Reflection on Depression

Depression and Weight Changes

Most symptoms of depression are hidden (which is both a blessing and a curse).  Weight changes, however, are public and embarrassing. People notice. They make you self-conscious.

The first two pics below are still hard for me to look at because they remind me of what a bad time I was going through. Still, they are worth sharing so that folks know these physical changes are a normal part of the illness.

 

This was taken around Christmas 2007--not long after I had descended into the worst depths of that last major depression.  My appetite was non-existent and my bones are starting to show. My smile here is deceptive -- I'm amazed at how normal I looked despite feeling so bad. 10 mins after this pic I was wallowing in bed, and was unable to stand up for more than a few minutes the rest of the day.

 

This was me later that spring, after losing even more weight. Not flattering. It would look even worse without the massively padded push-up bra giving me some curves.  

 

 

Whoops . . . . those medications sure helped but they made me gain back a little too much weight. (Notice how much weight my uncle has lost since the first picture!)

 

This pic was taken the summer I was studying for the bar exam. By then I had recovered physically (although I was still struggling with mood issues and intrusive thoughts). Still, not a bad pic for someone in the library 12 hours a day and not working out (ok -- I totally should have been working out, but instead I was wigging out like a lot of other bar takers. . . thank goodness it all turned out ok and I passed). 

 

Ahhh . .  back to a healthy weight.  Crashing an SLS party with a fellow alum. 

Major progress with physical training

After six weeks of once-a-week sessions with a personal trainer I'm seeing amazing progress. Yesterday I learned that my heart rate is twenty beats per minute lower than it was two months ago, and my blood pressure is back within the the optimal range (it had been mildly elevated ever since I started one of my current medications). The emotional benefits of exercise have been less dramatic, but still noticeable. I do feel better immediately following a workout, and I have more energy most days than I did before. 

It's nice knowing that, at the very least, exercise is helping me manage medication side effects like high blood pressure. . . . not to mention I now kick ass and fit back into my skinny jeans. Right now I'm doing some cardio about 2 times a week between sessions, but I'd probably see even better results if I could get in more often.

A few years ago I wouldn't have been able to work out for more than a few minutes because the intrusive thoughts would have been too disabling. It's such a great feeling to finally get back to it!

 

En route

Tonight I have the quiet serenity of a home office and an unexpected gift of time to put my thoughts in writing. Although scheduled to board a late-night flight from Washington-Dulles to San Francisco around this time, mechanical problems grounded the aircraft and I've been re-booked on a flight tomorrow. The extra time means one more night in my teenage bedroom, and in my parent's house, and in the city where I spent twelve of my most formative years.

My feelings toward my hometown are evolving. In part a place of love, it was also a place of anguish after I became ill. Local reminders of the trauma at 15 (the doctor's office, the houses of friends I've lost) once pierced tender wounds, but now those same reminders are less overwhelming. Like a scared child avoiding a haunted house, I used to avoid the school where I deteriorated from a bubbly freshman to a despondent senior. Now driving past that school isn't as stressful. Those memories--ghosts of events and experiences I would like to forget--no longer evoke overwhelming emotions.

While visiting my hometown I've been able to reflect on those early years when depression first hit; on the academic and developmental consequences of that trauma; and on the interpersonal effects that depression had in well into my twenties. Processing those feelings frees up bandwidth to enjoy the present.

Winston-Salem will always be a place of mixed emotion for me, but now those emotions are manageable with less effort, leaving more energy for fun. 

Personal training

At the beginning of the year I purchased 12 personal training sessions at a nearby gym, having concluded that drastic measures are necessary to get back my pre-depression physique.  

My body took a beating during the last episode. I lost my appetite--and twenty pounds--in a short period of time; then I gained back twenty five while recovering.  Now, even though the number on the scale is close to what is was before I got sick, my body composition is different.  The 20 pounds I lost included muscle, while those I gained are mainly flab. I may not look that different, but I feel different--I get winded easily and my tennis game is suffering because my footwork and stamina are poor.

I've had four training sessions so far--one a week for a month. And they're hard! The trainer has me circuit training, which involves fast paced weightlifting. It's so hard, in fact, that the first two sessions almost made me puke. At least this last one was better and I can finally tell I'm getting stronger.  

Working out is helping my mood as well. That surprises me because I've always been skeptical of the claim that exercise eases depression. Would aerobics have healed Andrea Yates? I doubt it. Plus, if exercise cured depression I don't think I would have spiraled into my first and second episodes while running nearly 40 miles a week. 

While exercise may be an inadequate treatment for severe depression, experience is persuading me that it's useful when depression is mild. I don't think it would have helped at my worst, but as a preventative and maintenance measure it seems beneficial. If nothing else, it makes me feel like I'm doing something good for myself, and that increases my sense of self-efficacy. 

That cheers me up--almost as much as this pic! :)

 

 

Law School Nightmare: Trusts & Estates

At the beginning of my third year of law school I was recovering from an episode of depression that, 9 months earlier, had reduced me to a shell of a human being. Although more functional than I had been at that nadir, thoughts of guilt, self-loathing, and morbidity still played on a constant loop in my mind. Medications had dissolved the most bizarre thoughts--the anxiety that my thoughts spread evil and the inexplicable and (as I was thankfully aware) totally irrational fear that my internal organs were rotting (a not uncommon delusion in severe depression). Those delusions melted away to reveal a more normal sort of depression, but the guilty feelings that fueled them remained. 

School was challenging because my mind couldn't perform heavy lifting. Instead of reading and absorbing an entire sentence in one go, I proceeded one clause at a time. My only goal in school was to pass--a low standard at a school where I had never, ever heard of anyone failing out.  I signed up for light-weight electives to minimize my workload: legal research was taught by the librarians and turned out to be a safe bet; I chose critical theory because the professor was handling both a newborn and a book tour. He was too busy--and too guilty about letting his teaching duties slide--to deal with the hassle of failing somebody.

I also signed up for Trusts and Estates because the course had a forgiving curve. Classes that prepare students for high-powered corporate gigs, prestigious clerkships, or high-minded social justice work attract the most students (and the most effort by students). The subject matter of Trusts and Estates isn't necessarily easier, but the course doesn't seem to inspire a high level of academic dedication, so competition is less fierce.

Taking Trusts and Estates at a time when I was struggling to suppress morbid ruminations turned out to be a mistake. Each case we discussed involved the death of a testator or trustee. The causes of death ran the gamut--murder, accident, old age, and illness. And I began to see myself committing the same acts; saw loved ones experiencing the same traumas. Soon I became fixated on a single death I believed was my fault. It was the death of a guy I had dated very briefly in college. Five years after I stopped returning his calls I read his obituary in the paper. He had died suddenly, after a brief fight with leukemia. I felt bad for being a jerk to a guy who, it turned out, didn't have a lot of time left; it hadn't been a full-fledged relationship, but we had dated enough that going AWOL wasn't an appropriate way to end things.  (of course, many 21 year-olds, hampered by immaturity, duck out of fledging relationships in the same way and I'm learning to forgive myself for acting my age).

The guilt put down roots in my mind and began to grow delusionally out of proportion.  I started connecting disparate dots . . . he was white and his middle name was Patrick . . . I'm white and my parents planned to name me Patrick if I had been a boy . . . . we must be from the same ethnic background . . . . therefore I must have been a bone marrow match . . . . if I had gotten tested it would have saved his life . . . . I didn't get tested because I didn't know he was sick, because I had stopped returning his calls and talking to him. QED:  his death was my fault; I was a bone marrow match--I just knew it--and I was directly responsible for his early demise.

This wasn't a logical leap my mind took once or twice--a possibility it entertained in a fleeting moment of guilt. It was a worry that occupied my mind every waking moment for weeks. I tried to ease the guilt by joining the bone marrow registry and giving money to leukemia and lymphoma research, but despite my efforts at atonement I remained convinced that my pain and depression were appropriate punishments for my insensitivity. 

I felt like I had hit and killed an innocent pedestrian while driving drunk (with my "living", despite knowing I was so bad, being the reckless equivalent to drunk driving). The guilt metastasized. I thought about how I much I hurt everyone whose life I touched--family, friends, even strangers. I thought about the two and half year relationship I had ended during my first year of law school, and felt some relief that I had left it before I ruined his life. To my sick mind, distancing myself from loved ones seemed like the healthiest option for everyone--like locking up a drunk driver to prevent more accidents.

When severely depressed patients begin to feel this level of pathological guilt it's no surprise they contemplate suicide. Not all depression is characterized by guilt; nor is all suicide characterized by depression; but those who claim that suicide is selfish fail to understand this type of depression--this type of suicide is born out of a genuine and selfless (if misguided) impulse to prevent suffering. The act may go against everything depressives are taught in sunday school or told by therapists, but the logic of suicide resonates so powerfully with their internal experience that emotions eclipse learning, and death seems like the righteous choice. The redeeming feature of depression is that most sufferers (not all)--even those who battle delusional thoughts--retain a glimmer of awareness that their feelings aren't accurate reflections of reality. And so they hold on until the guilt ebbs; until the impulse passes. 

On the morning of my Trusts and Estates exam that glimmer of sanity kept me going. I didn't know if I could face three essay questions--all involving death--and retain enough composure to stay put and formulate three coherent answers. But I did--in part because I suspected (although I wasn't 100% convinced) that the thoughts weren't rational, and in part because failing the exam would only add another burden to my loved ones if I lived. 

I got through it (at the low end of the curve). There would be no wasted tuition dollars and no additional anxieties for my parents. I had also survived the semester--15 weeks--a huge accomplishment when one day feels like brutal punishment. By not dropping out and not failing I saved my family some worry, and I felt good about that. It was the first pride I had felt in months, and a tenuous step toward recovery.

My TMS consultation

A week and a half ago I had a 90 minute consultation with the head of the Depression Clinic at Stanford Hospital to discuss undergoing transcranial magnetic stimulation (TMS), a treatment I've been following for the past several years as it has been winding its way through regulatory approvals and efficacy trials.  The doctor I met with at Stanford actually ran some of these early trials so he had a wealth of knowledge about the treatment. 

Prior to my appointment, my regular doctor sent the clinic a write-up of my medical history, and I completed an extensive intake questionnaire with a nurse practitioner on the phone. When I arrived I also had a chance to describe the course of my depression for thirty minutes or so. I recounted my unexpected descent into depression in high school, the residual symptoms that plagued me even after SSRIs took me out of the blackest depths, my breakdown and continual struggle in college, and my most recent major episode at age 25.  We went over all the medications I had tried, my robust but incomplete response to them, and the symptoms I continue to struggle with even when not experiencing an acute episode. I also expressed that I was doing very well today, and was leaning toward not having the treatment at this time.

He noted that several features of my depression stood out to him.  First, he said that the early age of onset, when followed by recurrent episodes, generally indicates a course that will need treatment for a lifetime (the nurse practitioner also noted my early age of onset and said that it's often an indication of bipolar disorder).  My type of depression, the doctor said, often responds well to mood stabilizing medications in addition to antidepressants.  (I told him that, in fact, it's only since I began taking a mood stabilizer, Lamictal, that my mind has regained much of the clarity it had before I became depressed.) 

He also noted that the extreme feelings of guilt and intrusive thoughts about past misdeeds that plagued me for months during my last episode are worrysome because the presence of this new symptom indicates that the episodes are becoming more severe.  While not quite delusional, these "overvalued ideas" indicate that my thoughts are becoming more detached from reality during my episodes. 

Regarding my residual cognitive complaints--lack of concentration, disorganization, etc. that worsen during each episode, he said it's likely that an acute episode of depression is neurotoxic, and that anyone who has experienced one will also experience some degree of subtle but lasting neurocognitive impairment. He stressed the importance of avoiding future episodes in order to keep these impairments from getting worse.

(This worried me because I was hoping that the cognitive changes I've experienced were a symptom that I could treat and get rid of--not a permanent change in my brain. Since the appointment, I've tried to remind myself that the brain is plastic and I may be able to figure out ways to compensate for any deficits.)

Regarding TMS, he said the efficacy rate is around 50%, and that researchers are still tweaking the TMS protocol.  Currently the 5cm rule--the rule of thumb that the magnetic pulses are aimed 5cm in front of the region of motor cortex that makes the opposite side thumb twitch--is one that doctors use based on convention, and he thinks there may be a more accurate way to identify the appropriate region of cortex to stimulate.  In a few years, improvement to the protocol may increase efficacy.

He also mentioned vagus nerve stimulation as an alternative treatment. It's where a pacemaker like device implanted in the chest delivers electrical stimulation to a part of the vagus nerve located in the neck which, in turn,  stimulates the brain. The benefit of VNS is that it doesn't wear off like TMS or ECT because the device remains on permanently (or until it is turned off or removed).

Overall the consultation confirmed some of my suspicions (the need for long-term medication; the complicated nature of recurrent depression and its possible relation to bipolar disorder; the usefulness of mood stabilizers in treating this type of depression; the subtle cognitive impairments that are so hard to overcome entirely).  And even though I've decided not to undergo the treatment it was good to learn more about it so that I can act more quickly in the future if I am in a situation where I need to use it.

TMS consultation

Despite feeling remarkably better in the past few weeks (for no apparent reason!), I'm going to my previously scheduled TMS (transcranial magnetic stimulation) consultation at Stanford Hospital tomorrow.  Given how well I'm doing I may not undergo the procedure, but I still want to learn more.

Specifically,  I'm going to ask the doctor about what types of depression respond best to TMS, who sees the best results, and how long these results appear to last.  I know that he hasn't performed the treatment enough to have figured out statistically reliable answers to those questions, but I'm hoping he may have some anecdotal insights anyway.

I'll let you know what I learn later this week!

Going to be evaluated for TMS!

I've decided to bite the bullet and finally go for it. I have the first of two intake interviews this week with Stanford's Depression Research Clinic where I'll be evaluated for TMS (transcranial magnetic stimulation). I've been interested in the electromagnet-based treatment for years now--it seems like a promising, side-effect free treatment option that might help me reduce my reliance on meds. 

I'm not acutely ill or in any need of an immediate intervention, but I have been in a slight slump recently so I think it's a good time to try this. After all, it takes 4-6 weeks to administer, so it's not something that would be effective in an acute, time-sensitive situation. Trying it when I'm relatively well, but with room for improvement, seems like the way to go.

I'm most excited by the possibility that this treatment could help me regain that last 1/3 of my health. Over the past 13 years meds have helped enormously--even saved my life (or at least my quality of life)--but they've never gotten me more than around 2/3 well. I've been left with residual mood and cognitive symptoms that I would like to tackle once and for all.

1997-2010:  Me (2), Depression (1)

My future goal:  Me (3), Depression (0)!!!!

Return from vacation

I haven't posted this past week because I was traveling to N.C. for my grandmother's 90th birthday (and scrambling to get ahead on work when not traveling).

It was an inspiring birthday--my grandmother has not only lived a long life, but a good life. She took care of my grandfather during his final years when he was in a wheelchair, she raised five kids, she played golf until she was 82, and she did it all in style--with large Jackie O sunglasses on (even indoors). She lived through the great depression of 1929, and my great depression of 1996.  And this past Saturday night she was still able to get up at dance at her party.

One of the best things about my grandmother is that she's remarkably calm and can always make the best out of any situation.  While I struggle with anxiety and depression, she takes even the most harrowing situations in stride, riding them out with a level head, a sense of humor, and an always handy deck of cards for playing gin rummy.  She knows how to live in the present moment--something so many of us with depression struggle to do.

How did she end up creating so many children and grandchildren with anxiety disorders and depression?  We'll blame that one on my grandfather's DNA.  Here's hoping her example can set me straight.

The Devil I Know

Depression crept back into my life a few months ago. Not the suicidal and delusional kind of depression that I fear the most (medication has done a good job of keeping that at bay), but the milder variety that saps my energy, causes me to tear up for no reason, and keeps me in a mode of tolerating, but not really living, my life. It's this depression that I can't seem to shake even when the meds extinguish the scarier symptoms. In truth, this depression never left after my initial descent into this illness--I never returned to the height where I was before it began. 

Maybe I will never get back to the way I felt before my first episode; maybe the extended episodes of severe depression have left a "molecular scar" on my brain; maybe, psychologically, I just can't go back to being as carefree as I was before the trauma of severe illness; maybe I have reason to be sad about opportunities lost to the depression.

On the other hand, things unexpectedly turned around this weekend. Although weekends usually exacerbate my depression (not because I want to be at work, but because the lack of structure and the alone time feed the disorder), this weekend was exceptionally happy. I felt relaxed and I enjoyed a good balance of socializing, rest, exercise, and housework. The combination was a more natural mix of activity than my usual 10-12 hour days at the office.

Who knows if it was this balance that made me feel better, or if feeling better allowed me to create this balance. Either way, I found my equilibrium--that place where I am upright, balanced, and moving forward in my life. These really good periods rarely last an entire weekend, however, and as this one wore on I became nervous that I felt too good. I feared I was slipping into a manic episode. Now I don't even know if I have bipolar disorder (you can't know until you experience the first manic episode, and although I've had periods characterized by some manic symptoms, I believe they were all medication induced). But given the severity and recurrence of my depression it's something that always haunts my mind. Much like a cancer survivor might worry over every new mole, bruise, or bump, I worry over my unusual (or unusually strong) feelings, even when they are good. 

It's Monday. I still feel balanced, but as the stress of the work week builds I will start to wobble. When I do, I will feel deflated, but I will also be relieved that I'm not entering the manic phase of this illness. Mania would begin a new and undoubtedly exhausting medical journey, much like the one I've finally gotten the hang of. As tedious and unpleasant as the residual depression--as wobbly as Monday--there's comfort in its familiar symptoms; comfort in knowing that, for the moment, the threat of mania has retreated.

Better the devil I know than the one I don't.