The scan results were fine.
“You have scoliosis,” the medical technician noted, eyeing the image.
“Yes, I’m aware. Thanks.”
(Pro-tip: If you’re going to say you “accidentally” swallowed a bunch of paint thinner—“‘Ingested’? Do you mean you inhaled it?” “No, I mean ingested”—at least come up with a half-decent reason you had it around. And why it was in a glass or mug or thermos or some other container a reasonable person might accidentally drink out of. And remember that reason long enough to get out of the hospital.)
Things might have gotten weird if the solvent had done any measurable damage: questions would have been asked for which I had no truthful answers. But I was fine, my lungs looked fine. I went home and tried to reconcile myself with the prospect of remaining alive.
What do you do while waiting to die? Read, or try to. You want so badly for it to end this way—apartment clean, phone off, sitting on your bed, book in your lap, glancing out the window onto light and sun and life below. But you’re impatient, easily bored: tough to lose yourself in fiction while anticipating a fatal hemorrhage. Less than an hour after ingesting fifty thousand milligrams of Aspirin, your first serious suicide attempt in years, you give up; your appetite for waiting wanes to a sliver, disappears. Self-discipline dissolved, you rise from bed, unlock your laptop, turn phone back on. Email your doctor, poor fucker, because you feel he should know and because in the vacuum of a botched attempt at death you crave even the rotest response. Call a friend, intrude on his workday, cause distress to someone you love because you need so badly to hear someone’s voice, hear someone say, “I’m glad you’re alive.” Compound that distress by refusing to go to hospital to get your blood checked or stomach pumped.
“I’m fine.”
“But what if you’re not?”
“But I am.”
“What if you pass out and don’t wake up?”
So be it, you don’t say. So much the better. You don’t pass out. The acid roils your bloodstream, rings in your ears, distorts your aural world so for the next twenty-four hours everything sounds underwater. You hold your nose and blow as though your blocked-cochlea feeling is an altitudinal problem and not a drug-induced hearing loss. You lie on your side in a chill sweat, swept with nausea, a thrumming ache behind your eyes that finally abates and leaves you drained. The ringing persists. But you don’t pass out. You still don’t die.
I was abashed at how stereotypically girly all my attempts were: Women tend to go for poisoning, as noted; sometimes suffocation; men shoot themselves or hang themselves or jump from high places. Twice a day, on my bike ride to and from Global News, where I was now working, I traversed a pair of bridges. Each time I eyed their edges, trying to calculate whether they were high enough for a jump to guarantee death. I expended brainpower wondering how to ensure I’d hit the ground headfirst; it’d be just like me to klutzily fall wrong and survive, badly injured. My depth perception and distance estimation is awful. And I am paralytically afraid of jumping from heights—cliff-jumping with cousins from a handful of metres above water was enough to freak me out.
In the seven years following my first suicide attempt I moved apartments once, changed jobs twice and tried to end my life at least half a dozen times, depending what you count as a discrete attempt. Each suicide attempt made me more reluctant to try again not because I didn’t want to die but because I couldn’t stand the emotional letdown of thinking it was all finally over only to realize it wasn’t.
I started wondering whether I really wanted to die badly enough, or whether I just kept punking myself. But the desire didn’t dissipate.
7
Know Thine Enemy
I procrastinate the hell out of everything imaginable. So maybe it’s no surprise I let my grandmother’s exhortations to write a book percolate for years without doing much about it. But I found myself continually, repeatedly, compulsively pulling out a notebook or opening a Word document and scrawling misery a few words and snatches at a time, often from bed when I was unable to sleep or unable to emerge. I began to read everything about depression and suicide that I could lay my hands on and it wasn’t enough: there was a gap in the discourse between redemptive narratives and antipsychiatry polemics and academic screeds. And found that my experience, and that of many others, falls into that wide gap.
So I started making calls—just tentatively, because I had no idea what I was doing, and because I had (and was desperately clinging to) a day job. But I couldn’t not: surely someone could shed light on this despair that buried me.
I reached out to Madhukar Trivedi, the founding Director of the Center for Depression Research and Clinical Care at the University of Texas Southwestern. He’s in the midst of a decade-long study of two thousand depressed people, tracking numerous clinical, biological, sociodemographic variables and outcomes, and he helped walk me through how the disease first hits you. “Half the people who get depressed will get their first episode before the age of thirty,” he tells me on the phone.1 “They have a whole lifetime of suffering.” He’d be the first to also tell you there is treatment out there now, and hope for better treatment soon—misery isn’t a given. But that’s a chilling thing to hear.
There is something perniciously unfair about a disease that strikes, as this one tends to, in early adulthood, just when you’re supposed to be coming into yourself as a human being. You’re poised within a world of opportunity—charging forward, flooded with plans and ideas and ambition—only to be trapped without warning in endless dark. That sense of purpose flickers back every now and then, only to be drowned out. I can’t. I can’t. It shafts your budding life partnerships, your education, your career.
Major depressive disorder starts, ostensibly, when clusters of symptoms cause serious, protracted impairment. How serious, how protracted does that impairment have to be for you to qualify as depressed? There’s no surefire way to tell. It’s easier to spot depression in its most awful extreme; far trickier to diagnose a much milder case.
“We dichotomize gradients.”2 Back in Toronto, where I live, Paul Kurdyak, a psychiatrist and the Medical Director of Performance Improvement at the Centre for Addiction and Mental Health (CAMH, familiarly known to locals as cam-aitch) has invited me to his office in an old brown-brick building close to the bustling streets of College and Spadina. The noise of the traffic and the late afternoon sunlight filters in through a west-facing window. A friendly man with dark brown hair who readily warms to his topic—I kept him talking in his office for hours and made him late, slightly, for a dinner—he balances clinical and research work and somehow manages to be insanely prolific and still piss off his own colleagues, as he did when he suggested there was little need for more psychiatrists—but a huge need for better care. I was drawn to his work on the burden of mental illness and showing the ways our system falls down on itself and fails its users, who if they’re lucky wind up right back where they started.
“We have to draw a line somewhere,” he says, “‘cause that’s just how clinical stuff works. We want to know if someone’s depressed or not depressed, so we create this threshold.” The worse your depression is, the more obvious it is you have it and the more effective the treatments tend to be. “There’s a point at which antidepressants seem to have the biggest bang for their buck, relative to placebo, and it happens to be at the more severe end.”
People in the fuzzy twilight between a mood disorder and a crappy mood state could be forgiven for thinking the whole thing’s a sham. They may not have an illness and if they do, available treatments are unlikely to help as much as they might were their illness more severe. When detractors decry antidepressants as little better than placebo, this is the patient population they’re talking about.
Who makes that call, dichotomizes that gradient? Usually the gatekeeper to care is your GP. I went to talk to Javed Alloo, a family doctor I reached through CAMH in my attempts to get a sense of what it’s like dealing daily with menta
l illness and mentally ill patients as a non-specialist, a general practitioner. He is one of the few GPs who seeks out patients with often complex mental illness, rather than the reverse. Speaking in a North Toronto food court over the din of lunch-hour rush, and the melting gelato my questions prevented him from finishing, he explains how he deals with mental illness and how he demarcates between serious psychopathology and mild mental angst. The key is function and duration, he says: How long does the shittiness last, and to what degree does it stop you from doing the things you have to do to live and to make life worth living?
“If they’re coming in to see me once every two weeks for fifteen minutes, and this is the worst expression of the anxiety in their life, their family’s not complaining to them, it isn’t stopping them from going out and doing stuff…then they don’t need treatment. Obviously, it’s not black and white. It’s a spectrum. But the question is, at what point does it become dysfunctional?” 3
* * *
—
IS DEPRESSION A NEW thing? An old thing? Is it becoming more prevalent, or are we just diagnosing it more readily? I discovered that while the more colourful and memorable depictions of mental illness tend to involve mania and psychosis, the Bible, Arab medicine, Greek mythology and centuries of European spiritual and pseudoscientific record-keeping all make reference to enduring despair beyond any external trigger. First-century physician Ishaq ibn Imran called melancholy “that feeling of dejection and isolation which forms in the soul because of something which the patients think is real but which is in fact unreal.”4
There’s a real and widespread and understandable impression that depression is everywhere and increasing. In The Noonday Demon, the early twenty-first-century’s seminal, masterfully written book on depression, Andrew Solomon describes the disorder as a malady profoundly exacerbated by modernity. Like skin cancer, he writes, “depression is a bodily affliction that has escalated in recent times for fairly specific reasons.” Where a depleted ozone layer and carcinogenic soup have made skin cancer a much more common scourge, the strain of modernity—“the pace of life, the technological chaos of it, the alienation of people from one another, the breakdown of traditional family structures, the loneliness that is endemic, the failure of systems of belief”—has driven a growing number of people to depression.5
All these things affect us in as yet unknown ways, some of them bewilderingly new. But crippling despair divorced from reality, by whichever nomer you choose, has been associated with the stress of modernity for millennia. As far back as Aristotle, sociologist Andrew Scull writes, melancholia was associated with “outstanding accomplishment”; in the sixteenth and seventeenth centuries, “melancholia became something of a fashionable disorder among the cultivated classes, an affliction to which it appeared that the scholar and the man of genius were particularly prone.” A century later, “nervous illness” became a marker of a civilized, refined individual or society, to which more supposedly primitive populations, busy with hunting and labouring and free of artifice and stress and the pursuit of excellence, were thought to be immune.6 All of these are relatives of modern-day mood disorders. All have existed for millennia. All have been associated with modernity, to various degrees, since the concept of modernity existed. So that’s not new.
There’s no shortage of literature decrying a ballooning epidemic of mental illness and depression. But population studies indicate depression’s prevalence is pretty steady, although its level varies. According to America’s pre-eminent institution for mental health research, the National Institute of Mental Health (NIMH), at any given moment about 7 percent of the American population has depression,7 which is about what depression’s prevalence was when the National Comorbidity Survey was conducted in the early 1990s;8 increasing use of antidepressants doesn’t necessarily indicate an increase in the prevalence of depression or even its diagnosis.9 World Health Organization statistics estimate prevalence at just under 5 percent globally—a number whose increase over time is in keeping with population growth and the growth in the number of older adults who are more likely to report prevalence.10 Lifetime prevalence is closer to 17 percent, which means that almost one in five people will be plunged into despondent despair at some point in their lives.
The toll is high. The World Health Organization multiplied diseases’ prevalence by the degree to which they wreck you and found depression to be the single largest contributor to disability in the world, swallowing up fifty million years lived with disability in 2015 alone.11
Suicide kills about 800,000 people a year globally but if you’re being brutalized by depression, suicide isn’t the only thing you’re at higher risk of dying from. “Let’s talk about heart disease. Let’s talk about diabetes. Depression increases your risk of dying after you’ve survived a heart attack,” Sarah Lisanby, head of translational research at NIMH in Maryland, says to me in one of multiple conversations we had as I fumbled my way through the field, and she was very understanding of my ignorance. Her job, largely, is to help translate esoteric, pie-in-the-sky cutting-edge research into new tools or insights that can be used in a doctor’s, counsellor’s or nurse’s office. Depression, she says, “worsens not only your mental health, but also your physical health. And so even though neuropsychiatric disorders are the leading cause of disability, and this has been recognized, they’re also the leading drivers of other causes of disability….The impact of depression on your health goes beyond your brain.”12
So why don’t we take this illness more seriously? In part, perhaps, because depression, as a concept, has become a victim of its own success.
While pathological despair is hardly new, “depression” as a mood disorder really emerged in the middle decades of the twentieth century, as psychiatry sought to cast off both its asylum baggage and its pseudoscientific reputation: psychiatrists were to be considered “real” doctors, treating relatively “normal” people—not confined inside mental hospitals but walking around in the world. By 1980 “depression” went from being a word primarily associated with economic downturn to a disorder warranting an entry in that doorstopper of a mental illness dictionary, the Diagnostic and Statistical Manual of Mental Disorders, and became one of the most prevalent mental illnesses in the public discourse. Throughout the ’70s and ’80s, “popular magazine readers were increasingly told that depression was something that could affect them—and that rising rates of depression were a serious national problem,” writes the psychiatrist and historian Laura Hirshbein (full disclosure: she’s my cousin). Major depressive disorder was on the vanguard of illness as “consumer product”—something you could shop and self-improve your way out of. This persistent repetition in mainstream media made depression seem a common treatable condition but also made “depression” a word used colloquially to describe a general feeling of malaise.13 This meant that having depression, the diagnosed illness, became easy to discount and easy to conflate with a ubiquitous human emotion that’s unpleasant but hardly pathological.
That’s one reason so many people fail to see depression for a real, diagnosed illness and instead see it as part of the normal spectrum of human emotion, creating a disorder where there is none, turning sick people into needy malingerers and those purporting to treat them into conniving charlatans. You can’t do a lab test for depression—at least not yet—you just sniff out its presence based on squishily subjective variables. That makes it easier to discount but no less real or debilitating.
8
Checking Boxes
For millennia, we’ve recognized the difference between “normal” sadness and crippling despair. But we’ve never been good at delineating between the two. So the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) defines depression by a list of symptoms rather than how it’s caused. Zeroing in on the causes could have revolutionized our understanding and approach to depression, but we didn’t because we’ve never known them. So you wind up with a morbid menu.1 Do you feel “depressed�
� or irritable almost all the time, almost every day? Are you less interested in stuff you used to like? Have you gained or lost at least 5 percent of your body mass? Are you sleeping way less or way more? Are you way more active than usual or not active at all? Do you have no energy? Do you feel guilty or worthless? Are you having trouble concentrating? Do you want to kill yourself?
Officially, medically, if any insurer is going to pay for your drugs and your psychotherapy, you need to check off at least five of those nine boxes—and confirm that the symptoms in those boxes cause you “clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
First of all, the above violates what I would consider Nosology Rule Number One: Don’t define something using the term you’re defining. I have depression if I’ve been feeling “depressed” every day? Rookie tautological mistake, American Psychiatric Association.
Reading these criteria after my own diagnosis made me feel like a flounder—flattened, two-dimensional, bottom-feeding. They could apply to anyone and no one, I thought. You could have two people presenting almost entirely divergent symptoms and diagnose them with the same illness. Sometimes you successfully treat depression only to discover the things you considered symptoms are actually separate illnesses that persist on their own.
Hello I Want to Die Please Fix Me Page 6