall out, but there is nobody militating against toothpaste. At least not in my circles.

And people then say, 'Well, but isn't depression part of what people are supposed to experience? Didn't we evolve to have depression? Isn't it part of your personality?' To which I would say 'Mood is adaptive. Being able to have sadness and fear and joy and pleasure and all of the other moods that we have,that's incredibly valuable. And major depression is something that happens when that system gets broken. It's maladaptive.' People come to me and say 'I think, though, if I just stick it out for another year, I think I can just get through this'. And I always say to them 'You may get through it, but you'll never be 37 again. Life is short, and that's a whole year you're talking about giving up.' Think it through. It's a strange poverty of the English language and, indeed, of many other languages, that we use the same word, ‘depression’, to describe how a kid feels when it rains on his birthday, and to describe how somebody feels the minute before they commit suicide.

People say to me 'Well, is it continuous with normal sadness?' And I think, in a way, it's continuous with normal sadness. There is a certain amount of continuity. But it's the same way there is continuity between having an iron fence outside your house that gets a little rust spot that you have to sort of sand off and maybe do a little repainting, and what happens if you leave the house for 100 years and it rusts through until it's only a pile of orange dust. And it's that orange dust spot, that orange dust problem, that's the one we're setting out to address.

So now, people say 'You take these happy pills and do you feel happy?' And I don't. But I don't feel sad about having to eat lunch, and I don't feel sad about my answering machine, and I don't feel sad about taking a shower. I feel more, in fact, I think because I can feel sadness without nullity. I feel sad about professional disappointments, about damaged relationships, about global warming. Those are the things that I feel sad about now. And I said to myself 'Well, what is the conclusion? How did those people who have better lives even with bigger depression manage to get through? What is the mechanism of resilience?'

And what I came up with over time was that the people who deny their experience, the ones who say 'I was depressed a long time ago, and I never want to think about it again, and I'm not going to look at it, and I'm just going to get on with my life',ironically, those are the people who are most enslaved by what they have. Shutting out the depression strengthens it. While you hide from it, it grows. And the people who do better are the ones who are able to tolerate the fact that they have this condition. Those who can tolerate their depression are the ones who achieve resilience.

So Frank Russakoff said to me 'If I had it to do over, I suppose I wouldn't do it this way. But in a strange way I'm grateful for what I've experienced. I'm glad to have been in the hospital 40 times. It taught me so much about love, and my relationship with my parents and my doctors has been so precious to me and will be always.'

And Maggie Robbins said 'I used to volunteer in an AIDS clinic, and I would just talk and talk and talk. And the people I was dealing with weren't very responsive, and I thought, that's not very friendly or helpful of them. And then I realised. I realised that they weren't going to do more than make those first few minutes of small talk. It was simply going to be an occasion where I didn't have AIDS, and I wasn't dying, but could tolerate the fact that they did, and they were. Our needs are our greatest assets. It turns out I've learned to give all the things I need.'

Valuing one's depression does not prevent a relapse, but it may make the prospect of relapse, and even relapse itself, easier to tolerate. The question is not so much of finding great meaning and deciding your depression has been very meaningful. It's of seeking that meaning, and thinking, when it comes again 'This will be hellish, but I will learn something from it'.

I had learned, in my own depression, how big an emotion can be. How it can be more real than facts. And I have found that that experience has allowed me to experience positive emotion in a more intense and more focused way. The opposite of depression is not happiness, but vitality. And these days, my life is vital, even on the days when I'm sad. I felt that funeral in my brain, and I sat next to the colossus at the edge of the world, and I have discovered something inside of myself that I would have to call a soul, that I had never formulated until that day, 20 years ago, when hell came to pay me a surprise visit.

I think that, while I hated being depressed, and would hate to be depressed again, I found a way to love my depression. I love it because it has forced me to find and cling to joy. I love it because, each day, I decide, sometimes gamely, and sometimes against the moment's reason, to cleave to the reasons for living. And that, I think, is a highly privileged rapture. Thank you.

[APPLAUSE]

Thank you.

End transcript: TED Talk: Andrew Solomon – The Secret We Share
TED Talk: Andrew Solomon – The Secret We Share
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In this moving and eloquent talk given in 2013, Andrew Solomon, Professor of Clinical Psychology at Columbia University, and author of The Noonday Demon: an atlas of depression (Andrew also writes regularly for The New Yorker and the New York Times), describes his personal experiences of living with depression, recounts the stories of others he has come into contact with, and describes how he has come to terms with depression.

  1. Andrew explains that he had always thought of himself as being tough, as ‘one of the people who could survive if[he]had been sent to a concentration camp’ as he puts it. What triggered his depression?

  2. How does he describe his depression?

  3. Andrew also experienced anxiety. How did his anxiety develop and how long did it last?

  4. When his depression became severely disabling, Andrew managed to seek help and started with medication and therapy. What does he consider as his two advantagesgoing'into the fight’?

  5. He describes the relentless relapsing and remitting course of his illness. How did Andrew come to terms with his depression at the time?

  6. He points out that people tend to confuse depression, grief and sadness. What important distinctions does Andrew make?

  7. Andrew set out to understand depression, to find out what causes some people to be more resilient than others, and to know what mechanisms allowed people to survive. He gives the example of his friend Maggie Robbins, a poet and psychotherapist. How did Maggie experience depression? What thoughts did she and others experiencing depression typically have?

  8. What therapies for depression does Andrew describe?

  9. Andrew says that he was struck by the fact that ‘depression is broadly perceived to be a modern, Western, middle-class thing’. He touches upon cultural views on depression and different approaches to treatment, talking about his visit to Senegal and Rwanda. How does he describe some of these differences?

  10. Through researching Andrew says that he has discovered that ‘depression is the result of a genetic vulnerability, which is presumably evenly distributed in the population, and triggering circumstances, which are likely to be more severe for people who are impoverished’, but that this is not being picked up, treated or addressed. What explanation does he give for this?

  11. How does Andrew respond to questions like ‘Isn’t depression part of what people are supposed to experience? Didn’t we evolve to have depression? Isn’t it part of your personality?’

  12. What is his response to whether depression is 'continuous with normal sadness'?

  13. What does Andrew think is the main mechanism of resilience?

Discussion

  1. Andrew says that he had a series of losses in 1991. His mother died, a relationship he had been in ended. He moved back to the USA after being abroad and then three years later he found himself losing interest in almost everything. He didn’t want to do any of the things he had previously done, and he did not know why.

  2. Everything he did seemed to involve so much work. He seemed to think about and view things differently. He gives an example of messages left by friends on his answering machine, and instead of feeling thrilled to hear from them, he would think to himself ‘what a lot of people that is to have to call back’. Carrying out everyday things such as having lunch would become a burdensome task – he would think about having to ‘get the food out and put it on a plate and cut it up and chew it and swallow it’. And he knew ‘it was ridiculous’ while he was experiencing these thoughts, and should not be a big deal, but when in its grip ‘unable to figure out any way around it’, so he began to feel himself doing, thinking and feeling less, which he describes as a kind of ‘nullity’.

  3. Andrew talks about his acute anxiety ‘setting in’ after his initial bout of depression and lasting for six months, as a ‘sensation of being afraid all the time, but not even knowing what it is that you are afraid of’.

  4. First, Andrew notes that ‘objectively speaking he had a nice life and that if he could only get well, there was something at the other end that was worth living for’. The second advantage was access to good treatment.

  5. Andrew says that while thinking about biological (chemical), psychological or philosophical explanations for his depression, he also came to the understanding that it was ‘braided so deep into us that there was no separating it from our character and personality’.

  6. Andrew notes that grief is explicitly reactive, and gives the example that if a person experiences loss, feels incredibly unhappy, and then six months later, they are still deeply sad but functioning a little better, it is probably grief which will ‘probably, ultimately, resolve itself in some measure’. If a person experiences a catastrophic loss, feels terrible and six months later can barely function at all, then it is likely to be depression triggered by the catastrophic circumstances. He defines depression as not simply ‘sadness’, rather ‘much too much sadness, much too much grief at far too slight a cause’, and that importantly the trajectory of the illness tells us a great deal.

  7. Maggie had bipolar disorder (previously called manic depression), and coming off her medication plunged her into severe depression. Andrew describes her as sitting in her parents’ apartment ‘more or less catatonic, essentially without moving, day after day after day’. He recalls at the time of interview Maggie describing thoughts in her mind telling her ‘you are nothing. You are nobody. You don’t even deserve to live’, leading to thoughts about suicide. He describes other people living with depression having similar thoughts: ‘no one loves me’ or ‘no matter what we do,we’re all just going to die in the end’ or ‘there can be no true communion between two human beings. Each of us is trapped in his own body’. Andrew emphasises that depression can be exhausting and lack of communication about it could make things worse: ‘it takes up so much of your time and energy, and silence about it really does make the depression worse’.

  8. Andrew mentions medication, psychotherapy, electroconvulsive treatment, meditation and even relatively simple things that could be done to lift someone’s mood or that they would do to make themselves feel better. He also describes the moving story of Frank Rukosoff, who underwent quite a radical surgical therapy (called a ‘cingulotomy’) to remove a small portion of brain tissue from his frontal lobe, after everything else he had tried had failed. Remarkably, his treatment was successful.

  9. Andrew refers to a tribal exorcism in Senegal, how rituals differ between East and West Africa, and how the practice of Western mental health workers can be viewed differently as relayed to him in Rwanda, which he recounts in a lighthearted way: ‘Well, they would do this bizarre thing. They didn’t take people out in the sunshine where you begin to feel better. They didn’t include drumming or music to get people’s blood going. They didn’t involve the whole community. They didn’t externalise the depression as an invasive spirit. Instead, what they did was they took people, one at a time, into dingy little rooms and had them talk for an hour about bad things that had happened to them’.

  10. Andrew says that if someone has a lovely life but feels miserable all the time, they would think ‘Why do I feel like this? I must have depression’ and they would set out to find treatment for it. If life is awful all of the time and the person also feels miserable all of the time, the way they feel would be commensurate with their life and it wouldn’t occur to them to think that maybe it could be treated. Note that this is one interpretation only, but it does draw out an important view, and touches not only on societal views but stigma as well.

  11. Andrew says that mood – the ability to express sadness, fear, joy and pleasure − is adaptive, and major depression is what happens when that system gets broken. It becomes maladaptive.

  12. Andrew agrees that there is a certain amount of continuity, but then gives an example using an iron fence analogy, where severe depression is an extreme form similar in his comparison to leaving the fence untended for 100 years until all that is left is ‘a pile of orange dust’.

  13. Andrew believes that people who tolerate, can come to terms with and learn from their depression are the ones who achieve resilience. Those who deny their experience, shutting out their depression, strengthen it. He notes that:‘Valuing one’s depression does not prevent a relapse, but it may make the prospect of relapse, and even relapse itself, easier to tolerate. The question is not so much of finding great meaning and deciding your depression has been meaningful. It’s of seeking that meaning, and thinking, when it comes again "This will be hellish, but I will learn something from it".’

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