A few months back, I was reading a few pieces on The Mighty, one of my favorite websites. It’s a platform for first-hand posts about mental illness, disability, and chronic and rare illnesses (some of my blog posts also appear on there). As I clicked on various links related to mental illness, I came across a post about something called “double depression.” I had never heard the term before, and as I read, the tiny lightbulb in my brain began to flicker and glow, until it became so bright that I wanted to shout, “Eureka!” (or something equally melodramatic). I felt like I had finally figured out why I could sometimes live in the day-to-day of my depression, while other times the illness was knocking me on my rear end so hard that I couldn’t get back up for days.
Double depression occurs when a person who has dysthymia also experiences a major depressive episode. To help us all understand what the heck this means, I’m going to explain these two different types of depression. Then I’m going to give you a ridiculous metaphor for each of them. Then we can talk about how fun it is when they join forces.
Major depressive disorder (MDD), which is what I’ve always been told I have, is characterized by all the things I’ve covered in previous blog posts. It can be emotional: sadness, hopelessness, loneliness, wanting to die. It can be physical: aches and pains, stomach problems, headaches, weight gain or loss. There can be irritability, fatigue, loss of interest in previously-loved activities. Sleeping too much or too little. Typically, those who suffer from MDD experience episodes of acute depression, during which they may feel suicidal or not, may self-harm or not, may function in their daily lives or not. But the key to MDD is that the episodes do end. They may last days, weeks, months or even years, but at some point they stop, and the depression lifts.
The type of depression I did not know about, dysthymia, I would best describe as the mellower cousin of MDD. The symptoms are similar, but while episodes of major depression are likely to come to a more tangible end, the hopelessness, low self-esteem, and disinterest that characterize dysthymia do not. That’s right -- although dysthymia is considered a milder form of depression than MDD, it is chronic. As in, it does not go away. I think one of the best popular culture examples of dysthymia is probably Eeyore -- always plodding along, always pessimistic, every adventure met with a sigh. Eeyore never seems able to pull himself entirely out of the gloom that surrounds him. That’s kind of what it's like to live with dysthymia.
Now, as promised, an absurd metaphor.
Imagine, if you will, a 600-pound gorilla (yes, Wikipedia told me that they can weigh that much) who is determined to beat the living daylight out of you. He sees you as a threat and he is going to attack you with all the weight and strength he’s got. He’ll shake you and kick you and push you around and maybe even bite you. You’re getting the crap beat out of you, but hey -- it won’t last forever. Eventually the gorilla will get bored or feel satisfied that you are no longer a threat, and he will leave you alone. You’re left to lick your wounds and eventually get back on your feet. You’ll have a few scars, but the gorilla will be gone. That’s major depression.
In contrast, dysthymia is the much smaller, cuter-by-comparison monkey that sits on your shoulder. He won’t mortally wound you, but he won’t ever go away either -- he’s always picking at your hair, screeching in your ear, smelling up your house, making your life inconvenient and chaotic and unpredictable. It’s not pretty and it’s not fun. Sometimes it’s painful, but it’s not like you’ll end up in the hospital with any broken bones. The thing is, you will never be rid of the discomfort and exhaustion you feel from dealing with him every single day. That’s dysthymia.
So, what’s double depression? Double depression is when the monkey on your back wraps its arms tight around your neck to hold on, and the gorilla comes at you swinging. You might have learned to live with the little guy -- annoying though he is, he’s your monkey, and most of the time he’s not all that bad -- but now you have to carry his weight and fend off the gorilla who is trying with all his might to kick your ass. You’re less able to defend yourself because the stupid monkey won’t let go, and you’re tired from carrying him around all the time, so the gorilla has an easier shot at you than ever. And then, guess what? When the gorilla finally decides he’s done with you, the monkey doesn’t follow after him and leave you be. He clings on, just like always, so it’s just a little harder to heal and recover. You’re perpetually swatting at the monkey, who won’t leave you alone, and meanwhile, you never know when the gorilla might come back for round two (or three, or four…).
To get back to the real world for a moment: double depression is when a major depressive episode occurs in a person with existing dysthymia. The depressive symptoms you thought you were doing pretty well living with are suddenly compounded, and you are thrown into a deeper, darker place than any you’ve been to before. Your fatigue is no longer nagging, but all-consuming. The minor aches that fade with sleep start to keep you up all night. The passing thought that maybe not much in life really matters is replaced by an unrelenting thought pattern of pervasive hopelessness.
Once I realized that I may have been living all this time with dysthymia, and that my hardest times were the ones punctuated with major depressive episodes, I spoke with my therapist and my nurse practitioner, both of whom agreed that this was the most likely scenario. I can’t say I feel relief at the diagnosis -- it feels pretty awful to be told that my light at the end of the tunnel is likely a hazier, dimmer one than I’d like it to be -- but having a label helps me better understand what I need to do to take care of myself. On the very best days, the monkey on my back lets me put him down on the couch for awhile so I can take a break. I’m learning to love those moments and use them to enjoy life, all the while preparing to pick the monkey back up, and even to face the gorilla once in awhile -- hopefully mustering up more a little spunk and optimism than Eeyore.
Medication for mental illness can be a touchy subject, and everyone is entitled to their own opinion. But I do honestly believe that some of us need psychotropic medication the way a diabetic needs insulin, the way short-sighted people need glasses, the way anyone else takes medication for a migraine or high blood pressure. Understanding that my brain is chemically imbalanced, and that I need medical help to balance it, has been a critical part of my illness and treatment. I refuse to be ashamed of that, and I’m happy to share my thoughts on it here.
You may recall from a previous post that I was started on Celexa by a college health center doctor who knew little about my personal depressive symptoms, and that I later learned that Celexa in particular can increase tiredness and fatigue (my primary, and most debilitating, symptoms). From there, I sought treatment from a psychopharmacologist who journeyed with me from Celexa to Wellbutrin, Prozac, and eventually Cymbalta, which I take now. At each visit she would ask how my mood that day was on a scale from one to ten. I’d answer as honestly as I could, tell her how the past couple of months had been, and we would discuss whether I felt good on the medication I was currently taking or if I was looking to make a change. As a person with depression, it’s always hard to know -- is this as good as it gets for me? Is there something that can help me feel even more like myself, with energy and passion and positivity?
But tinkering with medication is no joke. Each time we made a switch I would have to taper down slowly, sometimes adding in the new medication gradually, and take note of how I was feeling and what side effects I might be experiencing. I remember that Wellbutrin gave me a lot of energy, which was great, but when we bumped up my dosage I started to feel crabby and anxious, irritable and unable to tolerate even the slightest frustration. So we tapered back down. Some of the medications cause weight gain, or dry mouth, or hot flashes, so anything new that starts happening with your body sends up a red flag -- is this a side effect? My current medication (Cymbalta) causes hot flashes and excessive sweating, which is a lovely thing to deal with as a woman in her twenties. There’s nothing like being asked at a toddler’s birthday party if you’re crying, and having to wipe your cheeks and answer “no, I’m just sweating.” It’s a real self-esteem booster. But hey, at least I can smile while I answer. Cost-benefit analysis.
Other than that, I will sing Cymbalta’s praises (for me, and only me, as I’m not making ANY medical recommendations for anyone here). It has been a complete game changer for me. I was on a lower dose of it when I began to see my new therapist (who also now prescribes my medications), and she suggested going with the maximum dose to see how much it could help. And, you guys, IT HELPS! I went from feeling sort of okay some days to having REALLY GOOD days. My husband would come home from work in the evenings to find me having worked a full day, showered, dressed (these are bigger feats than I know how to explain) and cheerfully making dinner after doing several loads of laundry and cleaning some of the house. He said, on more than one occasion, “I haven’t seen this Lauren for at least five years.” I remember walking through my house one day, on my way to wash a dish or switch the laundry, and thinking to myself, “I’m just really freaking happy.” (Full disclosure: maybe my brain didn’t think the word freaking, exactly.)
Some people may argue that it’s unfair to simply take a pill and be happy, and to them I will say: this is not a permanent condition. There is no guarantee. I am not happy every day. I might not even be 50-50 on good vs. bad days. But my good days are so much better than the supposedly “good” days I have experienced in the past couple of years. More often, I am able to say that the highs of life feel as high as they should, instead of just moderately okay. More often, I am able to face the day without a mounting sense of dread or complete apathy. More often, I do what I need to do during any given day or week without missing work or canceling plans six different times.
Those who are against the use of medication to treat mental illness will say that the drugs are shortcut, a way of putting a bandaid on a wound that really needs stitches and professional attention to heal properly. They clamor that “putting in the work” (i.e., working through issues in therapy) is the only way to truly treat the disease. I will answer that while therapy may be the stitches and attention my wound needs to heal, the antidepressants are the ointment and dressing around the wound that keep it from getting infected, that make it livable, that make it tolerable and keep it safe while the healing occurs. I’m not choosing one or the other, but I will say that the meds help make this “wound” of depression tolerable while I’m working on healing myself in therapy -- and on some days, they’re the reason I can even get myself to therapy in the first place.
I want to make sure to note that I did not immediately come away from my first therapy appointment with a diagnosis and prescription. This is important! It took a several visits and lots of talking, as well as a couple of inventory-style tests, to determine that I was, indeed, depressed, and not just sickly and feeling down in the dumps.
After a couple of visits, my therapist had me describe the past year or so to her. I recounted the sudden ending of a serious relationship; a back injury that had caused me to drop a magazine internship and left me more or less lying in bed for a month; the recent theft of my laptop (and, as a result, the loss of the digital copies of all of my pictures from my semester in Madrid). I’m sure there was more. When I had finished, she said kindly, “I’m hearing about a lot of loss.”
I sat back and said, “Huh.”
I was happily in a new relationship (hello, husband!), my back had healed after some physical therapy, and I had a better, new computer -- and with most of my pictures on Facebook, I hadn’t really lost them all. In my mind, all of these losses had been resolved. Plus, they weren’t earth-shattering things -- they were normal life things that happen to everyone. But this wise woman explained how sometimes our minds and bodies can catalogue these losses, absorb the shock and sadness of them, and hold on to them, creating a kind of “circumstantial” depression. In her opinion, I was trying to recover from all these “life” things and just needed some help getting over the hump, as it were. She suggested medication to help with that, which I was open to, but I made her aware that I did not want to be on antidepressants for the long-term. “Am I on these for the rest of my life?” I asked nervously. She assured me that she didn’t see that being necessary in my case. I had every reason to believe that this was a temporary state of being for me, and I would come away healthier, happier, and ready to live my life again (without wanting to nap for an hour, every hour, on the hour).
I made an appointment with the doctor at the adjoining health center and she, without asking the specifics of my symptoms or what I hoped to gain from the medication, prescribed a smallish dose of Celexa to be taken daily. She told me it was a “middle of the road antidepressant” and I assumed she had conferred with my therapist (as I had given her permission to do), so I didn’t worry. I filled the prescription and began to take it.
The next few months are a blur, not because of depression but because I was entering the last two months of my college career. I think I did better. I took my medication and continued therapy. I finished and defended my thesis, which ended up being long enough and, I was told, good enough to have been an honors thesis as I had originally intended (too late). I attended all of the senior events -- my eating house formal, myriad college-sponsored celebrations, senior week at Folly Beach -- and had a fantastic time. I graduated cum laude and felt excited to see what was next. Saying goodbye to my friends and professors was hard, but I was content to move back home to Massachusetts with my family and figure out my next steps. By all appearances, I had made it over the hump of whatever circumstances were dragging me down, and in my mind, I was done with this “depression” thing.
I wasn’t done, or maybe it’s better said that depression wasn’t done with me. Now I understand that it likely never will be. I don’t say this with pessimism or hopelessness; just with the comprehension that depression, like most mental illnesses and many physical ones, is a chronic condition. With treatment, self-care and lots of attention, I can help it recede to the outskirts of my life on occasion (and hopefully, eventually, for longer chunks of time). But I’m learning to accept that my depression and I will never be done. Learning to live with that fact is another step toward a healthier life -- and so is cutting myself a break when the disease forges its way back into the center of my existence and takes hold. Depression may not be done with me, but I am most certainly not done with it.
Seven years ago this month, I found myself trudging up the hill and across the campus of my beloved, small-town Southern college to the local CVS. After browsing listlessly, feeling so exhausted I could hardly think straight, I rudely dropped a bag of peanut butter M&M’s down on the pharmacy counter and told the pharmacist I was picking up a prescription. She avoided eye contact and said, typing into her computer, “Celexa?” I nodded and wondered, vaguely amused, how many customers came in and wound up buying chocolate along with their antidepressants. Surely, I thought, I couldn’t be the only one.
As I dragged my aching body back across campus toward my apartment, I called my mother and my boyfriend (now my husband), tears in my eyes, to tell them that I had been diagnosed with depression and was starting medication, per the recommendations of the warm and reassuring counselor at the student health center. I felt simultaneously relieved and anxious; matter-of-fact and embarrassed; hopeless and yet at the same time, considering whether that might be a tiny blink of optimism I felt somewhere inside.
The diagnosis came after months of physical fatigue and malaise, vague aches and pains, a mind-numbing inability to concentrate, low-grade fevers, migraines. I thought everyone was tired all the time until, when I tired after about 30 minutes of shopping over winter break, my oldest childhood friend said to me: “Lauren, I don't think I ever feel tired like you do. Have you gone to a doctor for this?” This was a novel idea to me (Not everyone feels tired all the time?), and so I did as she suggested. My nurse practitioner tested me for lyme disease, mono, and the like -- nothing popped. She sent me to a rheumatologist to rule out fibromyalgia and an infectious disease doctor to eliminate the possibility of anything, well, infectious, and still: I got no answers.
Word of my mysterious ailment spread across our small senior class as I dropped my Spanish honors thesis, after several tearful sessions with my dear advisor, down to a regular one. “Tú tranquila,” he said to me. Calm down. “Sometimes life is more important than school.” I missed classes and passed on social events I would normally have looked forward to. Facebook recently dug up a post in my “Memories” in which a pre-med acquaintance who had heard I was sick asked if I had been tested for typhoid fever: “your symptoms seem to fit.” I was so very, very tired, and starting to be convinced I would never know why.
My roommates, friends and family did all they could to help. They organized a group of everyone I knew to write me encouraging letters (this was thoughtful and kind, and yet as I read them, my eyes stung with tears and my face burned with humiliation as I grew aware of how public my illness had become). They signed up for a farm share so we could enjoy healthy meals together. They encouraged me to exercise, to volunteer, to not just “sit around,” to which I said, fighting off tears, “I just can’t.” My mom came to visit, making the trek from Massachusetts to North Carolina just to be with me. Finally, two friends who had previously been helped by sessions with a counselor suggested I make an appointment so I could get help “dealing with not knowing what was wrong.”
That first visit marks the beginning of my journey with depression, in the sense that I was slowly becoming aware of what was really happening in my mind and body. I’m incredibly grateful (not to mention blessed!) to have had family and friends who supported me through such a stressful, frightening time; without each of them and their love, care, compassion and guidance, I may not have been diagnosed when I was. Seven years later, the struggle is realer than ever, harder than ever, and more painful than ever, but I have begun to learn that my personal moments of transparency and honesty -- with friends, with family members, with people in my social media network -- have allowed me a measure of peace, feeling that I am doing what I can to help my little corner of the world understand what it’s like to live with mental illness. That’s what I’m doing here. I’m going where it hurts, so that you can too, so that maybe one or two of you will better know how to approach mental illness when it touches someone you love. Because if it hasn’t yet, it will -- and they need you.