Dealing with Depression

Rev Stephen Atkinson
North Shore Unitarian Church, West Vancouver, BC
December 12, 2010

Depressed mood has been such a recurrent visitor since adolescence that I took it for granted for many years. Although the beginning is fuzzy, low self-esteem, high self-criticism, shame, sadness and worry were all there; I’m not sure I told anyone except my little brother who teased me about it. “Oh, I’m sooo deprehhhhssed,” he’d say. I prefer to suppress the thought that he might have been accurately imitating me, but it was actually helpful to laugh at myself as this has been my healthiest defence and coping mechanism. My worst strategy – isolation – also started then, but I must emphasize that this wasn’t a full-grade depression like adolescents can have. My moods were always shifting back and forth. I was still academically and socially successful and enjoyed life. But depression leant extra darkness to my shadow as far back as then.

A period of depression in first year of university led me into my first free and responsible search for truth and meaning so it had some positive effects even as it was the next step into years of struggling with depressed feelings and symptoms. During medical school, finally coming out helped temporarily because my secret sexuality was out in the open and people were accepting me as is, but soon the negativity just redirected itself.

I won’t go into a full blow-by-blow account of the following twenty years, although I’ll repeat that I was well and happy often; many who knew me would never have thought I was vulnerable to depression. There are depressive sub-types that are milder, periodic or sub-clinical and back then the approach was psychotherapy and keepin’ on keepin’ on.

The breakthrough episode began one afternoon in June 1998 odd as that may sound; it was deeper than previous experiences but was treated so successfully that I’ve been more consistently happy and productive in the years since than ever before. On Friday, before going to a movie after work I got my hair cut. I’ve no idea what occurred within my mind, but, during that hair cut, an overwhelming feeling of shame flooded me and anxiety followed; I couldn’t stand my reflection in the mirror. When the haircut was done, I couldn’t walk home fast enough; I couldn’t raise my eyes from the sidewalk, lest I see someone judging me. I’ve never heard a story like that from anyone else with depression, but that’s how it began for me, and each sufferer’s story is unique.

Although I continued to be able to work, my perceptiveness and insight were dampened, probably more than I recognized. I started to live on take-out because in a grocery store I couldn’t make up my mind about what I wanted, beyond milk, chocolate and diet Coke; the lights were too bright and it was all too public. Back then I used to go to at least two movies each weekend, but during that period, I couldn’t decide which movie I wanted to see, and even if I decided, I couldn’t figure out the best way to get to the theatre – do I walk out where lots of people could see me briefly, or take the subway or streetcar where a smaller number could watch me closely for endless minutes? Would there be a crowd at the theatre? It was so much easier to stay in – all the time. I ate too much comfort food too frequently, and had almost no energy for anything I didn’t have to do. Still, if I ran into a friend, I’d stop, talk and enjoy the conversation, letting on about nothing, but as soon as we said bye, I immediately lost any pleasure in seeing them. Suicide showed up in the sense that I felt determined not to kill myself; paradoxically, that is thinking about suicide.

I sought help; my psychiatrist agreed with my suggestions about what medication to try based mainly on side effects I did not want to deal with, and observations of which worked best. Knowing how often depression returns when treatment is stopped, and also how it can viciously refuse to respond to the same medication that worked before, I’ve been happy to stay on medication ever since. I only experienced what normal feels like after months of being virtually symptom-free, which gives me the right to use the word normal, even though that is not a single, definable thing. Still my shadow friend is always there like a tempting voice. Not all of my darkness or tendency to isolate is removed by meds, which I think is a good thing because these traits hold something essential about my character; their less frequent and shorter visits help me continue to practice coping. Looking back, though, I sometimes wonder what my life would have been and be like now if I’d been depressed even half as often as I was.

You may have seen that the symptom criteria are in your Order of Service so let’s look at this from a psychiatric point of view for a bit. The psychiatrist in me knows depression is still more often undiagnosed and under- or un-treated so this might help you decide if you need to talk to your doctor about how you’re feeling – or perhaps to someone you know about what you see they’re going through. These criteria are those for Major Depressive Disorder, which is only one form that depression can take.

Depressed mood is fact of life – of normal life, though that doesn’t mean that every person experiences it, just the vast majority of us. Feelings of sadness, loss, disappointment, discouragement and self-criticism are not depression. My professional approach was to label a mood state depressed when a number of negative feelings piled together, even if only briefly, and normal efforts couldn’t shake them, but for that mood to become depression it has to recur frequently enough or extend long enough for it not simply to fit into the changeable moods virtually everyone experiences; it must be severe enough to affect one’s functioning in life to some noticeable degree. In chronic depression this change of function can be hard to see; it might be more that one has never achieved what one predictably might have. On the other hand, some with depression put all their energy into not under-functioning because they think it can’t be depression without some kind of measurable failure. Variations like this occur in almost every single case so the views of others – family, friends or physicians – are helpful in assessing depression. I refer here to expressions of concern; if family, friends or your physician dismiss how you feel, or try to talk you out of it, it’s better for you to trust your own judgment until you can get feedback from someone more objective. Not even every doctor is ready, able, willing and well enough him or herself to be able to detect depression so second opinions might be necessary.

That brings us to treatments which depend on a number of things. First, if the depression is a recurrence, the treatment of choice will be whatever worked before, perhaps with a twist, addition or at a higher intensity. The current accepted first-line treatments for new episodes of mild to moderate depression are a few different programmed, short-term psychotherapy approaches delivered either individually or in a group. For instance, cognitive-behavioural treatment focuses on monitoring thoughts and altering specific behaviours, and interpersonal therapy aims to improve the state of or outlook on one’s relationships.

Sometimes medication is the first treatment or is begun at the same time as therapy. To require medication doesn’t necessarily mean that your depression is more severe, only that there is some reason that this may be the best way. A significant minority of people require something beyond the first-line of therapy, usually the addition of one of the other treatments mentioned or extending the period of treatment longer. It gets more complicated when depression recurs repeatedly, or is complicated by more severe symptoms, or the person is at risk of harming anyone. What’s most important in any course of treatment is that you fully comply with what’s being suggested for the full period of time recommended. Not to do that risks, first, an inability to judge whether something is working or if it would have, and second, failed treatment or the prolonging of symptoms both of which can make further therapy less effective.

My guess is that some of you just had resistant or suspicious thoughts when I encouraged full compliance. After all, there are disreputable therapists, harmful side effects, and it is possible, though unlikely, that psychiatric illness might lead to a temporary loss of your civil liberties. So… if the person treating you is giving you the willies, or you have a sense that your boundaries are being crossed, or the recommendations seem quite unusual, don’t return until you get a second opinion, but do get one as soon as possible. If you are having side effects of your medication, depending on what they are, at least discuss them with whoever is treating you preferably before you stop them, but certainly afterwards if you feel you have to discontinue quickly.

As to civil liberties, it is all too obvious that the liberties the law has given to psychiatric patients has freed them from the hope of even a difficult recovery, releasing them into the open-air imprisonment of hard and hungry streets, SRO housing, and vulnerability to drugs, criminals and the sometimes blind reflexes of law enforcement. It is past time for that ill-advised, under-informed, politically self-serving and socially apathetic approach to be shed. It quickly became the unconscionable excuse to cut funding for psychiatric treatment without ever investing adequately in community options. This is a social sin.

I’ve told you my story and spoken to you as a psychiatrist; now let me speak as your minister, first by assuming that at least someone here has undiagnosed or untreated depression. There are many understandable reasons why anyone might delay, resist or refuse being assessed for an emotional difficulty, but I’ll say flat out that it is a denial of our first principle to keep doing that; you are not treating yourself as a person with inherent worth and dignity precisely because, most often, depression itself is distorting your self-worth and your judgment about what you deserve – which is the best shot at feeling as normal and happy as possible. I feel compassion and I identify with your fear and shame about disclosing how you feel and possibly being ‘labelled’ with a mental illness, but your fear and shame are like the swelling when you sprain your ankle. They are symptoms of an ongoing injury – one that affects your brain, your personality, your spirit and your relationships. You are not to blame for your suffering, but you are responsible for getting better. You can’t do that alone, so let someone help you just as you’d let someone help you off the field to ice your ankle and get that damage assessed.

In fact, the simple act of letting someone help, whether that person is your relative, your friend, your doctor or your minister, is the most crucial step to recovery. That’s not just because it is the first and necessary step, but because the most significant factor in recovery from depression is your relationship with others. Research shows that the part of life most vulnerable to one or more depressive episodes is social connectedness. Depressed people invariably in some way withdraw or pull back from others, which in turn distances others from the depressed person unless this is intentionally addressed. Even the best treatments can only help you regain your desire to connect. If the connections have been affected, much of the time they can only be partially rebuilt, but even partial rebuilding is immensely helpful in the long run.

This is one reason why I’m a believer in group therapy, not to mention it’s also a reason why I’m Unitarian Universalist. One of our most commonly held theological positions is that human beings are meant to help each other. Our principles talk about justice, equity, compassion, democracy, responsibility, interdependence and global community – all of these refer to human interactions. We raise interconnectedness up into the realm of all that we think of as sacred. My personal experience includes many moments in which I felt or witnessed what can only be called holy moments of healing taking place when people talk to and share with each other. Recently, I’ve been in on some professional processing conversations that have felt just like the best moments of group therapy – which can also feel like moments in church. There is something common or similar about these times when hearts reach out to each other.

Those of you who are depressed, I entreat you to open your hearts to the hope of healing by letting others in, by maintaining some kind of contact and by working hard when you’re able again to rebuild or increase your ties to others. If it sounds as though I’m telling you to get over your feelings and come to church, that’s not what I mean. Rather, I want you to see the potential harm to you of always giving in to negative feelings. When you can, resist them and make a connection. This might be more than just life-transforming but even life-saving.

And so you the congregation must know what I’m going to say now. Assuredly, we are a network of human beings within which depression is constantly present in someone, in some form, in memory or in fear. We enjoy coming together, but more than that we help each other and even heal each other by connecting ourselves through the church. Such connections no doubt have differing qualities from person to person, yet still they help us be whole.

This fall I’ve said the same thing in at least three different ways: it can be hard to come to church. It can be hard to come to church when in financial hardship because of the prevailing atmosphere of success, whether it’s a true reflection of the average congregant or not. It can be hard to come to church when you feel your neediness is obvious because of the prevailing atmosphere of self-sufficiency, whether that’s accurate or not. For a number of reasons it can be excruciating to come to church when depressed: shame or fear; fatigue or restlessness; feeling cut off from the joy around you or envy of those who are happy. It is up to individuals to decide if they will face the difficulty of being here.

It is up to the congregation to develop a sense of community so trustworthy and caring that the courage of those in pain as shown by their willingness to be here while vulnerable will be met with sensitivity, compassion and support. We must be aware that we have enormous potential to help and to heal. We must take so seriously the importance of what we create together that we can readily believe that from time to time we will save someone’s life.

Let us ensure that this is so.