(Originally posted July 18, 2018)
Despite four years of medical school, five years of post-graduate medical training, a second graduate degree, and a history of having been raised by not one but two psychiatrists… I had no idea I was depressed.
Make no mistake, I knew quite clearly that I was unhappy. But, highly skilled in rationalization, I was able to contrive reasons for my emotional state from various and sundry aspects of day-to-day life with little sense that anything “clinical” might be behind it, nor any interest in applying a diagnosis to my situation.
It took a lot to pry my eyes open. The headings you see below held no meaning for me when the story originally unfolded. However, my comprehension crystallized later. Read on, and you’ll see what I mean.
Post-Partum
My first pregnancy and the four years that followed are a general blur in my memory other than certain poignant moments, like the shock of discovering early in our second pregnancy that our child had an ultrasound abnormality indicating high-risk for major complications. Even that melted into a steady but whining hum of difficult emotions as subsequent testing yielded reassuring results, albeit always with reminders of the caveat that the worst might still happen.
Anhedonia
Thankfully, both our kids came out healthy, but the poor things now had me to deal with. I hovered between asinine determination to “do it all” and crushing guilt upon discovering I couldn’t. Doing anything took exorbitant effort that I could barely muster. But it had to be done, so I poured every ounce of my energy (and most days there were probably only a few ounces) into the tasks of child care and homemaking, with none to spare for emotional engagement.
To be honest, I knew something was wrong when I couldn’t sing. For my entire life, since early childhood, music had been the cathartic outpouring of all my passions. But the rhythm of our life as a family interfered with my ability to participate in the church choir that had once been my outlet. My husband was in the thick of his own medical training which frequently consisted of those 80-hour work weeks and overnight calls up to twice a week, so he wasn’t exactly available for backup parenting. One day, unexpectedly alone with our then very little ones, I had to skip out at the last second on a Christmas concert the choir had been vigorously preparing for and that I was particularly looking forward to. My voice box quit for several years after that. For one thing, the bitter pain of disappointment didn’t seem worth the hope of what might be high reward. But even beyond the rationale that joy might break through with a little singing, there was just NO desire to try.
Catatonia
Somewhat rogue and solitary by nature and upbringing, I largely kept the internal chaos to myself. My pride was so impenetrable, there was no way I would let on how broken I was, although I’m sure it was more apparent than I realized. On reflection, the truth is that I kind of couldn’t. My husband would ask… invite me to share. And I could swear the clearest, most articulate, most heartfelt explanation of my inner thoughts would play itself out from beginning to end. I said it all, I said everything… but it was stuck in my head. It just wouldn’t cross the brain-lip barrier. I remember several moments like this in more detail than one might expect: nothing came out of me but silence and a glazed, directionless stare, even though my mind was not just active, but almost racing with thoughts that fueled disappointment, fear, even rage. I wanted to move, to yell, to cry. Instead I just sat there. (https://www.healthline.com/health/depression/catatonic-depression#causes)
There were a few instances where I attempted to verbally express the eloquent soliloquies circulating in my mind. I would open my mouth, and my voice was tense, my words halting and the content essentially gibberish. So I quit trying. It was a very challenging time in our marriage.
Sleep-Deprivation
I would eventually peel myself out of these cocoons and resume function around the house, knowing I had to. Meanwhile, I worked graveyard part-time in the hospital and frequently went into my first shift for the week having not slept all day, commonly amounting to 30 hours at a time without rest on a weekly basis, and averaging 3-4 total hours of sleep every 24 hours the rest of the week. My assumption was that I should be able to handle this, since 30-hour shifts were a standard part of medical residency training, which I had just completed. As a doctor AND a mother by this point, I felt it my duty to endure seemingly insurmountable obstacles in the name of resilience. Staying highly functional while critically sleep-deprived was something I considered a badge of honor.
Poor Nutrition
Turns out the two are essentially mutually exclusive, as “high” functionality proved to be very relative in the setting of poor sleep. Most days my function did surpass catatonia – I guess you could call that a victory. Still, fueled by pride and repeatedly declining opportunities for self-care, I ate whatever was around which commonly consisted of bread and butter, mac & cheese, Cheerios, and dinosaur chicken nuggets. My night shifts operated on vending machine loot, usually Snickers bars or Pop Tarts.
Self-Loathing and Social Isolation
Probably the most crippling feature of this period for me was the isolation. I had gotten chubby, my hair was thinned, my skin dry and splotchy, and I felt perpetually bloated. I simply loathed myself and couldn’t bear to subject others to my company, so I avoided public appearances. As a mom of young kids, though, there were inevitable trips to the grocery store, “Target runs,” and visits to local playgrounds. Everywhere I looked, I found evidence that I was an inadequate mom: everyone seemed to have it together more or have better-behaved kids than I. On rare occasion I found myself at times seeking out “worse” family situations to prove I wasn’t as bad a mom as I felt. The judging and comparing only proved more emotionally exhausting, so I would quickly retreat to my living room and the warm, fuzzy distractions of PBS Kids and Nick, Jr.
I never really talked it out with anyone else, I had no idea who to talk it over with. Most of my friends had not started having kids yet, and those historically closest to me were distanced not only by miles but even time zones, so coordinating a conversation simply felt beyond my capacity. The occasional times I would chat about parenthood were with my mother or mother-in-law, who provided extremely valuable help on a weekly basis, so I could –theoretically– rest after my night shifts (although I proved to never be a good day-sleeper). They were soooooo well-intentioned, but most of those conversations ended in advice I couldn’t fathom following for one reason or the next such as “Cook and blend your own baby food,” or pat reassurances like, “Your kids will survive you.”
Deep down I knew it wasn’t advice I was looking for anyway; I didn’t expect or even want some magical solution to make motherhood easier somehow. I wanted to be validated. Just to be heard and understood. I had no idea where to go for that, so I just turned further inward and wallowed in resentment.
Mood Symptoms
If anyone were to ask on any given day how I felt, the honest answer (which I never provided) would have been one of two things: upset or numb. I wouldn’t really have described myself as “sad” most of the time.
I was certainly irritable, and the unfortunate most frequent recipient of my snapping and snarling was my older son, as the younger was still too infantile to grasp it. My husband was more frequently dealt the silent treatment.
I was angry, which is an emotion generally tied to a cause: we become angry “at” something or “because of” something, rather than thinking of anger as arising on its own. Therefore, it was reflexive to pin my frustrations on what was happening around me, things I perceived as happening “to” me. Because the needs of my family filled out my time every day, I felt they didn’t care about my needs, which made me angry. Then, I would think as a good Christian my own needs should always be secondary to caring for others, so I became angry at myself for spending even a moment coveting attention to self-care.
Largely, the anger was straight up exhausting and interfered with getting things accomplished so I taught myself to numb the emotions and just function.
Suicidal
That self-oppression could only last for but so long, though, and eventually I was having suicidal thoughts every night, typically when trying to get my restless kids to sleep. I mostly wanted escape from the mental chaos, but I will now openly admit there was an element of me that wanted to inflict the punishment of my loss on those who I saw as the authors of my turmoil: my family. My ideations of suicide were so vivid and advanced (yes, I came up with multiple plans) that it would inevitably lead to visions of being found by my children. At this point I would realize there was NO way I wanted to damage them that badly for the rest of their lives. You could say that would be when I would “chicken out,” and just cry myself to sleep.
A turning point of sorts
My personal unraveling eventually came to a head, but as a family we somehow survived it and started working more constructively towards collective recovery. This included the good fortune of finally finding a therapist I connected with (I had seen a couple of therapists through the years prior, but without much progress). Part of the reason she worked for me was that she listened without applying a diagnosis, at least not in my hearing. As such, I had some opportunity to feel validated without worrying that I might be “crazy.” Painful, arduous, but effective, this embarked me on what would be a very long journey towards recovery.
Meanwhile, some major career changes happened in our household for both my husband and myself at roughly the same time. For me, this involved changing from a shift-working hospital doctor to regular office hours practicing Primary Care, which I was certain would mark a positive turn for my sense of well-being, expecting the regular office hours to help reset my badly deranged Circadian rhythm. I also predicted job satisfaction would improve as I built longitudinal relationships with patients. Some of this turned out to be true (http://www.thriveapc.com/2014/10/the-worst-patients/), but I had another thing coming (http://www.thriveapc.com/2017/06/thriving-part-1/).
Then it happened
In September 2015 I was struck by the phenomenon of depression from a whole new angle like an anvil to the cheekbone when it claimed the life of my only sibling.
http://www.thriveapc.com/2015/10/in-loving-memory/
From the moment of learning he was gone, I pulled a tact from my previously built frameworks of coping with death of close young people (nope, this was not my first experience with devastating loss, nor would it be my last): “I have to care for the living, and the living includes me.”
Among other things, this firm resolution at least played a role in carrying me through meeting the officer tasked with reporting his death to me, reading farewell notes, viewing the body while my parents cried on my shoulders (although this was a detached and surreal moment for me, still unemotional to evoke it even now), organizing the memorial service according to his wishes (whereas his clearly stated preferences were simple: not in a church, but in a way that would provide comfort for those left behind, and with me in charge), writing and delivering the eulogy, and eventually spreading his ashes on the side of a mountain.
The most difficult moments were on the plane ride home, while reading through his smartphone. All the darkness and torment he had so skillfully kept under wraps could be found there in blistering detail, between self-hateful memos he kept for himself, message chains with certain impactful people ranging from devoted to broken and spiteful, discoveries of habits and preferences he was clearly ashamed of and had hidden even from those who had thought themselves closest to him, and all the stages of his planning including drafts of farewell notes dating back more than 6 months… including notes written to his nephews, my sons (which he didn’t leave behind to be found, they were only in the phone). Along with a handful of other deeply guarded traumatic memories that will never see the light of day, I have locked the contents of that phone into a mental vault, which otherwise dissolved with the phone’s loss of battery power. I don’t plan to ever bring them back for anyone else’s viewing.
The “other things” that bolstered me through this episode, when falling seemed like the obvious next step, would clearly be the vast list of family and friends pouring from the woodworks to provide love and support in all forms. I dreamed of doing justice to all these caring inputs with some form of online memorial or publishing/performing one of the songs I’ve written in his memory, or something. My lack of capacity to pull this together in some form fueled my ongoing internal struggle for a while after.
But I guess you could say my contribution to honor Abe’s loss is what you are reading right now. It’s taken me a while. But here it is.
Realizations
If you were to read the eulogy linked above, you would see I had already become fully cognizant of depression as a disease. I knew there were parts of it I could relate to, but still wasn’t so ready to apply the diagnosis to myself.
Several months later, my husband and I were spending time with good friends, one of whom happened to be trained as a psychiatrist. She was talking to me about a member of her own family struggling with post-partum depression.
I don’t quite know why it took me so long to connect the dots, but here I was, listening to a psychiatrist talk about this well-known condition as she basically described my life 3 to 6 years hence.
I finally managed to apply enough insight to review what had simply seemed to be “life circumstances” but now read more like a “history of present illness” and the above bold/italicized headings came to light. Some describe causative factors, some describe symptoms. All form a picture of clinical depression.
Barriers to clarity
I couldn’t tell you how many times I have heard people voice frustration over being labeled with Depression or Anxiety by clinicians, asking rhetorically for example, “Why do I have to be ‘Depressed’? Why can’t I just be sad?” I once heard these exact questions from a patient whose closest friend had just died from cancer. Clearly there was a legitimate reason for her to experience negative emotions, so she didn’t like the label of Depression. Meanwhile, she was repeatedly contacting or returning to the office because her previously stable chronic back pain was out of control.
The issue is that there are both pros and cons to the label. Often people are seeking an explanation for manifestations of a physical nature that tend to accompany deeply penetrating negative emotions. On the flip side of that coin, there is dread of an explanation that carries the stigma of mental illness. The problem with the label of “depression” is that it takes legitimate, recognizable, well-described clinical correlates and ties them together with a mark of “being crazy.”
A system set up to fail
Meanwhile as an overtaxed, overburdened clinical community, we apply the label then are disinclined to properly manage it because… well… because many if not most of us are also victims. Proper management of clinical depression takes sizeable amounts of time and empathy. There is a blindingly disproportionate volume of patients relative to the numbers of primary care providers and psychiatric providers available, so the few who are in practice get overwhelmed. Guess what happens to people who are overwhelmed?
They become anxious and depressed.
Which leaves little room for empathy.
The mask of privilege
Left and right, we judge one another’s character based on their resilience under pressure, or lack thereof. We tend to be harsher on the socioeconomically privileged, because “They have it all, what reason do they have to be depressed?” Well it turns out people with means and resources are ironically less likely to seek help, often because privilege accompanies intellect and pride.
Intellect and pride in turn lead to a higher likelihood of successful suicide. We can pooh-pooh the toils of celebrities all we want because of that “have it all” thing. But when suicidal depression is real, stardom or no, it still leads to death. Just ask the families, friends, and fans of Robin Williams, Kate Spade and Anthony Bourdain. Chester Bennington. Chris Cornell.
Same goes for doctors, who seem to closely follow celebrities amongst general society as enviably privileged. It is automatically assumed that physicians make tons of money, but this is not always the case, and also ignores the question of “at what cost”? https://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html
Back to that system problem
The bottom line here is that suicide is sadly a real contributor to the attrition of available doctors. Short of suicide, burnout is a whole other epidemic amongst clinical providers of all varieties, leading to exodus from patient care through multiple avenues: early retirement, transition to non-clinical roles like education or administration, complete career changes, etc. Fewer available clinicians leads to more burnout for those who remain, and the spiral continues. All of it ultimately leads to less opportunity to educate and guide patients towards their own options for recovery of this very serious, highly prevalent set of conditions known as depression, anxiety, fibromyalgia, chronic fatigue, irritable bowel, etc.
So, now what?
I have good news and slightly less good news.
The good news is that recovery is possible. And this is where self-advocacy takes on a whole new meaning.
Because my other news is good but with caveat. Recovery often (hear me properly: often but not always) depends far less on clinical intervention than we seem to think. But it does require a personal investment of time, effort, and insight into the various causes. Oh, and did I mention time? Patience is critical to success. And the “effort” piece predicates having to overcome that very real hurdle of “anhedonia” that is nearly universal with these syndromes. But as much as it feels so… it doesn’t have to be hopeless.
I guess another bit of “slightly less good” news is that I have far exceeded my access to your attention in this post, so stay tuned for Part III about the road to recovery.
Thrive Adult Primary Care 