Reflection on Depression

Following Up

I continue to get inquires about this site but don't check it a lot, so the best way to get in touch is by looking me up on FB. I've continued to write about healthcare reform on my public FB wall.

Currently I'm working with a start-up mental health charity in North Carolina. Check out the recent panel on Mental Health and Faith we hosted with Active Minds: 

http://oldgoldandblack.com/?p=39264

http://www.journalnow.com/news/local/forum-explores-role-faith-can-play-in-assisting-people-with/article_9c7f1d0e-ad7b-11e3-a999-0017a43b2370.html?mode=jqm

Looking for other media? My posts should all be here, and my Project Happiness podcasts can be found here: http://www.projecthappiness.org/author/abby/

Take care,

Nina Poe

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.

Speaking up about depression

Katherine Stone (Postpartum Progress) posted wonderful thoughts last week concerning her decision to speak up about postpartum depression and OCD. The link to her post is here.  

Like Katherine, I sometimes second-guess my openness. Will people who find out about my depression think I'm weak? Will it hurt my career? So far, people have been very receptive (and those who aren't have at least kept their mouth shut, I suppose).

I'm glad that my decision to speak up was not dictated by fear of what other people would think, because so many of my choices already are. I try my best to subtract fear from my decision-making equation. When I do, I can see the substantive reasons behind my choices much more clearly. In this case, when I let go of the fear I see that I want to help others and I want to fight stigma by writing this blog.

There are very real concerns behind my disclosure--some people won't like what I say, others will think I'm weird, and it might even be the (illegal) reason that someone doesn't hire me--but, for me, the benefits of fighting stigma add up to more than the risks.

That won't be the case with everyone, because some people have concerns and responsibilities that take precedence over disclosure. I would probably share less if I were a parent relying on my job to support my family. Fortunately, the risks are minimal in my case--I have a supportive network of friends and I'm in a position where no one else will be harmed by my decision to share my experience. I don't know that I'll have that kind of freedom my whole life, so I want to make the most of it now by using personal disclosure to promote understanding.

Depression, work, and healing

The past week at the office has been crazy. After a month-long lull, all of my cases picked up at the same time. The good news is that I did some actual brief writing this time and really enjoyed it (which is good since I'll probably be spending a big chunk of my career writing briefs).

Despite the sometimes furious ebb and flow of my workload, I couldn't be happier for my job in this economy. Having work gives me both structure and security. It keeps me motivated, busy, and connected to other people, and deflects the type rumination that so often leads, not to insightful breakthroughs, but to debilitating obsession over past hurts and currrent anxieties.

I'm lucky that my job provides a good training ground for mental wellness techniques. Each new assignment requires me to practice those cognitive skills that wilted under the veil of my last depression. And dealing with my inevitable mistakes at work forces me to stay productive without getting mired in self-criticism. Basically, my job is paid rehab.

When coming out of a depression, my minor victories at work remind me that self-efficacy, once lost, can still be regained. For the past 13 years since depression first hit, I've been trying to remaster those skills that depression impaired; to build them up like muscles in order to maintain control even when weakened by the disorder.

But several depressions later I'm also doing something else--something I never thought I would do. In addition to fighting the debilitating effects of depression, I'm accepting that they will, to some degree, be part of my life. And instead of panicking when they hit, I'm starting to keep a level head. Ironically, acceptance diffuses the panic, restoring some of my control.

I suppose I've finally absorbed the lesson of the serenity prayer that I've heard hundreds of times:  "God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." Put differently, I've learned to pick my battles.

 

A good day's work

Many people dread the beginning of the workweek, but for me it's a happy reminder that I'm healthy enough to work. Having been sidelined at times by my depression, I can really appreciate just what a privilege working is, especially in this economy where a good job is hard to find.

Acute, melancholic depressions have prevented me from working or getting my schoolwork done a number of times. These are the dangerous depressions--the ones in which I'm barely able to get out of bed or eat more than a few bites. They rarely last more than a few days or weeks, but they feel much longer, the way having your hand on a hot stove for just a second feels like an eternity. Medications swiftly lift me out of these depths, and returning to work or school after recovering feels like coming back after appendicitis or a bad bout of the flu.

For much longer periods though, my capacity to work has been reduced, but not eliminated, by a lower-grade depression where my ability to feel positive emotion is blunted. Rather than intense negative emotion, during these episodes I'm plagued by anhedonia (the inability to experience pleasure).

Anhedonia creates a day to day dreariness that dampens productivity and weakens attention. Moreover, its symptoms can be so subtle and long-lasting that the sufferer doesn't realize she has a treatable disorder. She may feel that her gloominess is part of her personality, unlikely to ever change.

A depression caused primarily by anhedonia produces apathy, causing those afflicted to appear lazy and unmotivated. And indeed, when I'm experiencing this sort of depression I am less motivated (although I hesitate to apply the term "lazy" because of its undeniably moral overtone). Unable to feel any satisfaction from my activities, I am predictably less likely to engage in them.

Dysregulation of the brain's reward system is probably to blame. Running silently and almost invisibly in the background of the mind, this system creates the impetus we feel to undertake everyday tasks and pursue long-term goals. Only in its absence do we realize its force. 

Simple tasks like going to the grocery store or paying bills may not seem particularly rewarding, but even such mundane activities reward the healthy with a feeling of satisfaction, or at least relief, when completed. Without this reward, sustained effort becomes almost impossible. Routine tasks feel like insurmountable mountains, and working full time becomes an unrealistic aspiration. 

Someone suffering from anhedonia, like a well designed car without fuel, possesses all the necessary endowments for the job, but lacks the power to get going. Except for rolling down hills where gravity forecloses the need for effort, a car without gas can't move; likewise, a person without motivation may be unable to accomplish even a simple task if it requires affirmative action. 

So this week I'm grateful for a reward system that is not on the fritz, an attention span that permits me to focus, and a job that allows me to practice and strengthen these abilities. For me, there's no reward like the satisfaction of a good day's work. 

Addendum:  I ran accross this article on CNN today. It's a more spiritual take on apathy. Struggling with a "bad thought." Really interesting!

Pilots now allowed to take antidepressants after 1 year "adjustment" period

 Pilots taking antidepressants  

Fascinating - I didn't know until I read this that, until now, pilots haven't been allowed to fly when taking antidepressants, but it makes sense that we watch pilots' health closely. I'm not sure what the FAA's policy with regard to drugs for "physical" illnesses is, but I suspect it's similar.

I'm glad pilots can now use these four medications for treatment of depression, and I'm confident that these are four of the safest antidepressants on the market. Generally, SSRIs like Prozac don't cause side effects like sleepiness, and will, in most instances, make pilots more fit to fly--especially if the pilot has been suffering from severe vegetative symptoms such as insomnia or an inability to eat. The waiting period is a good precaution because patients can have severe and unexpected reactions to almost any drug. 

One whole year seems like a very long time, though. That's longer than the entire course of treatment for many patients. I hope the FAA has sound science backing up its decision to make the monitoring period so long, otherwise requiring a hiatus of this length may be discrimination. 

Phoebe Price's Death - Bullying and Suicide

Nine teens have been charged with harassment in the death of Phoebe Price, a Massachusetts high school student who killed herself last fall after suffering from intense bullying at school.

The Death of Phoebe Prince - Bullying and Suicide

Observers in the case have largely concluded that the bullying drove Price to suicide. However, a defense attorney will no doubt claim that Price's death is due to a pre-existing mood disorder. Which side is right? What "caused" Phoebe Price's suicide? 

Unfortunately, when it comes to human behavior, cause and effect are rarely straightforward. Not all children would have reacted to Price's situation by committing suicide. Some people are simply more susceptible to emotional dysregulation. In this case, Price may have been predisposed to extreme sadness and depression, and the toxic environment at her school may have accelerated an inevitable descent into depression. On the other hand, even the most psychologically resilient children can be driven to despair in a difficult enough environment. 

Some combination of "nature and nurture" probably made Price vulnerable to suicide. After all, human environments and human temperaments exist on a continuum, and a child on the losing end of both faces an unenviable challenge. What can we do, then, to strengthen both the emotional resiliency of a child and the supportiveness of her environment?

One approach would teach both bullies and the bullied to identify and regulate their emotions more effectively. Just as Price was unable to regulate her sadness, the bullies who tormented her may have had trouble curbing their anger and hostility. Both would have benefited from programs that teach school-age children and adolescents how to manage their feelings and develop empathy for others. 

Groups like Project Happiness provide this sort of emotional education for children. It's time we put these programs in every school to foster children's compassion and resiliency. (More on Project Happiness another day). 

I did it! Today I'm officially an Attorney-at-Law

Today I took the attorney's oath to join the California state bar!

Most people attend a courthouse swearing in ceremony shortly after passing the written bar exam, but I was sworn in today, by a notary (my secretary), 5 months after learning that I had passed the written test. 

I was delayed in taking the oath by the pending approval of my "Moral Character and Fitness" application. This is a behemoth of a form that asks for information going back to high school--every place I've lived, every job I've held, character references, a background check, and fingerprints. It also asks for access to your medical records if you're currently suffering from a serious mental illness that could impair your ability to practice law.

Now this is a pretty vague request. It's not clear what "currently" means, or, for that matter, "serious mental illness." Is one "currently" sick if asymptomatic but suffering from intermittent episodes of a recurring illness like bipolar depression or recurrent unipolar depression?

During my third year of law school, after first examining the application, I met with the director of disability services at my school and a disability rights attorney. Both assured me that I didn't have to disclose anything. Because I had gotten through high school, college, and law school without any special accommodations, they reasoned that I was more than "fit" to practice law. 

I have no doubt that their legal conclusion was correct, but I still wasn't comfortable turning in my application at that time. After all, I was recovering from a serious episode during which I had recurrent, intrusive thoughts that so paralyzed my mind I was barely able to complete my schoolwork. For weeks I had been confined to bed much of the day, and I has lost 20 pounds from being unable to eat. I didn't feel fit to practice anything, and I certainly wouldn't have hired myself as a lawyer in that condition.

Ultimately I decided to submit my application if and when I felt "fit" to practice law. I ended up waiting until I had studied for and taken the written test. By that point I had recovered and been stable for more than 8 months. I had also regained confidence in my ability to hold down a difficult job, as I had just completed 8 weeks of twelve-hour-a-day bar studying. 

Legally I probably could have submitted the application earlier, but I felt better taking the oath today knowing that I had submitted the application with the honest belief that I was qualified. After all, regardless of what the state says, I'm ultimately responsible for practicing the law responsibly.

So now y'all know that I'm a reliable, honest lawyer . . . (Yes. Such a thing exists.)

TED Talk: A Surgeon Beats Depression with Electroshock Therapy

TED's website has a fascinating collection of 20-minute speeches on "ideas worth spreading." The issues discussed range from technology and design to healthcare and the human condition. In this talk, Sherwin Nuland recounts his battle with severe depression, his close-call with lobotomy, and the electroshock therapy that saved his life. Ultimately able to return to his surgery practice and rebuild his life, his story is inspiring.

Sherwin Nuland on Electroshock Therapy