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Depression in Men: Why is it Different?

Four times more men die by suicide than women, and yet half as many men are diagnosed with depression as are women (1). In researching this topic, I was encouraged by the shift our society is making towards understanding depression in men and the factors that push them to such lengths. However, there is clearly still a long way to go. A book I skimmed early on in my search, aptly titled Men and Depression, by Sam Cochrin and Frederic Rabinowitz, mentions in the introduction that “A book that examines distress and depression in men may be seen by some as politically provocative.” In 2000, when that book was published, many researchers and clinicians were working to move public perception of mental disorders in men inch by inch. They recognized that the disparity between the number of men diagnosed with depression and the number of men who kill themselves indicates a hidden population of men who battle their depression in secret. 21 years later, the number of articles under a “depression in men” search in Google Scholar numbers over 3.5 million.

As a woman who suffers from depression, I feel relatively safe in disclosing my diagnosis. People are generally sympathetic and understanding when I discuss my symptoms. But how do men feel about the way their depression is received? A man I know has been dealing with depression for a long time, so I asked him exactly that question. Thankfully, he told me that his social circles have been largely supportive, which I think is an encouraging sign for our culture’s direction. But what factors make the rates of suicide between men and women so different? If we’ve come from “politically provocative” to millions of research articles in two decades, why are many men still suffering in silence? I want to dig into this issue to understand the historical trends, what sometimes makes depression in men different, and what we can do to keep the conversation going.

Historical Epidemiology of Suicide

In a really deep dive, we could go way back to Hippocrates and Galen to explore the perceived gender divide on mental disorders, which would be interesting. But in this context, we’ll stick to the 20th and 21st centuries. Let’s take a look at this set of data from the CDC’s Data Finder (12). It’s compiled mostly by decade between 1950 and 2015. This graph of the data, which I made with my rusty skills in Excel, illustrates the suicide trends by rate among men in various age groups.

Although the rate of suicide among all ages has remained relatively stable, trends within age groups are concerning. Suicides among 15-24 year-olds have increased dramatically, as have those among 25-44 year-olds. Despite a somewhat steady decline in the suicide rate of men aged 65 and older, they remain the group with the highest rate. By 2019, the rate of suicide in men had increased from 21.1 deaths per 100,000 to 23 deaths per 100,000 (13). For every 100,000 men, 23 deaths doesn’t immediately sound shocking. But to illustrate the numbers in a different way, consider that in 2019, a horrifying total of 37,256 men killed themselves in the U.S.

It introduces another layer of complexity to compare the data on men to the data on women. The suicide rate among women of all ages has increased since the 50’s more than it has among men, but it still sits markedly lower. In 2019, the overall suicide rate among women was 6.2 deaths per 100,000 people (13). Compared to 37,256 male suicides, the country saw 10,255 female suicides. Both of those numbers are unimaginable to me, but it’s worth investigating; why is the rate for men so much higher than it is for women?

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Photo by Mykyta Martynenko on Unsplash

Diagnostic Factors

The wildly higher rate of suicides among men than in women, combined with the average 2:1 ratio of depression diagnoses in women versus men, convincingly suggests that depression in men is going undiagnosed. An increasingly accepted hypothesis regarding this conclusion is that depression in men and women can be experienced in different ways (10). The current diagnostic tools don’t capture all of the symptoms of depression that men commonly face. The gender differences in symptomatology have led some to argue for the recognition of separate depression diagnoses for men and women. Magovcevic and Addis conceptualized the differences as constituting typical depression plus a subtype, masculine depression (6). Subsequent research shows that some men who don’t fully fit the diagnostic criteria on traditional depression questionnaires may be diagnosed when masculine depression symptoms are considered.

Masculine Depression Symptoms

“Masculine depression” (also called male depression and a variety of other terms), is characterized by more symptoms of anger, aggression, risk taking, and substance abuse than tend to occur in women. These symptoms are examples of “externalizing features.” They serve to express a person’s emotions in an outward, active way. “Internalizing features” of depression are identified by retreating into one’s self, such as by ruminating, engaging in negative self-talk, and isolating from others.

New Self-Report Scales

To investigate the efficacy of adjusted self-report scales at identifying depression in men, researchers created the Gender Inclusive Depression Scale (GIDS) using two other male depression scales validated with small cohorts. When symptoms of masculine depression – the externalizing features – are included in a traditional diagnostic survey, the rates of depression diagnoses among men and women are not significantly different (7). In other words, the gender differences disappear. Another scale, the Male Depression Risk Scale (8), measures emotion suppression, drug use, alcohol use, anger and aggression, somatic symptoms, and risk-taking. The sensitivity of the MDRS is similar to that of the PHQ-9 in recent suicide attempt identification (9).

Why is Depression in Men Sometimes Different?

To be clear, it’s a continuum; many men are diagnosed with depression using traditional questionnaires. But for the ones who aren’t, the answer is probably based in gender norms. Men who have depression and who identify with traditional ideals of masculinity are more likely to experience masculine depression symptoms (4). In a society that has traditionally viewed men who express sadness as “weak” or “feminine,” it makes sense that sometimes, depression in men is displayed as anger or in attempts to cope with it through substances. Sadly, it’s more socially acceptable for men to express anger than sadness, self-doubt, or anxiety.

Photo by Jordan McQueen on Unsplash

Why is the Suicide Rate Among Men so Much Higher?

If newer diagnostic scales indicate that the rates of depression in men and women are actually more alike than previously thought, what is going on with the suicide rates? Why would men die by suicide four times more often than women? It’s hard to know how many suicides could have been prevented by mental health intervention, but it’s logical to think that men who aren’t seeking counseling or who are dismissed without a diagnosis would be more likely to turn to suicide as the answer. Additionally, we know that although men complete suicide more often than women, women attempt it more often (11). Men tend to use more lethal methods, and for some men, the act of suicide represents an affirmation of strength and independence (2). It is crucial that we improve identification and treatment of depression in men (5).

A Note on “Masculine” and “Feminine”

With all of this discussion about a “masculine” depression facet, I have a small fear that readers of this post will leave feeling as though their diagnosis of depression must have been of the feminine kind. It’s not. It’s just depression – men, women, nonbinary people – it doesn’t impose judgement on your identity, it simply is. Just as men may experience more anger and impulsivity as part of their depression, women may be more likely to suffer body image issues and self-harm behaviors. But it’s a bell curve; just because men are more likely than women to exhibit anger as a sign of depression doesn’t mean that women can’t as well. Statistically, neither gender is more closely associated than the other is with the typical symptoms (8). The only gendered difference exists in the subset of “masculine” symptoms. The core set of symptoms that are covered in typical scales like the PHQ-9 remain the main diagnostic components of what we know depression to be. Expanding the criteria by creating a subset of symptoms more associated with men is just a way of widening the net in order to keep people from falling through the cracks.

For more reading on how men can view depression, suicide, and masculinity, check out this article. The author provides evidence for a variety of views that men hold about how mental health and suicide relate to masculinity.

Identifying Depression in Men Going Forward

For a long time, our definition of depression was too narrow. The research on gender differences in depression, which I have only barely scratched the surface of, is vast and still growing. Although the standard depression questionnaires remain focused on internalizing features to the exclusion of the externalizing ones, authorities on the matter have acknowledged the issue in other ways. The American Psychiatric Association has a webpage from 2005 that describes the early research and what to watch out for in men who may have depression. They now have a number of web pages, magazine articles, fact sheets, and books about men and depression. Someday, I hope that standard depression questionnaires will include measures for symptoms that men exhibit, but until then, we can continue to reduce stigma and spread the word about how depression in men can manifest.

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Photo by Marco Bianchetti on Unsplash

You can pass online resources on to the men you know. You can talk about it with your doctor. You can listen to your friends, fathers, brothers, and sons. Assure them that having feelings doesn’t make them less of a man, it just makes them human.

Resources

  • National Suicide Prevention Lifeline: 1-800-273-TALK (1-800-273-8255)
  • Advice on looking out for friends: beyondblue.org
  • Potential symptoms and tips for self-care: texashealth.org
  • Information, resources, and community: headsupguys.org

Citations

  1. “By the Numbers: Men and Depression,” December 2015. https://www.apa.org/monitor/2015/12/numbers.
  2. Canetto, Sylvia Sara, and Anne Cleary. “Men, Masculinities and Suicidal Behaviour.” Social Science & Medicine 74, no. 4 (February 2012): 461–65.
  3. Cochran, Sam, V, and Frederic Rabinowitz E. Men and Depression: Clinical and Empirical Perspectives. Academic Press, 2000.
  4. Genuchi, Matthew. “Anger and Hostility as Primary Externalizing Features of Depression in College Men.” Psychological Sciences Faculty Publications and Presentations, August 1, 2015. https://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1223&context=psych_facpubs.
  5. Keohane, Aisling, and Noel Richardson. “Negotiating Gender Norms to Support Men in Psychological Distress.” American Journal of Men’s Health, October 11, 2017. https://pubmed.ncbi.nlm.nih.gov/29019282/.
  6. Magovcevic, Mariola, and Michael Addis. “The Masculine Depression Scale: Development and Psychometric Evaluation.” APA PsycNet, 2008. https://psycnet.apa.org/record/2008-09203-001.
  7. Martin, Lisa, A, Harold Neighbors W, and Derek Griffith M. “The Experience of Symptoms of Depression in Men vs Women: Analysis of the National Comorbidity Survey Replication.” JAMA Psychiatry, October 2013. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1733742.
  8. Rice, Simon, M, and Anne-Maria Moller-Leimkuhler. “Development and Preliminary Validation of the Male Depression Risk Scale: Furthering the Assessment of Depression in Men” 151, no. 3 (December 2013): 950–58.
  9. Rice, Simon, M, John Ogrodniczuk S, David Kealy, and Zac Seidler E. “Validity of the Male Depression Risk Scale in a Representative Canadian Sample: Sensitivity and Specificity in Identifying Men with Recent Suicide Attempt.” Journal of Mental Health, November 2017, 132–40.
  10. Rutz, Wolfgang, Jan Walinder, and Lars Von Knorring. “Prevention of Depression and Suicide by Education and Medication: Impact on Male Suicidality.” International Journal of Psychiatry in Clinical Practice, January 8, 1997. https://www.tandfonline.com/doi/abs/10.3109/13651509709069204.
  11. Schumacher, Helene. “Why More Men than Women Die by Suicide.” BBC Future (blog), March 17, 2019. https://www.bbc.com/future/article/20190313-why-more-men-kill-themselves-than-women.
  12. “Table 30. Death Rates for Suicide, by Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950-2015.” CDC, 2017. https://www.cdc.gov/nchs/data/hus/2017/030.pdf.
  13. “Underlying Cause of Death, 1999-2019 Request.” Data Table. CDC WONDER. Accessed January 17, 2021. https://wonder.cdc.gov/controller/datarequest/D76.

Fighting Anxiety with Purposeful Action

When my depression lifts, I often suffer from a kind of aimless anxiety that seems to have no discernable cause. Unfortunately, I also get anxious about how long I’ve been putting off large goals. Double anxiety. Having recently started taking Wellbutrin, I’m also dealing with the jitters. Triple anxiety. Luckily, feeling less depressed gives me newfound motivation and energy. I’ve been putting that motivation to use in an effort to calm my anxiety.

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I’ve been writing more, for one thing. I’m much more motivated to be creative when my mood is ok. And, maybe the cortisol increases my typing speed. Gotta get that words per minute rate up, right?

I’ve also been renewing my dog training efforts. I work with Stella on our daily walks to teach her polite leash walking skills. I generally let her wander the length of the leash and sniff around. She knows not to pull (too much), but I’d like her to walk at my side on command. We’re definitely making progress. In a silly-but-functional goal, I’m also attempting to train her to open her mouth on command and let me brush her teeth without her writhing around like an unearthed worm. It’s ambitious, but hey – they teach hippos at the zoo to do that. Surely, Stella is smarter than a hippo.

Tackling tasks that I’m already comfortable with, like walking the dog or writing something, is one thing. It’s a great way to distract myself from anxiety that I can’t address at the source. But tackling the anxiety that comes from avoiding something is different. When I’m anxious about something large – something that I perceive as a big step – I’m paralyzed. If you struggle with procrastination, you might relate to this. The thing is scary, so you avoid the thing, which makes you anxious because you haven’t done the thing yet, but the cycle continues. The more you avoid it, the bigger and scarier it becomes in your mind.

These are the two sides to the “big step anxiety” coin for me. There’s the anxiety of doing the thing, and the anxiety of knowing I’m putting it off. Usually, I remain inactive until the latter anxiety outweighs the former. At that point, I’m forced to examine the steps I’ll need to take in order to alleviate the discomfort of procrastination. I have this problem where I jump ahead to the end goal and get overwhelmed by all the steps in between. Even though I know that I can break it down and do a little at a time, it feels like a big commitment to get started because I know that I’ll have to do all of the hard parts at some point.

I have a lot to work on in this department, so I’m obviously not the picture of success (yet). What I do know is that in the same way that purposeful action helps me deal with general anxiety, getting started on something I’ve been putting off usually feels better than procrastinating. Having a direction to go in, as long as I can get my motivation past some undetermined threshold, is comforting. I like structure. It helps me organize myself and not do that thing where I skip to the end and get overwhelmed. (It helps a little. I always do that thing).

By procrastinating, you’re suffering both sides of the anxiety coin. Rationally, you can save yourself some stress by chipping away at unpleasant tasks bit by bit, right away. Too bad people are not always rational, and avoiding immediate pain is more attractive than choosing the benefit of the long view. So in essence, fight human nature, beat back entropy, and go conquer your goals! Boom. Fixed procrastination.

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Having Good Days with Depression

Every time I have a sudden improvement in my depression, I’m blown away by how much easier life is. When you live with something every day, you get used to it. It no longer catches your attention when your symptoms don’t stand out from the daily noise.

Yesterday, I had a good day. I called a friend, went for a run, attended a virtual writing group, and only napped for one hour! This is a dramatic improvement from recent weeks. I can’t believe that such a mundane day could feel so novel and exciting. Today, I woke up and thought, “What am I going to do today?” Not in my usual “I’m tired, every day is the same, and I’d rather stay in bed but I have to do something.” way. More of a “I could accomplish something today” way. I actually feel slightly enthusiastic about it. I’m looking forward to the near future but nothing in particular, which is a foreign feeling to me. It’s a kind of vague “the day is full of possibilities” feeling that is a dramatic change for me. I attribute this shift to a second ketamine infusion I had just a few days after my regularly scheduled infusion. The goal was to sort of trampoline-double-bounce me, and hooray – it worked!

I had a conversation somewhat recently about how easy it is to doubt yourself when you have a chronic, “invisible” condition. You might start to forget what “normal” feels like, which makes it hard to tell if you’re there or not. For instance, I often find myself questioning whether I’m being sluggish because of depression or because I’m not putting in enough effort. When you check in with yourself often (“Am I feeling better yet? Is _____ working yet?”) it’s easy to get bogged down in minute details and lost. But a sudden shift in my mood shows me that I can easily tell when I feel better. It’s a change that I notice right away. It’s somewhat validating, actually.

I also try not to dwell on the anxiety that this improvement could be short-lived. I’m accustomed to the very slow seesaw of my moods, which makes a worsening of my depression at some point in the future seem likely. It’s an exercise in mindfulness to focus on the day as it happens. Right now is pleasant and noticeably easier than just a few days ago. The future will unfold as it will, so I may as well appreciate the present.

Here are some things I appreciate: As I’m writing this, my dog is asleep with her head on my legs. I can feel her twitching as she dreams of canine life. I’m astonished at how much she helps me – how important she is to my mental health. I’m grateful beyond words for her. It’s almost noon and I am still awake, having made it several hours past my usual nap. I’m getting tired, but that’s ok. I’m going to enjoy the improvements and be kind about the symptoms that remain. I appreciate comfortable clothing, raspberry tea, and the flexibility my job provides. I recently learned that clams have internal organs but mussels do not, and I’m thankful for Wikipedia. I appreciate my curiosity, both for random facts and for how far I can go with this newly lightened mood.

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Kaleidoscope: The Ketamine Chronicles (Part 29)

Right away, I could hear my heartbeat in my ears and head, and my face seemed to be pulsating with the rhythm. My ears became surprisingly hot, but all of that faded away after a few minutes. Usually when I close my eyes, I see bizarre images, but they’re mostly distinct and recognizable. This time, there were points when I felt like I was traveling through a three-dimensional kaleidoscope – just shapes and colors that morphed together as they moved. The real world was also especially distorted this time, and once, when I opened my eyes, the wall across from me appeared to be covered in pale yellow cobwebs. There were two tiny silhouetted figures standing among the cobwebs, engaged in what looked like a silent argument. After a minute or so, one of the figures sprouted wings and fluttered away like a moth. I don’t think I’ve ever had my ketamine dreams intrude upon the real world when my eyes are open before. It was really trippy.

I don’t remember much of the internal experience, but I know that there were a ton of lines – straight lines, wavy lines, crosshatched lines, diagonal lines, lines moving away from me, and lines coming closer. Sometimes, I was looking for something among the lines, but it was always hidden out of sight. If you’ve ever seen those “deep dream” images created by Google’s neural net API, you know roughly what my experience was like this time. Here’s one I just made out of a picture of a sloth.

I had always assumed that trippy pictures like that were just weird approximations of what it would be like to be high. But no, it really looked a lot like that. Just take that image and imagine it moving, and that’s pretty much it.

There were rarely any distinguishable objects in my inner view this time, though. It was mostly just a sea of odd, moving blobs and spirals. When the lines and colors and moving kaleidoscope patterns got to be too much, I’d open my eyes briefly. I’m technically not supposed to do that, but it did serve as an effective break from my brain’s wild mishmash of subconscious vomit.

At some point, I switched my crossed ankles and was immediately struck by the sensation that my legs were melting. My bones seemed rather rubbery, and the weight of my feet extending past the footrest made me feel as though my shins were bending in the middle. I remember thinking that I felt just like a Salvador Dali clock, melting over the edge of the footrest. My whole body threatened to melt, at which point I’d slip off the chair into a puddle on the floor. It occurred to me that it would be difficult to get back to the car that way.

During my moments of open-eyed room viewing, I noticed that the door looked unusually soft. It appeared to be made entirely of clay or putty. The color was the same, but it looked temptingly squishy, like if I went over there and pressed my hand on the edge, it would just mush in on itself. Perception is so interesting. Just 20 minutes earlier, I had interpreted the same visual signals in a completely different way.

Ever since I wrote that post about water in my ketamine dreams, I haven’t had any further peaceful drowning experiences. Maybe it’s a coincidence, but I do think it’s interesting that after contemplating potential meanings of that recurring image, I no longer find myself experiencing it. What does still happen is the spreading darkness. This time, I was trying to look through a bright skylight while inky blackness approached from all around. It closed in until all that was left was a pinprick of light. Whenever that happens, my mind just switches gears and I begin a new dream-like vision.

My next appointment is three weeks from now. I think I already feel lighter, although still a little spacey. My memory of yesterday is kind of foggy, and conversations I had feel choppy and surreal. I got home mid-afternoon and promptly fell asleep. At 11pm, I awoke suddenly, wondering where I was. I had fallen asleep on top of my blankets, oriented the wrong way with my feet on my pillow. I sometimes nap this way in order to differentiate naptime sleeping from nighttime sleeping, but it was still incredibly disorienting. I managed to do all the usual things I do before bed and then crawled under the covers the right way.

I hope this ketamine infusion works; I’m feeling discouraged again. I’m tired of being tired and unmotivated. The pandemic set me back a good deal, and I find myself forgetting that I had made some good progress last winter. It just feels like I’ve felt this way forever.

If you liked this post, consider starting from the beginning of The Ketamine Chronicles, or visit the archives for month-by-month posts.

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Balloon Head: The Ketamine Chronicles (Part 28)

Before yesterday, it had been about three weeks since my last ketamine infusion. Lately, I notice an improvement in my depression in the days following an infusion, but it doesn’t last for as long as I’d like. Changing or adding a medication seems like a good option at this point. For a couple of weeks now, I’ve been battling my pharmacy and insurance for access to Wellbutrin. It’s been quite a hassle, but I hope it will be worth it.

For this infusion, I used a scopolamine patch and took cimetidine, both of which may help the effects of ketamine last longer. When we’ve done this combination in the past, I’m pretty well zonked for the rest of the day, and the experience of the infusion mostly disappears from my memory. Scopolamine makes me feel slightly off balance, and it gives me wicked dry mouth. Not just dry mouth, though – it’s also inside my nose and throat. Yuck.

Often, the first sensation I notice during a ketamine infusion is warmth in my head and neck. This is quickly followed by a sense that my head is either expanding or shrinking. This time, it was shrinking. It felt a bit like the skin around my head stayed in place, but everything underneath it was crumpling into a little tin foil ball. At some point, the feeling reversed. The warmth radiating upward evoked a strange floaty sensation, and I remember thinking that my head felt like a hot air balloon, stretching out and lifting off.

Perhaps the dryness in my mouth and throat is what led to the first image I can remember: a drab, grey fish drying out on a sandbar. Somebody came by and tossed it back into the ocean, only for it to find itself surrounded by sharks.

The fish dream did not last long, and I soon moved on to other things. Once again, numbers dominated parts of my experience. Spreadsheets, tickets, and measurements scattered throughout my brain. My mind seemed to be going a mile a minute, and interspersed with the numbers were seemingly random objects and animals that flashed into focus and then disappeared. It started to become overwhelming, so I opened my eyes a few times. After the speed and intensity of my split-second ketamine dreams, the room was suddenly, jarringly quiet and still.

Something I’ve noticed about ketamine is that when I open my eyes, everything is so blurry and unstructured that I can’t tell where the people around me are looking. It’s interesting to note how much it bothers me to not be able to read people’s expressions or body language. I don’t notice that being so crucial in my daily life because it just happens naturally for me. But when I suddenly can’t do it anymore, it’s almost like the people around me are aliens whose emotions and thoughts are completely inscrutable.

At times, quiet conversations and activity in the hallway and other room seemed incredibly loud and close. I wondered if there were people standing right over me, but when I opened my eyes, the noise stopped and the same calm, serene room greeted me. When I looked up, the ceiling tiles resembled oil paintings of pastel landscapes. I closed my eyes and was met with more odd images, many of which I don’t remember. There were translucent shrimps on the sea floor, skeletons, and a curtain made of long, interwoven strips of orange, red, and pink fabric. At one point, a sequence of images told a bizarre story. I had found two birds and put them in a cage until I could figure out what to do with them. But as I turned away, the larger of the two birds veeery slowly swallowed the smaller bird whole. WTF. I’m relieved that I managed to interpret my post-infusion notes, because what I wrote down in reference to that particular ketamine dream was “mbira dram” (bird dream). Even autocorrect couldn’t help me with that one.

I went to bed early last night, but woke up around 11pm extremely confused about what day/time it was. I had completed my whole nighttime routine before going to bed, so I just decided to not worry about it and went back to sleep. I was awoken a couple more times in the night because of how dry my throat was. It felt so desiccated that just breathing irritated it. Definitely unpleasant, but bearable if it means the ketamine works better. I was developing a headache when I went to bed, and it’s still hanging on around my right eye and forehead, but in a mild way. I had a headache after the previous infusion as well, which I had assumed was PMS. Perhaps not, though.

To try to boost my mood, we’re going to do another ketamine infusion in a few days. In the meantime, I’m going to enjoy the fact that 2020 is officially over.

Happy New Year!

If you liked this post, consider starting at the beginning of the Ketamine Chronicles, or visit the archives to find month-by-month posts.

Mental Health is More Important Than Academic Success

Growing up, I was always motivated by grades. I liked having that definitive mark to indicate whether I did well or not. Clearly, the beginnings of my perfectionistic tendencies go way back. Even in middle school, I remember carrying around a lot of anxiety about tests and grades. When I got to college, I was excited to be focusing more time on my interests – biology and anthropology – but the pressures of academia and my budding mental health issues wore me down.

Still, I was determined to do well. I had learned that I could earn good grades if I just put in enough work, even in subjects that didn’t come naturally to me. School was what I knew, and I felt tantalizingly close to the finish line. So, when I was diagnosed with major depressive disorder in the middle of my college career, I didn’t slow my progress down. Like many students, I simply forced myself to put my mental and physical health behind academic success.

At its worst, I went back and forth from my bed, desk, and class, taking naps when necessary but skipping meals and forgoing social interaction to conserve emotional energy. I thought about suicide a lot. I had several plans in mind, and I kept the worst of it from my therapist, fearing that she would force me to go to the hospital. The worst part of that potential event, in my mind, was missing class and falling behind. When I look at photos of myself from this time, I remember how forced it often felt to smile. Even on graduation day, I didn’t look happy; I just looked exhausted.

I hoped that if I could just make it to graduation and go home, I could rest and recover, and my mental health would improve. Instead, the sudden lack of structure combined with my admittedly fragile emotional state made things much worse. I tried – for months, I went diligently to therapy and attempted to pull myself out of my depression, but ultimately slipped back into suicidality. I was hospitalized for over a week, then released on condition that I do a partial hospitalization program for two more weeks.

I don’t know that all of that was caused by the stress of college. I am in my early twenties, when many mental illnesses make their presence known, so it’s possible that my symptoms would have been just as severe had I not gone to college at all. But I suspect that my perfectionism surrounding academics and the pressure I put on myself to succeed made an already risky situation worse.

When I can find compassion for myself these days, it makes me sad that I treated myself so poorly. Yes, I got a good GPA, but at what cost? To imagine anyone else doing what I did – valuing their academic success over their own life – is unbelievably sad. There is no grade that matters more than your wellbeing. I’m not exactly sure how my perspective was so narrow for so long. I knew that I could have taken a semester off – my mom suggested it, once – but I was vehemently opposed. I didn’t want to fall behind my peers. The thought of returning to campus without my friends made me anxious, and it left a vaguely shameful feeling in my chest. To take a semester off felt like a failure to me. That was my perfectionism speaking. There is absolutely nothing wrong or bad about taking a semester off. Or two. Or however many you need.

If I could go back, I would do things differently. I did love my majors – I would keep those. In fact, finding subjects that sparked my curiosity was a positive force on my mental health. Knowing that I had something to use in a career gave me a sliver of hope that was enough to let me imagine a future in which I wasn’t depressed. But two majors in four years is hard. I took a lot of credits each semester, and there was no way to avoid pairing difficult classes together. If I could go back, I would do it all more slowly. I’d take fewer credits per semester and accept that it would take me longer than four years. I’d also apply for accommodations. Beyond the assistance of longer exam times, it would have been nice to have my professors in the loop about my depression.

A lot of my perfectionism surrounding academics existed long before college, but there is something to be said for the culture that permeates my alma mater. There’s a sort of competitiveness among perfectionistic students for who can push themselves the hardest. If you say you’re stressed, people ask you how many credits you’re taking, as if your stress doesn’t count unless your course load is full. It’s not stated outright, but the general atmosphere is one of suffering-related humblebragging. If you’re stressed, it means you’re pushing yourself. If you’re not stressed, you might be slacking. Again – I love my university, and I’m proud to have gotten my degree there. People are motivated to achieve at Michigan, which is wonderful. That said, the limitless pressure to succeed can be dangerous.

Suicide is the second-leading cause of death for college-age people in the US, and its rate is increasing. Around 1,000 college students die by suicide each year. When young people are off at college, often away from home for the first time, they’re vulnerable to the prevailing ideas. Submerged in a competitive culture, it’s easy for students to believe that their future will be ruined by a bad grade. And I get it – students have plans beyond college that require top-notch GPAs. For a while, I thought that veterinary school would be my next step. Instead, my plans seemed to come to a screeching halt after college. Depression has altered my life enormously. If I could talk to sophomore me, I’d say, “I haven’t gone to grad school, but my life is not ruined.” Through the waves of depression, I catch glimpses of what really matters, and none of it is a letter grade or a GPA. I think I have a healthier perspective on life and academics now.

I sincerely believe that most of my depression is biochemical. That said, I’m pretty sure my college experience sped up the decline in my mental health significantly. Again – I don’t regret going to college, but I do think that if I had taken time to consider my innate traits, really thought about the stresses of being a highly introverted person at a university with more than 40,000 students, things might be different for me today. I did my best at the time, but I wish that I had honored those parts of myself; the quiet parts, the parts that need calm and routine, which were frazzled and burnt out after four years of high pressure. My sensory differences made the pace of life I’d chosen at university unsustainable, and by the time I graduated, I had an almost constant low level of vertigo, loud noises made me cry, and lots of movement in my visual field (like in a busy dining hall or a crowded hallway) made me disoriented.

I would encourage anyone who is pursuing a degree now or considering doing so to remember that it’s your education and your life. Everyone goes at their own pace, and what anyone else thinks about your pace doesn’t matter. Furthermore, what you think other people are thinking is likely more harsh than the reality. Taking care of yourself and your mental health is not always easy, and going against the grain takes courage. Think about the resources and environments that would support you and seek them out. Make friends who understand you, and above all, put your health first.

(There were parts of college that I really loved. The friends I made and the things I learned were priceless. Football games, waffles, fancy events at my dorm, exploring campus – there are tons of great things about college! I didn’t intend for this post to turn out so dark. It’s all about moderation.)

Watching rotund squirrels eat nonspecific trash was always fun, too.

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Changing My Depression Medication

It’s come to my attention that my depression medication doesn’t seem to be doing much. IV ketamine infusions are also doing less than they used to, unless it’s the case they they’re doing just as much but my brain is kicking its level of stubbornness up a few notches. Who’s to say what the cause is? Maybe it’s just the curse of 2020.

I got sidetracked. The point of this post is this: I’m about to start taking Wellbutrin, a medication that I tried a few years ago and really liked. I was only on it for about a week, though, because I promptly broke out in a blotchy rash that spread from my chest, up my neck, and all over my face.

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(the rash of 2018)

It seemed like a cruel joke played on me by the universe. The only oral antidepressant I’d ever tried that made a sudden, discernable difference in my depression is one that I’m allergic to.

Cut to now – I’m once again finding myself floundering in the soupy mashed potatoes of my depressed brain, looking for some way to change things. I’ve always carried a little bit of disappointment about my failed Wellbutrin trial, especially because I was taking the generic at the time. What if I wouldn’t have a reaction to the brand name version? Would it be stupid to try?

You know those prescription medication commercials that include a disclaimer like “Don’t take [name of drug] if you’re allergic to [name of drug],” and you’re like “Well, DUH”? I am now the person that those disclaimers target. To me, the risk of an allergic reaction is worth the potential benefit of taking Wellbutrin. I think it’s telling that when faced with the possibility of a rash, swelling, even anaphylaxis (unlikely), my reaction is “sign me up.”

I remember being so amazed at how motivated Wellbutrin made me feel. It was the only oral depression medication that’s ever given me that “I didn’t fully realize how depressed I was until I wasn’t” feeling. I was in my last semester of college when I took it. By that point, I had tried several medications and was struggling to get through the last few months before graduation. I was over the moon when I realized that Wellbutrin was working for me. It was SO much easier to get my work done and interact with people, even just for the few days that I was on it. When I got the rash, I stopped taking it abruptly, and the sudden changes did not do good things to my mental health. I had already been utterly overwhelmed by classwork and worn down by the near-constant suicidal thoughts that had plagued me for over a year. I canceled my trip home for spring break because I wanted to be alone, and I reluctantly started yet another combo of meds. I just remember the whole thing being bitterly disappointing. It was like Wellbutrin had swooped in, showed me how much easier everything could be, and then ditched me with the gift of an itchy, burning rash after just a few days.

So, I’ll take the chance of a rash if it means I might feel better. That said, if I let myself get too hopeful and the result is a letdown, I know I would feel incredibly defeated. I’m trying to temper my expectations. If I get a rash or if it doesn’t work, at least I’ll finally know for sure if it’s an option for me. I’ll write an update soon.

Overcoming Phone Anxiety, One Vet Trip at a Time

I hate making phone calls. A strange sort of performance anxiety makes me script it out in my mind and practice over and over with the number dialed in, waiting for me to hit the call button. I never feel ready. Eventually, I get so fed up with myself that I have to just press the button and hope that my verbal skills are adequate for getting me through the act of ordering delivery or making an appointment or whatever it is. And, they are. I’m not actually bad at phone calls. I don’t think I’ve ever had a call that validated my fear – that I’ll just forget how to talk and have to hang up after embarrassing myself with gibberish. Once I’m on the phone with someone, it usually goes smoothly. For whatever reason, the lead-up is the worst part.

I’ve had to call the vet numerous times in my two short years as a dog owner. My dog, Stella, is what you’d call “high-energy”.

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Zoomies around the couch.

She needs activity, either vigorous exercise or a long, meandering “smell outing”, as I call them. (There’s not much walking. It’s mostly smelling.) She gets into a lot of weird, wonderful stuff outside – sometimes she puts it in her mouth, sometimes she rolls on it. She plays fetch with reckless abandon – skidding to a stop or wiping out in a cloud of dust. Stella’s ability to seek out disgusting, physically risky situations is pretty incredible. First, it was giardia. Then, it was an eye infection. Then tapeworms, then another eye infection, kennel cough, a bloody, broken nail, and finally, another eye infection. Actually, this time she had an ulcer on her eye. Yowch. When I woke up and saw her swollen, watery, goop-laden eye, it wasn’t hard to pick up the phone.

I think it’s common to feel braver when you’re doing something for someone else than when doing the same thing for yourself. It’s easier to give up when the only one impacted will be you. When you’re being depended upon, either by volunteering to help or because it’s your responsibility, there’s much less room to waffle. I’ve found that in calling the vet for vaccinations, checkups, eye infections (ugh!) my anxiety is dramatically reduced because I don’t consider it an optional task. When I have to do it, I have to do it; there’s no point in waiting.

I also find an extra boost of authority in advocating for someone else. It’s like I’m calling up the vet and saying “Ah, yes. I’m calling on behalf of my dog. She… doesn’t know how to talk, so I promised to call for her.” And then it’s like I’m not even a part of the phone call. I’m just a proxy for a four-legged creature with a goopy eye.

I think I might start using that when I have to make other phone calls. I’ll just imagine that I’m calling on behalf of my anxious self, who I promised to take care of. “Yes, hello? I’m calling about Gen’s prescriptions. Yeah, she’s overthinking right now and can’t come to the phone.” I’ll be her more courageous counterpart. She needs me, poor thing.

I know people who use this tactic for public speaking – pretend you’re someone else. You’re playing a character. That way, the attention isn’t actually on you, because you’re not really being yourself. It’s an interesting little mental trick that, I’d imagine, takes a lot of commitment to pull off.

For a while, I thought that my anxiety about phone calls was because of the lack of visual social cues. It seemed like the potential for misunderstanding or blundering mistakes was higher when I couldn’t see the person I was talking to. But why, then, wouldn’t texting make me anxious? The written word is where I’m most comfortable, mostly because it gives me time to think through what I want to say and edit before I hit “send”. Maybe that advantage outweighs the anxiety of not being able to see the recipient of my words.

In any case, I hope that Stella chooses to be a little more cautious in the future. But if not, I’m prepared to call the vet for her, seeing as I’ve had plenty of practice.

A “low-energy” moment

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The Subtleties of Water: The Ketamine Chronicles (Part 27)

I’m always looking up at the sky when the water closes over me. This time, it was cold, and an eggshell-thin layer of ice formed above me while I watched. Gentle waves followed one another, freezing over the previous layer and leaving a frosty texture on the surface. Darkness spread from the periphery of my vision until I strained to see through the last window of light, the only notable image being the shadow of a person standing above me on the ice.

I didn’t put a lot of effort into remembering this infusion. I know there were graceful, disembodied hands dancing amid blue and red lines, swirls, and dots. There was more water – ripples and waves, mostly. There was a pyramid with a circle above it, which turned into a blinding white light. I’m certain that there was a lot more, but it’s faded away from me by now.

My mental health is declining. I’m not sure why. Ketamine doesn’t seem to be working as well for me, now. Every day, I have to rate my mood on a ten-point scale. It’s hard to capture how I feel in numbers. Potatoes are easier, but still not quite enough. Honestly, sometimes words themselves seem too limited. How can I describe how I feel? This morning, I woke up at 4. I got dressed in the cold – same clothes as yesterday – and went to the kitchen for some food. I walked the dog when the sun came up, but we came home quickly because of the sharp, cold air. My eyes feel heavy. Not the lids – the actual eyeballs; they sit heavy in their sockets, like wet marbles or enormous caviar. I wonder, if I tip my head forward, will they fall out? When my depression is worsening, I often notice this feeling in my face. Everything is heavy and hard to move, and I’m sure my expression is grim. I think the clinical term is RDF – resting depression face. At least my pandemic mask covers most of it.

Maybe the person above me on the ice in my ketamine dream is me. I’m on thin ice. Skating across a just-frozen lake in my wool socks at 4am. Someone else is waiting beneath the surface, straining to see through the darkness. Is she also me?

__________

My recent ketamine infusions have all featured water, and I’m often drowning in it. It’s not scary – it’s peaceful. It’s soothing. I’ve never stayed up by the surface before; always finding myself sinking into the dark, quiet depths. But this time, I was floating – pressed against the underside of the ice, trying to see through it to the person on the other side. I was curious about this person, but the darkness closed in before I could begin to unravel what was happening, and then I found myself in a different scene, which I do not remember.

I’m fascinated by this recurring theme of water, especially because in my regular life, I’m not a big fan of it.

I have sensory processing disorder, and as a young child, I flat-out refused to swim. I was overwhelmed to the point of tears by the splashing, the echoes in the pool, the temperature change from air to water, and most of all, the fear of people touching me. I eventually came around to the idea, but never enough to take lessons. So, having never properly learned how to swim, I nearly drowned at a friend’s birthday party when I was 8. I remember being uncomfortable going into the deep end, but my friend was insistent. I lost my grip on the side of the pool and began to sink. When people say that drowning is not a dramatic event – there’s no splashing or screaming – they’re right. My head tilted back instinctively as I went under, and I could see my hand, extended above me, slip under as well while the rest of my limbs flailed uselessly underwater. A panicked hopelessness overtook me as I choked on chlorinated pool water. Then, my friend’s hand broke the surface, reached down, and grabbed my wrist.

I have never felt relaxed on or in water, and it’s not just the near-drowning that explains it. The same sensitivities that kept me from participating in swimming lessons have persisted into my adulthood. I dislike the unsteadiness of water, the unpredictability of how it will splash, the feeling of water on my face. And yet, when I’m reclined in my doctor’s office, ketamine moving into my bloodstream, visions of water are soothing. I can feel the cool, constant pressure of being underwater without the anxiety or the sensory overload. I can feel myself standing on the deck of a boat, watching the foamy water beneath me leap forward and recede, and I feel peaceful. I’ve seen whirlpools, rivers, melting glaciers, and the unbelievable enormity of oceans. It’s a strange experience to suddenly realize what water might be like for other people, as those feelings are foreign to me in my waking life.

I feel as though, unhampered by the symptoms of my sensory processing disorder, I can connect to a larger, evolutionary interest in water that I am unable to find under normal circumstances. Humans have been fascinated with water for millennia. In fact, some evolutionary anthropologists believe that nearness to water supported the development of large brains – that we are, in part, the heritage of small, coastal communities of early humans whose lives revolved around the movement of water and the food within it. To this day, many island and coastal cultures retain great reverence for the ocean. When we gaze out upon a watery horizon, it is difficult to not be awed by the vastness before us. In my eye, to find our place in relation to bodies of water is akin to our struggle to find our place in the vastness of space. Questions of identity and survival are found in the depths, and I believe we carry the answers within ourselves.

My depression is a constant in my life. It is all-encompassing, lonely, and feels like drowning. I’m not one to find meaning in every dream, but the images of water that I experience during ketamine infusions have begun to feel profound. What does it mean? Certainly not that I should give in, wave a white flag and let the water crush me. Nor should I wait breathlessly under the ice, squinting as if to look through a frosted pane of glass, uncertain if I’m even above or below. Rather, I believe my visions of water are windows into the nature of the human experience. Perhaps they’re snapshots of how I feel – how depression feels to me. My mind is an ocean, and at times, it’s oppressive. I sink within myself, finding it easier to let the water cradle me as I descend than to keep swimming. At other times, I find comfort in accepting the changing nature of my illness. Like a river flowing downhill, impermanence is unstoppable, and the emotions of being a human move inexorably back and forth. When we crest the top of a wave and begin to fall down the other side, we wait for the next one, just as we take each arriving day. And when you are drowning, reach up. A helping hand may be just about to break the surface.

To start at the beginning of my journey with IV Ketamine for treatment-resistant depression, check out Part 1

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Self-Compassion When Living With Depression

I had a conversation the other day about the balance between recognizing that treatment-resistant depression is chronic and pushing oneself to do difficult-but-healthy things.

It started with a question: What advice would you give someone about dealing with depression?

Personally, I find it helpful to remind myself that depression gets in the way of my ability to think clearly. Depression brain is a liar. It makes me think that I’m a stupid, horrible burden and that everyone would be better off without me, even if they say otherwise. It makes me think that feelings are forever, and that I must be too weak to effectively change myself.

It’s really hard to change the way you think, especially when depression is sitting on you, yelling into your ear about how terrible you are. Sometimes it helps to remember that I have a disorder that skews my thinking. But that doesn’t mean that I shouldn’t push myself. It’s a difficult balance; to recognize that my symptoms explain my behavior, but they aren’t the be-all-end-all of what I do.

You know how frustrating it is when a well-intentioned but misinformed person tells you that if you’d just try barefoot ultra-marathon running or hot goat yoga at 5am, you wouldn’t be depressed? That person is inside my brain all the time, and because I know that it’s unreasonable to expect myself to just *poof* try harder and not be depressed, I’ve always struggled to write something on this subject. I don’t want it to come across in the same way that my brain talks to me, because I would never, ever talk to anyone about their depression in same the way I think about my own. My brain says stuff like this:

“Yeah, you feel pretty crappy today, and you know why? Because you only ran one mile. Maybe if you’d run THREE, you’d feel better. You only have yourself to blame.”

The example that I’d like to set as a person who writes about mental illness is something more like this:

“I still feel crappy, even though I went for a run. I’m glad I did it, though, because I know that it’s helpful – even if it doesn’t feel like it.”

That kind of thinking is really hard to implement, and I won’t lie – I’m pretty far from doing it naturally. It’s hard in part because we know that things like exercise, being outside, and social connection are helpful for depression. How much pressure should I put on myself? How much am I capable of when I’m depressed? Should I be expecting these things to “fix” me? Whenever I ask myself these questions and get bogged down in the details of how much I’m doing, my plans for doing more, why I should be doing x, y, z, I miss the obvious point.

I’m mean to myself.

I’m trying to convince myself that it doesn’t really matter how much I decide to do in miles, minutes, or step-by-step sequences. It only matters that I did a little bit more than I wanted to. It only matters that I did something because it’s good for me, not because I bullied myself into it. It’s good to set goals (or clams, if you’re being fancy) for yourself, and it’s fine to go at a pace that works for you under your current circumstances. I know that for me, I often fall into the trap of expecting myself to function at the same level that pre-depression me did. Sometimes I worry that if I don’t berate myself enough, I’ll get complacent and stop striving to improve. In reality, I know from experience that the motivation to grow returns naturally when I’m feeling better. It’s tough to believe it, but my first priority should be to treat my depression, and everything else will fall into place.

If you’re hard on yourself for not meeting your own expectations while depressed, I relate. A lot of people relate. After all, feeling bad about yourself is itself a symptom of depression. And to be clear: trying to be nicer to oneself is not advice intended to invalidate that symptom. It’s not to say “you’re doing it wrong, just be nicer to yourself”, it’s that combatting negative self-talk with positivity (or at least positive-tinged neutrality) is a strategy intended to treat that symptom.

I’m not very good at it yet, but I’ll keep working on it. Gently.