Tips for the Depressed

As we all know, unless you can afford a medical concierge and the most expensive insurance and facilities, the for-profit, private-insurance-based health care system in the United States is somewhere between a headache and a nightmare. Inpatient mental health care is no exception. The quality of life is ultimately defined by your insurance company’s concern to avoid liability.

The stupidest, most exasperating piece of advice commonly offered to suffering people is also the truest and most comforting

Jon Pylypchuk, Untitled. 2015, enamel on gessoed panel. 78 × 78". Courtesy of the artist and Petzel, New York.

The following is an excerpt from George Scialabba’s How to Be Depressed, out this month from the University of Pennsylvania Press.

The phenomenology of depression is endlessly varied. Some of these tips may be useful to many readers; some to a few; some to none at all. If any of them helps lighten anyone’s suffering by a grain, it will be worth the effort. There is no authority behind any of these suggestions beyond my own long experience of depression and what I’ve gathered from reading about others’. I don’t think any of them are risky, but if you have any doubts, talk them over with partners, friends, caregivers, or fellow sufferers.


Waking Up

For many depressed people—for me when depressed—waking up is the worst moment of the day. Emerging from unconsciousness, you are completely undefended. Sometimes there’s an instant of blankness and you wonder: is it gone, am I free? Then the horror seeps or surges back. Whatever strength you’ve gathered during sleep just seems to have amplified it. You’ve recharged the battery, but the static is louder than ever.

I don’t know what you can do about this, except be prepared for it. And see “Sleep” below.


Getting Out of Bed

A hideous ordeal. Probably the best way is to have an obnoxiously loud alarm clock on the other side of the room. It should have a “snooze” button, in case you crawl back into bed, as you probably will. At some point, perhaps after the third or fourth snooze, try to slip into the bathroom and splash cold water on your face.

You’ll know you’ve decided to stay up when you start shaking all over. Maybe you won’t, but I do. Just one semi-voluntary spasm after another for anything from five minutes to an hour. Take deep breaths, stretch, splash more cold water.

Years ago, somewhere or other, I read this advice: “The most important thing a depressed person can do is: Get dressed!” Curiously, it helps. Lying in bed seems like a natural response to agonizing pain, but usually the pain just gets worse. Maybe the few minutes it takes to make the bed, wash up, and put on clothes are enough to break some deadly mental circuit. Try.


Getting from One Room to Another

Usually cannot be done with dignity. You will lurch, shuffle, careen. Your head will hang down, your shoulders hunch, you will be a slumping shambles. And when you get to the next room, you will discover that you forgot something you need in the room you just left.


How to Keep Your House from Becoming a Disaster Area

This is straightforward: you pay someone to do it. Otherwise, forget it. After a while, depression is exhausting beyond words. Vacuuming, dusting, laundry, changing the sheets, washing the dishes, cooking, shopping—together these are as hard as running the Boston Marathon would be for the average out-of-shape non-depressed person. You will forget things, lose things, drop things, spill things, break things, run into things. Don’t be mad at yourself—remember, you’re being invisibly, silently, savagely tortured. You have a perfect right to let things go a bit.


Water

Don’t dehydrate. Drink plenty of water, on a regular schedule. Don’t wait till you’re thirsty. Your urine should be pale, not vividly colored.

For some reason, being depressed burns up a lot of energy. Of course there’s no output—you don’t achieve anything—but your metabolism is racing. And you cry. Not enough water and you become slightly feverish and groggy. It’s very unpleasant, and it’s unnecessary. Fill three or four water bottles at the beginning of the day and put them around your house or workplace, where you can’t miss them. In cold weather, make yourself a lot of tea.


Food

Everything is hard when you’re depressed, even eating. And besides, you’re probably not moving around much, so you don’t build up an appetite easily. I always lose a lot of weight when depressed.

To minimize the damage, make a smoothie the first thing every morning. Toss a banana, blueberries, yogurt, almond milk, fruit juice, wheat germ, and protein powder into the blender. (If you can stand it, add a little of some weird-tasting plant-based powder—Perfect Food, Ultimate Meal, lots of others—but don’t force yourself.) Then, whatever else you do or don’t eat all day, you won’t be malnourished.

If it’s hard to eat, it’s just about impossible to cook, so have a lot of snack food in your fridge. But let it be healthy snack food: hummus, Greek yogurt, cottage cheese, hard-boiled eggs, almond butter, whole-grain crackers, celery, carrots, fruit.

Some people eat compulsively when depressed, for comfort. If you have to, don’t fight it. But remember, some healthy things are delicious too. Usually they cost more, but they’re worth it. Junk food—candy, cookies, chips, soda—is a kind of drug, and will eventually make you feel worse.


Exercise

It is universally recognized, in fact trumpeted, nowadays that regular exercise is good for your mental health. It is less often acknowledged that for a severely depressed person, vigorous exercise can seem as difficult as running two Boston Marathons in a day.

At least walk. Ask your spouse/partner/friends/relatives/hired helpers to drag you outside, or even to the gym. Try for a little aerobic exercise—i.e., something that makes you short of breath—each day.


Mindfulness

Is mindfulness the wisdom of the East finally made appealingly practical for Westerners, or is it just another form of Positive Thinking? I inclined to the latter view until I came across Sam Harris’s Waking Up. If this aggressively skeptical rationalist has found great value in meditation for wholly secular reasons, then no one else need feel overly fastidious about trying it.

At its worst, the pain of depression obliterates ordinary consciousness, as the pain of terminal cancer is said to do. The pain consumes, annihilates, your awareness of anything else. By teaching you to focus on discrete sensations and tasks, mindfulness practice can help remind you that there is a you beyond the pain. It can help you hold on until the pain recedes—which, unlike the pain of terminal cancer, it will eventually do.

A useful place to begin is Mindfulness by Mark Williams and Danny Penman. Also The Mindful Way Through Depression, by Williams, Jon Kabat-Zinn, et al.


Acupuncture

It isn’t cheap, insurance usually won’t pay, and it doesn’t help everyone, to say the least. But it helps some people; and unlike nearly all antidepressants, it seems to have no side effects.


Passing the Time

A minimal definition of depression is: the inability to feel pleasure. As its severity increases, it becomes what William James called “a positive and active anguish, a form of psychical neuralgia wholly unknown to normal life.” At the extreme, pleasure and even distraction are impossible. But before that, or after it, popular culture can be a solace. Friday Night Lights got me through one depression, and (I blush to admit) reruns of 24 and Sex and the City through another. There’s also Harry Potter, Bernard Cornwell’s many epics, Game of Thrones in print and living color, vast tracts of science fiction (don’t miss Kim Stanley Robinson’s magnificent Mars trilogy), and, on the border of entertainment and art, Patrick O’Brian’s Aubrey-Maturin novels. There’s something for everyone in American popular culture.


Sleep

Sleep medications can be helpful, but only temporarily; in the long term, they can be addictive. Getting some exercise during the day should help. Another thing to try is music. For years now, I’ve fallen asleep to Renaissance sacred music—that exquisite vocal polyphony that sounds like a choir of angels. Try also, for an hour or half-hour before sleep, sitting quietly (or pacing, if you must) and listening to some soothing music. I’m a classical music fan, so what works for me is Bach, Haydn, Mozart—mostly chamber music, but some orchestral—or earlier: lute, viol, and consort music from the 16th and 17th centuries. Something or other will work for you—ask friends with similar tastes for recommendations.

Typically, you will fall asleep without too much difficulty but will awaken during the night or at first light and be unable to fall asleep again. Don’t lie awake too long. Get up and pace or listen to music or try to read. It is a hellish time. William Styron in Darkness Visible has a pithy sentence about this experience: “The combination of exhaustion with sleeplessness is a rare torture.” If only it were rarer.


Strangers

On bad days, you’ll look and act like a zombie. Fortunately, most Americans have heard the word “depression” by now—there are, after all, millions of victims—and know that one is supposed to feel sorry for depressed people rather than wary of them. Don’t be embarrassed if your voice quavers or your eyes fill with tears. Try to smile: it will put other people at ease, and they’ll appreciate your gallantry.


Friends

If you’ve earned someone’s unconditional devotion, for example as a parent, child, spouse, partner, or friend, then you’re lucky indeed. But even if not, it’s likely that some people, perhaps many, love you and will want to help. They can, very much.

It’s primal: when you’re hurting badly, you don’t want to feel alone and abandoned. You want to be held: literally, if possible; or figuratively, in a web of affection and concern. Ask friends to email, call, or visit regularly: some every day, some every other day, some once or twice a week, depending on how close the friendship. The contact can be brief, but it should be regular. Banalities are fine: “I love you.” “Hang on.” “How bad is it today?” “It will get better.” “Have you eaten?” “I think of you a lot.” They can tell you what they’re doing and thinking about. Or you can sob. Or you can be silent together.

You can send out bulletins: “Liking that novel you brought me.” “Took a walk.” Or to especially close friends, simple cries: “Can’t get out of bed.” “Pain level at minus 9 today.” “Oh God!”

Don’t hesitate to ask friends for material help: to shop for you, to cook, to drive you to doctor’s appointments, to come over and watch television with you, or to just be there while you clean the house or do your laundry or pay bills, if you find those things too hard to do by yourself. And a note to friends: ask often. Don’t ask only once, or assume that because a depressed person doesn’t ask, they wouldn’t say yes if you offered. They may simply be unable to ask.


Money

Depression may give you a deeper appreciation of Karl Marx’s observations about money as social power. Rich people may or may not be happier than non-rich people, but the quality of their unhappiness is definitely better.

If you’re non-rich, it’s probably best not to make large discretionary purchases when you’re depressed. If you’re strongly tempted, or it’s a great bargain, at least run it by friends or a therapist. On the other hand, do pamper yourself in small ways: almond milk, the best nut butters, artisanal bread, cheese, and beer, gourmet deli sandwiches, that exquisite scarf or vintage leather jacket. Raid your Amazon “Saved for Later” list.

Try not to miss paying bills. If you can’t bring yourself to pay them as they come in, have a little box or basket in which you toss them, and every couple of weeks ask a friend to come over and help you get through them. Or, of course, pay them online.


Drugs

After fifty years, billions of dollars of intensive marketing campaigns, and tens of billions of dollars of profits for pharmaceutical companies, it is still far from clear that antidepressant drugs are any more effective than placebo. The only group of people who have demonstrably benefited from the widespread use of antidepressants are pharmaceutical executives and investors.

Still, many intelligent and honest physicians and scientists believe that they do help some people a great deal. It’s definitely worth trying medication if you’re badly depressed. Be sure to ask about the possible side effects and investigate them online yourself. In my case, none of the drugs worked spectacularly well. Only a couple had intolerable side effects or made the depression worse. One side effect I wish I’d known about is that the SSRI (selective serotonin re-uptake inhibitors) family of antidepressants, used long-term, may cause anorgasmia. (Look it up—you’ll sympathize.) As I have been living, nevertheless, on the cutting edge of the pharmacological wing of depression therapy, here are some personal notes on efficacy and side effects.

Ativan (lorazepam): An anti-anxiety drug, one of a class called “benzodiazepines,” from its chemistry.  It’s very effective at putting you to sleep, but also very habit-forming. Helped me calm down after Prozac.

Buspirone: A somewhat idiosyncratic antidepressant-plus-anti-anxietal, whose supposed mechanism I don’t remember. Didn’t have much effect on me.

 Desipramine: This is a “tricyclic” antidepressant, a term derived from its chemical structure. It made me feel a little sluggish, but I think it worked: I gradually felt better. Very gradually, though.

Effexor (venlafaxine): A SNRI (serotonin-norepinephrine re-uptake inhibitor). Supposedly a double-barreled threat. Hopes were high, and it seemed to work at first. Eventually I fell into a severe depression while on the drug and, for some reason, blamed it on Effexor. Apart from Prozac, the only time a drug actually made me feel worse (though in this case, I’m not so sure it was the drug).

Klonopin clonazepam: Another benzodiazepine, which I took to help me sleep but didn’t find terribly effective.

Lithium: This is more often used for bipolar disease (aka manic-depression). But there’s also a long tradition of using it for depression alone. It made me pretty sluggish and didn’t help greatly.

Pamelor (nortriptyline): another tricyclic, which we went to after Prozac.

Parnate (tranylcypromine): This is an MAO (monoamine oxidase) inhibitor. I forget exactly why one wants to inhibit monoamine oxidase. These were the first class of antidepressants discovered. They’ve fallen out of favor because they involve serious (for some people) dietary restrictions: you can’t have red wine, sausage, cheese, chocolate, fava beans, and a few other things while taking MAO inhibitors or you may have a stroke.

Prozac (fluoxetine): This was the first of the SSRIs, and it more or less put antidepressants on the map. First, because there was an excitingly plausible theory of how they worked: (1) emotional well-being depends on the smooth functioning of a person’s neurons, the cells that relay information around the brain; (2) neuronal transmission is facilitated by chemical substances called neurotransmitters: serotonin, norepinephrine, and a few others; (3) sometimes neurons absorb neurotransmitters at too high a rate, so there’s not enough left to carry information; (4) if you can prevent (inhibit) this uptake of neurotransmitters, the brain can go back to functioning normally. And second, because there didn’t seem to be any side effects at first. Alas, there is a rare but dangerous one: akathisia, or intense agitation, which has in some cases (or so it’s claimed) driven people to suicide. I did get akathisia from Prozac, but not a severe case, and it subsided quickly when I discontinued the drug. In Listening to Prozac, Peter Kramer popularized the phrase “better than well” to describe how Prozac makes you feel. But when it induces akathisia—restlessness, intense agitation—it’s worse than bad.

Ritalin (methylphenidate): This is not an antidepressant but a stimulant, often given for ADHD or (sub rosa) to help students stay up all night writing papers or studying for exams. I wasn’t depressed at the time but lethargic, and the doctor thought it might give me a boost. It didn’t.

Trazodone: a non-benzodiazepine anti-anxiety drug. Not as effective but not as habit-forming.

Valium (diazepam)Still another benzodiazepine. All the benzodiazepines work, if you take enough of them. But if you do that, you can’t function very well, and you may get addicted. Just as “air fresheners” don’t actually disperse the smell but only cover it over with an even stronger (but less unpleasant) smell, benzodiazepines don’t cure your anxiety, they just make you less able to feel it.

Wellbutrin (bupropion): Another idiosyncratic antidepressant, whose mechanism is not well understood. It’s often used to supplement other antidepressants, and it’s supposed to have a benign side-effect profile—in rare cases, an epileptic seizure. I took it a couple of times because it’s supposed to counter the sexual side effects of SSRIs. Alas, I seem to be allergic to it; I broke out in a rash both times.

Zoloft (sertraline): an SSRI, which seemed to work better than anything else to date. I’ve been on and off it for the last two decades. It would wear off periodically, but at first it seemed to have no side effects. Only much later was it recognized that a large proportion of people who take Zoloft and other SSRIs over a long period find their sexual functioning impaired.


ECT/TMS/Ketamine

Like drugs, electro-convulsive therapy has helped many people over the last several decades. As with drugs, no one knows exactly why. It has been said that we are as far advanced in the understanding of depression at this moment as was the European conquest of the Americas when Columbus first set foot in the Bahamas in 1492. The conquest of depression will undoubtedly be much slower than the conquest of the Americas. Federal funding of depression research is projected to be $406 million in both 2016 and 2017. By contrast, dozens of hedge-fund managers receive more than $1 billion in annual income (on which some of them will pay the same effective tax rate as those earning $55,000, the national median income), and the Pentagon has budgeted $1.5 trillion for the Lockheed-Martin F-35 Lightning II fighter-bomber over the next several decades.

Even now, ECT is a fairly blunt instrument, but when first introduced in the early twentieth century, it was a sledgehammer. For very good reasons, patients were frightened of it. It has become much less arduous over the years: there is far less injury, discomfort, and memory loss. It used to be an ordeal; it is now only a pain in the ass. And it usually helps, sometimes dramatically. If you are in unbearable distress, you should consider it.

Besides being a logistical headache (if you’re not an inpatient, you will need a ride two or three days a week, and because you’ll usually be at the hospital for three hours or more, your driver will have to give up most of the day), ECT temporarily lowers your alertness and concentration. If you’re doing it several times a week, you may not be able to keep working. That could be disastrous for you, financially and career-wise. I was blessed with an enlightened employer and—even more important—a strong union, so I twice got to take a three-month paid medical leave. I don’t know what I would have done without them. This is one of many ways in which strong unions are a matter of life and death. There’s plenty of data proving that poverty and economic insecurity increase depression and suicide rates. There’s also plenty of data showing that the decline of (more accurately, the successful assault on) unions has increased poverty and economic insecurity.

TMS (transcranial magnetic stimulation) is a new and very promising development. A magnetic current is induced within the brain for 20 minutes or so. It’s outpatient, with no anesthetic, no memory loss, no other side effects. The disadvantages: statistically it’s not as effective as ECT; it’s done consecutively every weekday for six weeks; it’s not as commonly covered by insurance.

Ketamine, an intriguing drug with psychedelic and anesthetic properties, is the newest thing (along with another new—but also very old—thing, psilocybin) and has produced some dramatic cures. It is expensive and not widely available, but if nothing else works for you, investigate it. 


Hospitalization

As we all know, unless you can afford a medical concierge and the most expensive insurance and facilities, the for-profit, private-insurance-based health care system in the United States is somewhere between a headache and a nightmare. Inpatient mental health care is no exception. The quality of life is ultimately defined by your insurance company’s concern to avoid liability: they tend to negotiate very strict controls on hospitals, so that whatever happens, you don’t hurt yourself or others, at least in any way that could result in a claim against them. The result is a nightmare of “safety” restrictions, intrusive monitoring, and utter lack of privacy. That the food is so horrible, the environment so drab and featureless, and the staff so much like cheerful robots, on the other hand, is probably as much the hospital’s fault as the insurance company’s.

In general, hospitalization is for those who are helpless or out of control. If you’re jumping out of your skin, or conversely, unable even to speak, or if you’re actively contemplating suicide, by all means seek admittance. Otherwise, you’re probably better off in familiar surroundings.

If you are admitted, try to have friends and family check in frequently—not just with you but also with your doctors, nurses, and attendants. All patients are, in theory, special; but their overworked caregivers sometimes need reminding of that.


Suicide

Nearly every depressed person wants to talk about suicide. Apart from mental-health professionals, hardly any non-depressed people do, except perhaps as a philosophical problem (cf. Albert Camus). Depressed people want to open their hearts, to confess their fears and forbidden urges, to be comforted, reassured, persuaded that life is worth living despite this intolerable, indescribable pain. They want the other person to open his or her heart, not recite from a script. The communion of hearts is healing.

(Speaking of scripts: Mental-health professionals frequently ask severely depressed people over and over: “Are you safe/in any danger of harming yourself?” Eventually this starts sounding to many of us like “Am I (or my institution) safe from legal action if you should harm yourself?” Sometimes it seems as though “Do no harm” has morphed into “Incur no liability.” They might, as Robert Lowell once hinted, get more useful answers if they asked: “Suppose you had a little button on the back of your hand, and you could simply press it for a quick, clean, painless death. Would you? Would you ever have?”)

What one should tell depressed people, I think—tell them emphatically, authoritatively, over and over, as often as the demon of depression urges despair, which is all the time—is that if they hang on, they will eventually feel better. This is close to a scientific certainty; depressions virtually always end.

That may not be enough. As David Foster Wallace explained in a well-known and terrifyingly graphic passage, a suicidal person is a little like someone who jumps from a burning building. Sometimes the pain cannot be endured another moment; it must stop now. If that happens to someone dear to you, then for their sake, apart from all the other good reasons, think deeply about how to lessen the amount of unnecessary suffering in the world.

Whether a world that is unable or unwilling to prevent or heal intolerable pain ought at least to make it a little less harrowing and humiliating for the sufferer to exit, or even to discuss that freely, is a question I’ll leave, for now, to others.


In a Burning Building

If waves of agony and despair are rolling through you and over you; if gusts of sobbing shake you for hours; if you’re choking, burning up, speechless; if nothing matters except that the pain stop now . . . then call someone, anyone, 911.

And shame on the rest of us for letting another human being come to that. Above all, shame on the 1 percent, who by the best scholarly estimates are hiding around nine trillion dollars in offshore tax havens. That money could relieve an awful lot of unnecessary suffering. As certain hardhearted people constantly remind us, it follows from the Second Law of Thermodynamics that there’s no such thing as a free lunch. That may be true in the very long run, but now and probably for a long time to come, it’s a much harsher, hungrier world than it needs to be.


Recovery

Recovery from a severe depression is gradual. You won’t regain your full powers immediately. You’ll make a lot of frustrating mistakes, and a lot of ordinary tasks will still seem beyond your strength. Be patient with yourself. Ration your effort, and make plenty of provision for small pleasures.

The poet Sara Teasdale wrote:

For one white, singing hour of peace
Count many a year of strife well lost.

 I’m not sure I like those proportions for depression. “Many a year” sounds a little glib to anyone who’s known the worst. Still, it’s true that even a little happiness is worth a lot of pain.

The stupidest, most exasperating piece of advice commonly offered to suffering people is also the truest and most comforting: time heals. Not always, to be strictly truthful, but almost always.

One more consolation: you might think that so horrible an experience would leave you with a kind of post-traumatic stress disorder, prone to nightmares, haunted, even obsessed, by memories of torment and fears of a recurrence. It doesn’t. It takes a toll, of course. But eventually you become yourself again, released into blessed everyday unhappiness.

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