A short drive up a dirt road after a long drive up a canyon, there is a cabin in the woods. Inside, there is a sleeping dog–wearing her coat of all-black fur, resting on her side, one upright ear has flopped over. She has sniffed every inch of this cabin since we arrived yesterday afternoon. Her job complete for now, she allows herself a brief intermission to do what puppies do– nap soundly and sweetly.
I am sitting in an armchair near the sleeping dog. I came to the cabin for a short reprieve, to escape the relentless tide of life’s obligations. Most of them, I left behind. But one, I can’t seem to shake. A black dog followed me up here, and not the one at my feet. It goes where I go, does what I do. It can be menacing and imposing, or familiar and safe. This black dog is of my brain’s own creation, made from worry and sadness and guilt. It was set in motion before I knew of its existence. It came from faulty neurotransmitters, genetic predispositions, and the fickle imaginings of chance.
The black dog at my feet jolts awake — a noise on the stairs. It is only the cabin creaking, so she returns to her slumber. We both settle into the peaceful sounds of the woods. A duck laughs on the pond. Swallows swoop and chirp over the water, plucking mosquitos from the sky. A gurgling brook feeds the pond, and its sound is a balm to a worn-out mind. But a balm cannot evict the black dog of depression. It howls its objection, then herds me back to bed, nipping my heels with fatigue and foggy thoughts. As I sink into sleep, I know that soon, my other black dog will come to wake me. She will breathe on my face and wag her tail. She will tell me that it’s time to get up, time to go out, time to take in the sounds and smells of this short reprieve in the woods.
I have an appointment coming up with my psychiatric nurse practitioner, and that means my thoughts frequently settle on the effectiveness of my mental health treatment. By now, I’m familiar with the questions she’ll likely ask me, but somehow the answers never come easily. Determining how I feel is not something I’m very good at, although I’ve gotten better at it. This time, I’ll attempt to describe the seemingly endless plateau of “meh” on which my mood currently resides. I have occasional dips into the dark chasm of “really bad,” but for the most part, things are ok. But as I decided after I was released from the hospital, I’m not settling for “ok” this time. I want to feel great, exuberant, joyful, even- happy. Happy would be good.
At this point, it seems like I’m running out of viable mental health treatment options that come in pill form. I was told I was a candidate for and encouraged to try Electroconvulsive Therapy (ECT) while in the hospital (a treatment that has changed immensely since it first began). My mother’s worried googling turned up IV ketamine as a promising treatment that my psych NP also encouraged. I knew people in my partial hospitalization program that moved on to do Transcranial Magnetic Stimulation (TMS). These are all safe treatments that, if they work, can change your life for the better. So, why am I so resistant to the idea?
I think it comes down to acceptance. When I first became depressed, it took me a long time to get to a place where I felt comfortable taking antidepressants. I clung to (and sometimes still do) the idea that if I just tried harder, all my problems would be solved. This is because, like many of us, I’m way too hard on myself. But it’s also because it was scary to fully accept that I have an illness that can’t be overcome through sheer force of will; a fact that my biochemical imbalance predetermines. On one hand, taking responsibility for your mental health is an important part of managing it. On the other, there’s an element of frightening imposition that comes with accepting that the very fact of your diagnosis is out of your control. I carry my depression around with me- not by choice or through lack of effort, but because its complex tangle of symptoms, neurological effects, and genetic alterations are not things I can leave behind.
Despite coming to terms with the apparent chronic nature of my depressive episodes and the fact that right now, I need antidepressants, I see this next step in mental health treatment options as Phase Two of my personal acceptance hurdle. It was tough to accept that I needed antidepressants, and now it’s tough to accept that I may benefit from another level of psychiatric treatment. I like to mull things over for a very long time, so until or if I decide to make that leap, I’m just considering it.
This guest post was written by the wonderful blogger, Just M.
⚠️Tw – suicide⚠️
“You can’t love someone else until you love yourself.”
I’m calling it.
I’m calling bullshit.
I’ve always hated this quote but as years go by I dislike it more and more. I’m aware that people use it as an insensitive to be kinder to ourselves and that, in itself, is a good thing but I don’t like the quote and here’s why.
For many people with mental health issues, like myself, loving yourself can feel like a colossal task. Many mood and anxiety disorders can be rooted in low self esteem, and if not, it can still cause you to feel pretty bad about yourself.
I struggle with depression and anxiety and I know that loving myself is something that I’ve not quite mastered. When you’re ill, self hate is often easier than self care but that doesn’t mean I’m not capable of love.
One thing I can always hold onto, even in times of terribly low self esteem, is that I’m a very loving person. I have a huge capacity to love stuff. People, animals, films, music. You name it, I probably love it.
Because I over think, I over feel. And because I over feel, I over love. I love with a fire, with a strong and powerful spark and I think this is why I get so angry when I hear this quote.
I also know many other people in my life who are extremely affectionate and also extremely ill. They can co-exist. It’s not impossible to be unwell and loving at the same time.
You can take my word for it, but I imagine you would like some evidence so I’ve got a story for you.
Not too long ago, I had my second suicide attempt. I took an overdose of paracetamol. I went to the shops before school to buy a couple of boxes of pills and when I got out of the shop I was determined to die. My mind was on one thing, escaping. I was speed-walking to school when I was distracted. A small black and white cat was sitting on a wall. I love cats. So I stopped to pet it. Even in this moment, knowing what I was going to do, I had capacity to love.
I was at crisis point. I was on the edge of the cliff. I was on what I thought were my final hours. I stopped to love. I stopped because that’s who I am. I stopped because I could. And I’m glad I did.
It’s something that I didn’t even have to think about, I naturally did it and moved on. It didn’t stop me overdosing. It didn’t even really slow me down. But after I had taken it and survived it, it proved to me something that I already knew.
It doesn’t matter how ill you are, how down or useless you feel, how badly people treat you. You can always love.
M xx
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Did you know that immune changes are associated with Major Depressive Disorder? Let’s dive into what scientific research says about how depression affects immune system function.
Lately, I’ve been fascinated by the research on depression and immune system function. Perhaps you’re more in-the-know about this topic than I am and this doesn’t surprise you, but I was shocked to learn that not only do there appear to be measurable changes to the immune system with Major Depressive Disorder, but there are also numerous studies on it dating back decades. This isn’t a fringe area of research! Let’s take a look at how depression affects immune system function and what it means for people with depression.
The Evidence: T Cells and Depression
Photo frombodytomy.com
T cells are a kind of lymphocyte, which are themselves a type of leukocyte, or white blood cell. Lymphocytes are involved in what’s called adaptive immunity; they use molecules on other cells – the body’s and invading pathogens – to recognize foreign material and defend against it. Kinds of lymphocytes include T cells, B cells, and Natural Killer cells. Different types of T cells perform different roles, such as “helper” cells (Th- cells), “regulatory” cells (Treg cells), and cytotoxic cells. CD4 and CD8 (which refer to markers on the cell surface) are the two main categories of T cells. CD4 T cells are mainly helper cells, and CD8 T cells are mainly cytotoxic, meaning they mount direct attacks against invaders.
Both main types of T cells, CD4 and CD8, have other molecules attached to their surfaces. Some are receptors that grant the cell access to infections; two such receptors are known as CXCR3 and CCR6. Antidepressant-free patients with MDD have been shown to have significantly lower expression of both receptors on both types of T cells. The same study also found a significant trend in MDD towards fewer Natural Killer cells, a finding that was corroborated in another study.
Research has shown that T cells have a neuroprotective quality. T cells migrating to the brain can reduce stress, promote neurogenesis (growth and development of nervous tissue), and reduce inflammation. Study after study have found inflammation, changes in immune cell composition, receptor alterations, and gene expression changes associated with Major Depressive Disorder.
Causes and Effects of MDD Immune Changes
All of these changes are fascinating in themselves, but are they the results of depression, causes of it, or some intermediary factor?
The Sickness Behavior Hypothesis
Some researchers view depression as a maladaptive result of what’s called “sickness behavior”. Sickness behavior is a vertebrate trait that, through behaviors like somnolence, anhedonia (loss of interest or pleasure), and reduced or no eating, conserve energy that can be directed towards fighting infection. Researchers have presented evidence that both sickness behavior and depression are mediated by pro-inflammatory cytokines– proteins that act in cell signaling roles. These two observations- depression and sickness behavior share symptoms as well as mediators- led to the following hypothesis. Depression is the alternate, maladaptive pathway of molecular processes that, on the other pathway, lead to sickness behavior. Under this hypothesis, the depression pathway leads to neurodegenerative changes that make repeated episodes more likely. Adding that to other research that shows a link between sickness behavior and major depression, and a fascinating picture emerges.
Approximately 60% of people with MDD who experience a single depressive episode go on to have a second episode, and about 70% are likely to experience a third episode. Similarly, having had three episodes increases the chances to about 90% that a fourth episode will occur.
Functional Consequences
Biochemically, these changes are significant. Functionally, do they affect the people who have them? The answer may be yes. One study found a 59% increase in the risk of infection following one depressive episode. The increases weren’t linear, but the risk did go up again after the fourth episode. In addition, among college students, poor mental health is correlated with acute infectious illness.
Fortunately, treatment with antidepressants, if effective for depression, also returns T cell subsets to normal ratios. Differences in the subset ratios between those who responded to treatment and those who didn’t may help determine the chances of efficacy for a particular patient with antidepressant treatment.
I was recently flipping through a journal and came across the first poem. I remember writing it. I was sitting on a bench outside, feeling utterly defeated by depression. I had gone for a walk on a trail I’d paced a hundred times, but felt foreign on the path and in my own body. Everything heavy, I sat on a bench and looked numbly at the world around me. All the parts of being outside that I love the most- the sun, the animals, the plants- seemed wrong. The sunlight was flat, the grasses moved unnaturally, and the birds seemed oblivious to my presence- as if I had already faded away.
These days, I still walk the same trail. Sometimes it feels like a chore, and sometimes it feels just right. I listen to the meadowlarks sing and the prairie dogs yip, and moving forward is easy. One foot in front of the other, I let the motion of my legs carry me without a thought. Other days, the weight of depression demands my attention. When that happens, and I’m overwhelmed by the sense that I shouldn’t be here- I shouldn’t be anywhere- all I can do is breathe, and wait for another good day.
It seems that every stage of depression recovery comes with its own tortuous fear.
I’m depressed, and I’m afraid I’ll feel like this forever.
I’m depressed and can see recovery in the distance, but I’m afraid I won’t be able to handle it. What if I don’t even know who I am anymore?
I’m less depressed, and I’m afraid that if I give myself a break, everything will fall apart again.
I feel good, but I’m afraid that my depression will come back at any time.
I’m less depressed, and I’m getting out of the house and going for runs and doing yoga and going for hikes and doing the shopping and talking to neighbors and making appointments and I’m terrified. I’m terrified that if I stop even for a second, everything will fall apart. I’ll be right back where I started, in the deep nothingness of depression.
I wish it were easy to maintain balance; add a sprinkle of joy on this side, toss in a handful of rationality over here. But entropy won’t allow it, and neither will the laws of inertia. If an object at rest stays at rest, I must keep moving.
Except- there are outside forces acting on this object. I cannot keep moving indefinitely. Eventually, I must rest. Then, when I’ve replenished my energy, I’ll move again, each time becoming more and more balanced.
There’s a plateau that I always seem to hit in my recovery from a bout of depression. Since the first time I became depressed, I don’t think I’ve ever gotten past the plateau. I call it “Depression Limbo”. Here’s what I mean:
Depression Limbo is an in-between place where things aren’t terrible, but they’re not great, either. Because you’re not in the pit of darkness, it’s easy to think you’re doing alright; and you are- comparatively. Things aren’t great, but they are ok. This makes it hard to find the motivation to pull yourself out of Depression Limbo. You think “this isn’t so bad. I can settle for this.” And that’s where it gets dangerous. Depression Limbo is flat, so you have no idea how close you are to the cliff and, therefore, to crisis. You could be anywhere along the plateau, but it all looks the same.
I’m in Depression Limbo. It’s a familiar place; I’ve been here several times before. I can laugh again. I’m enjoying my hobbies. I’m exercising again. I’m tempted to say it’s good enough, but I know that that’s risky. I’m tired all the time, I don’t really want to eat, and I tend to be trapped in my routine. This time, I won’t be settling for “good enough”. I’m going all the way to the top.
Love, Your Brain 