Reflection on Depression

A difficult conversation: Telling your parents you're depressed

More later, but this was definitely a difficult conversation for me when I was 15.   It's an embarrassing, difficult, painful thing for a kid to tell their parents, and it's made worse by the inability of most parents to understand the severity of the disorder right off the bat.  I hope kids have the courage to speak up, because even if it's too awkward for them to talk to their parents about it, parents can still get them a doctor or therapist--someone the child feels comfortable being open with.  It's hard to pry this confession out of kids, though.  For me at least, I didn't want to let my parents down or to make them feel responsible for my pain. 

Read more about telling parents you're depressed.

Guest Post: My Sister

Below is a post written by my sister. As you'll see, she's a wonderful writer with an insightful perspective--a great combination! She's seen me through a lot, and she's also been through her own life-changing challenges.     

  
   

If a psychologist attempted to use the DSM-IV to diagnose me at various points in my life, I would likely fit the criteria for five or six substantially different conditions.  As a result, I feel compelled to ask, "What is the value of diagnosis, really?".  In theory, we (the medical community, specifically) have developed artificial constructs intended to label a certain so-called 'disorder' or 'condition', made up of a certain set of symptoms, that a person may have.  In reality, we just have a person. And issues that people have do not typically fit into neat categories. 

In a way, I'm playing devil's advocate. To downplay the slightly therapeutic (in an odd way) effect that a diagnosis of a major depressive episode can have, for instance, would be harsh. For some struggling with depression, especially without a good deal of emotional support from others, a diagnosis can at least help shed light and understanding on an otherwise baffling condition.  Human nature likes to define problems concretely before tackling them.  We must remember, though, that whether diagnosis occurs or not, the symptoms are the same, and the pain lingers on.

From my (outsider's) viewpoint, depressive episodes seem markedly painful, and oftentimes, very similar- loss of appetite, loss of motivation, depressive ideation, hopelessness, and the list goes on. This grouping of symptoms deserves some sort of label, though the DSM-IV criteria surely fail to encompass the full range of symptoms and trauma that a person with major depression feels. I have witnessed major depressive episodes first-hand in close family members and since realized that the reality and the concreteness of those conditions is difficult to deny. I am not arguing that putting a label on major depression is useless; quite the contrary. 

My confusion stems from my own experience as being an 'outsider'- by that, I mean that I have never experienced a major depressive episode. Siblings, we now know, have very similar DNA makeup. What, if anything, does this genetic link mean for the siblings of those with major depression?  While I have not ever experienced major depression, I have still had prolonged periods in my life during which I felt somewhat 'off', or 'low', or whatever you may call it. The ambiguity of this condition can be unnerving, as it seems as if the sufferer is in a perpetually bad mood. During graduate school at William and Mary when I first read about this condition- Dysthymia- I felt a small sigh of relief.  "Dysthymia, darnit, maybe my condition DOES have a label!", I thought. The condition still seemed vague, however: (def. A type of depression involving long-term, chronic symptoms that are not disabling, but keep a person from functioning at "full steam" or from feeling good. Dysthymia is a less severe type of depression than what is accorded the diagnosis of major depression).  I thought to myself, I cannot believe there's actually a label for that!  I felt relieved in the weird way that self-diagnosis can be cathartic. 

You see, I've certainly flirted with depression, in the way that a person who is afraid, but may not be completely phobic of the dark (that label being 'ACHLUOPHOBIA') still attends movies in a dim theatre.  Situationally-induced dysthymic depression, accompanied by low levels of chronic anxiety, seems to be a label that I can accept for myself. When I consider myself healthy and happy, as I do at the present moment, I can view these episodes in my past more clearly. As a person who has dealt with and overcome an eating disorder, and as a rape victim turned rape survivor, I have at times walked with dysthymic depression by my side.  

Therapy has taught me that mental illnesses, such as depression or anorexia, should be treated as outside influences, insidious third parties, that have a knack for stealing our joy in life. Therefore, I use the third person.  If only we could banish those influences from our life, everything would be all right!!  OR so I thought at one time.  Funny the falsehoods that we use to think ourselves into a perfect state of being.  No- while we may not welcome mental illness and trauma into our life, it has a way of making us more insightful and more compassionate people if we allow it.  The experience of mental illness gives us an entry ticket into a sort of 'fraternity of pain' made up of people who have similarly dealt with dysthymia, major depression, anxiety, or other traumas that can or cannot be labeled.  It can take a while to open oneself up to talking about mental illness or trauma to others.  Doing so, though, can build emotional bridges that allow other people to be honest with themselves and emotionally vulnerable.  Whether a person's condition has been labeled or not, you can be a listening ear, allowing them into the fraternity.  Labeling depression matters, in my mind, to prescribe appropriate medication and to reassure individuals that other people share this condition. We must keep in mind, though, that lines can be blurry, conditions vague, and diagnosis is only the first step.  Understanding the intricacies of each other's experiences is the next.

Parenting, blame, and childhood mental illness

In a recent post, CNN columnist Dr. Charles Raison suggested that the family of a child with bipolar disorder try psychotherapy before medication. He reasoned that, because the child was only acting out in the home, the diagnosis might be incorrect--the problem could have more to do with family dynamics than a psychological disorder. In response, Raison received a slew of angry emails from parents who felt like he was blaming them for their children's mental health problems. 

Last week Dr. Raison responded with a thoughtful post acknowledging that the scientific literature, as well as his own clinical experience, suggests that bipolar disorder has a genetic component. In his earlier post, he says, he was encouraging parents to seek therapy where there is evidence that familial tensions may be contributing to a child's difficulties. Even this suggestion, however, was painful for some parents to hear since it still appears to impose "blame" on them for some non-biological contribution to their child's problems.

I would reply that, even in cases where an environmental trigger like family tension causes or exacerbates mental problems, parents shouldn't blame themselves. Family tensions are not necessarily a sign that something (or someone) is off-kilter. That's because we don't choose the personalities of our relatives. Sometimes they will resonate beautifully with ours, but just as often, through no fault of our own, they may clash. When that happens, miscommunications and misunderstandings are bound to occur.

Personalities develop in surprising ways, and a low-key parent can, for instance, wind up with a high-strung, anxious kid. Imagine how that child feels when his parents can't understand his pain. What if they laugh when he is terrified of a puppy because they don't understand the level of distress his phobia causes? Does that cause pain, even psychological damage? Sure. But it's no one's fault. The best this family can do is to seek help to bridge the gap in their understanding. Maybe that means family therapy, maybe it just means sharing more, but it's a common scenario.

When parents get caught up in blame, however, they all too often get caught up in denial, failing to seek the therapy their family needs. Eliminating blame from the discussion, then, can open the door to healing. In the example above, parents willing to go to therapy to better understand their son will learn how to help him. Parents who refuse to examine their behavior, however, not only fail to learn how to help him overcome his phobia, but they also risk leaving him with the impression that they laugh at his pain, cannot be counted on for comfort, and cannot be trusted. Ultimately these collateral effects will prove more damaging to his emotional health than the intitial phobia.

The no-fault approach to family conflict shortcircuits the defensiveness that parents sometimes feel when confronted with their children's problems, and encourages them to seek understanding. It's based on the reality-centered oberservation that family tensions will always contribute to psychological distress, but these tensions are just as inevitable as the genetic contributions we normally think of as absolving parents of responsibility for their children's disabilities.

I'm lucky to have a family so willing to work hard to understand me (and I've had plenty of irrational phobias and feelings--far worse than being scared of a dog).

Weekend Update: Trip home

I've been mostly offline the past few days since I took my first vacation day (!) from work and went back to North Carolina for a long weekend to see my parents.  Nothing soothes the soul like pampering from my family (and there was plenty of pampering . . . massage, pedicure, filet mignon dinner).  But most importantly, I got to spend time with my mom and dad (and even snuck in visits with a great friend from home and my grandmother).  

Enjoying visits with my parents is a great reward for all the hard work we've put into our relationship. Because of my depression it has sometimes been difficult, but our relationship has ended up stronger. When I was at my sickest, I know I was difficult to handle, and I know they sometimes lost their way in figuring out how to be there for me. For a long time it felt like the blind leading the blind through the course of this disease because we all knew so little about how to deal with it. But with work (and family therapy) we've come so far. They are now my best friends, and the people I trust most to understand what I'm going through.  

Depression is a disorder that impacts the whole family unit.  It also takes the whole family unit working together to fix it. Ideally, family members should receive expert training on what to expect from and how to handle a depressed relative, because family support is probably just as big a factor in recovery as any therapy or antidepressant. In fact, some research indicates that, even without medication, schizophrenics do better in third world countries where they live with extended families, than in the first world where they receive "state of the art" drugs and therapies.  So be there for your relatives, whether it's by plane (like me), train, bus, email, phone, or Skype :).

Schizophrenia recovery in the third world

Mother's Day: Looking back at the myth of the schizophrenogenic mother

Until the 1970s, medical textbooks still attributed schizophrenia to bad parenting--an overprotective mother and a too distant father. Laying blame on parents in this way only added to the pain of families dealing with schizophrenia.

NAMI was founded in 1979 in part by activist mothers tired of being blamed and stigmatized by their children's illness. Due to their efforts and the work of doctors who never stopped trying to understand this disorder, we now know that schizophrenia is a treatable illness caused by a malfunctioning brain. 

PBS documentary on the Myth of the Schizophrenogenic Mother - PBS is airing a documentary today in many areas (later in the month in others) about how medicine erroneously blamed mothers for schizophrenia for years. 

Thanks to all those mothers who never gave up and who kept fighting for better treatment, and better understanding!

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). 

Were children better off in the past?

Fake Nostalgia for a Pre-Therapy Past

Recently, much has been said about the over-diagnosis and over-medication of mental disorders in children. In this New York Times article, the author confronts this criticism by looking back at his own past.

He quotes a psychiatry skeptic who complains, "Back in my day you didn't have young kids going around talking to shrinks yakking about their fee-ee-ee-lings, getting all doped up on medications." And the author concedes that, in fact, fewer children visited psychiatrists in the past. 

But he examines the natural follow-up to this question: Was it necessarily a good thing that not as many children received psychiatric treatment in the past?

Recounting his own impairments from what he now recognizes as ADHD, the author wonders if he would have been more more studious, more successful, and more productive had his problematic behavior received more attention. Maybe . . . maybe not. The frustration he feels is from not knowing what could have been.

He then describes his memory of two students who committed suicide when he was in school, suggesting that severe mental problems have been an unfortunate part of some children and adolescents' lives for as long as anyone can remember (see my post discussing childhood schizophrenia if interested: http://reflectionondepression.typepad.com/my-blog/2010/03/siblings-of-the-mentally-ill-victims-too-.html.) 

The author is right to challenge the assumption that widespread treatment is problematic. Precisely because the developmental stakes are so high, childhood mental disorders should be treated at least as aggressively as adult disorders. That means quickly and thoroughly assessing a child's condition by seeking a professional evaluation (preferably from a psychiatrist or psychologist, not a GP), and, when necessary, seeking the most effective treatment as quickly as possible.

Skeptics like the one quoted above believe that childhood psychiatric problems are overblown and that we are doping away children's individuality. But ADHD, depression, and schizophrenia bestow "individuality" the same way missing limbs and blindness do; it's not the kind of uniqueness we want to cultivate in children.  

True, some children have been unnecessarily medicated (with antibiotics as much as antidepressants), but scores more have suffered from under-treatment. Unfortunately, the treatment of mental disorders is inherently imprecise--mainly because we don't fully understand how the brain works. We still rely on fuzzy qualitative interviews to establish a diagnosis, perhaps (but not necessarily) allowing for too many false positives. 

Imprecision is no excuse for avoiding treatment though. True, treating an ear infection might be more straightforward, but you don't get to pick your child's illnesses--only how to respond to them.

Early treatment is important because in some cases it can prevent the progression of a relatively mild or moderate problem into a full-blown mental illness. New research indicates that teens at a high risk for schizophrenia, if put on antipsychotics prophylactically, develop the disorder at a lower rate than teens with the same genetic risk factors who are not treated (although, because the incidence is still so low, this has not become standard practice). 

I'm not advocating that all children displaying abnormal behavior be medicated, psychoanalyzed, or labeled "mentally ill." I'm simply arguing that the possiblitity of mental illness be taken seriously and, when necessary, treated aggressively. As the author of this piece observes, it's better to face the issue than bury one's head in the sand and later wonder what might have been.  

Siblings of the mentally ill - victims too?

A powerful 20/20 report this past weekend revealed the pain and fear that children with schizophrenia live with on a daily basis. Almost as heartbreaking as the children's plight is the pain of their overtaxed parents. These parents live not only in a very difficult present situation, but also with constant anxiety about their child's future (Will their child take their meds when they turn 18? Will they wind up homeless? Will they be taken advantage of or abused? Will they kill themselves?). 

One family's struggle

The show interviews several siblings of the mentally ill children. In one family, the youngest of three daughters is unnerved by her schizophrenic and unpredictable older sister. Another family rents two apartments -- one for each child -- to keep their sick and sometimes violent child away from the healthy sibling. In each family, the sick child clearly absorbs much of the parents' energy and attention. 

I still feel guilty for the attention I took away from my younger sister during our adolescence. Did I scar her with my irritability or anger? Did I set a bad example as an older sister? Was her bellybutton ring a cry for attention that she never received from my parents because they were focused on me?  

Years later I've realized that she goes through her own drama, her own struggles. And, because I've experienced some success with recovery, during those times my parents' attention can be on her, where it should be. But I feel for the families who never get there, for the healthy siblings who rarely get to be in the spotlight, and for the sick ones who are burdened with guilt. 

Are there ways that growing up with a mentally ill sibling might be beneficial? I suppose it could lead to a better understanding of illness; more empathy; and more gratitude for one's own psychological good fortune. But siblings are undeniably victims of these illnesses too. 

Talking to a depressed friend

I live in Silicon Valley where many folks are transplants from around the world. I'm nearly 3,000 miles from my family on the east coast. Given that so many people live far from their immediate and extended families, friends are becoming an even more important weapon in fighting mental illness. It's often the people who see you the most--on a daily or weekly basis--that can spot those changes that signal trouble. In legal scholar Ellen Sacks' memoir "The Center Cannot Hold" she describes how it was one of her Yale Law School professors who, during office hours, first recognized her psychosis and took her to an emergency room.

The trouble is, many people don't know when to speak up or what to say if they do. Others feel like it's none of their business. Checking in on a friend or acquaintance who seems to be struggling can be lifesaving, though (remember, depressed people are often bad at maintaining relationships, so even if you don't consider them part of your inner circle you should speak up. They may not have an inner circle). Just the act of expressing concern may be enough to sustain them. And if you don't know what to say, don't worry -- no one does. In this case it's truly the effort that counts. All you may be able to say is "I don't understand how you feel, but I know you're in pain." That's ok. It's knowing that someone can sit with you in your pain that makes a depressed person feel more human and more connected. The following article from today's CNN Health provides some useful advice on talking to a depressed friend.

How to Save a Friend from the Brink  

Sometimes speaking up may feel intrusive or patronizing, so it's a judgment call. People will not always be receptive. But, for the most part, I think people are not offended by genuine and well-meaning concern. And the results from not speaking up are far worse than the awkwardness of saying too much. 

I cannot even begin to describe how grateful I am for those people in my life who sit with me in my pain, tolerant of my inability to carry on a normal conversation or normal activities. I know I can't be fun to be with at those times, but their concern sustains me and makes me feel like I am loved, even at my worst.

Kendra Wilkinson acknowledges postpartum depression

I was encouraged to see reality star and former Playboy Playmate Kendra Wilkinson open up about her postpartum depression recently. She even admits to one of the more embarrassing but least talked about symptoms of depression--failure to complete those basic personal hygiene tasks that seem so difficult when depressed. 

In the weeks after delivering her first child, she admits she couldn't even brush her teeth or shower. It's comforting to know that someone as glamorous as Wilkinson has struggled with the same personal hygiene issues that plague many depression sufferers. I know that when I'm depressed I feel like a total failure when I can't even get out of bed to brush my teeth. But knowing Wilkinson was able to bounce back and recapture her glamour gives me hope.

Wilkinson credits husband Hank Baskett III and her family for getting her through the struggle. Hopefully her openness will inspire more new moms who suffer from postpartum depression to acknowledge the problem and reach out for help. 

In true playmate fashion, Kendra also credits having sex as helping her recover from her depression (although in this case, it was against doctor's orders because she had just given birth). 

Go Kendra! Both mom and baby seem to be healthy and happy now. 

Starplus - Kendra Wilkinson's depression

Great blogs about PPD:  

Postpartum Progress

Make mommy go something something