Depression: First, My Geology Metaphors  

It threatens to undo my carefully structured façade, the crumbling strata of highway roadcut, a scar where the millennia are represented together in one complete view.  Revealed are the barest hints of a fault line developing.  Manifest by my inability to keep the scaffolding intact, a break in the framework of my ego- that organized, structured part of the unconscious mind-  becomes visible, a sure sign that the layers built up over many moons, even eons of time, are about to fracture, buckle, or bend, and just like that, my bedrock will rearrange itself again.  These strata seem so rigid, ‘set in stone’, as the saying goes, but are merely the current configuration, and their perceived organization is deceivingly delicate.                                                                                                             

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This framework, designed of cellular building blocks, discarded remnants of tiny aquatic creatures culled from their shallow graves and replaced by minerals, is layered over multiple epochs.  The gap will eventually yawn to swallow that impermanent landscape, all that was built atop destroyed.  I grit my teeth and feel a seismic ripple, but I know that the most I can do now is wait and hope the overlying structures, sure signs of civilization, do not come tumbling down.  There and then I know this, too, shall pass.  My id- that instinctual aspect of my psyche-  knows nothing stays ordered forever, as entropy takes over my mind.

As a gaseous well rises, I feel it taking up more space within me, becoming lighter and expanding as it bubbles upward, freeing itself from the pockets where it lay trapped in the molten rock mantle of my super-ego, yearning skyward until inevitably issuing forth in criticism and overly judgmental oratory, breaking the barrier of poor self-realization.  In this instance it takes the form of tears and expletives founded in fear and frustration, brought about by a self-induced isolation, both unsettled by and giving rise to lackadaisicalness.

Today it is a steady stream like a mineral spring, hot and brimstone-laden, but sometimes goes bursting past that surface violently as in the form of a geyser.  The latter are understandably unsettling, occurring all at once and then gone again for a time, but the former committing some fraud in surreptitiously overtaking by degrees.  Emanating signs of distress, at first, I attempt to hide the approach, feigning ordinariness, then feel it outstrip even my rational mind, slower than one could walk, like a gently oozing lava flow spilling towards the shore, destroying barriers in its path while onlookers remain helpless to stop it.  Yesterday, it erupted in an angry spate of rhetoric misdirected at loved ones.  Vacillating from one to the other, I am able to stopper the malfeasance during my workday, but it can be contained no longer once the long day is done, my family an easy target as I know they will forgive my moody fluctuations.

More typically for me, the approach is a frozen waterfall in the mountainside or the semi-rigid hot springs ‘falls’, formed by deposits in the mineral-rich liquid, but fixed into place as it solidifies.  This is not unlike the formation of stalactites, the evidence it occurred obvious, but curiously, no one witnessed it happening.  Just as dangerous, the caverns that house those ‘rock-cicles’ are dark and yawning, and a vulnerable person such as myself, would not enjoy being trapped inside, fearing a quake causing the projections to break and impale the delicate flesh of my mind.  Contemplating the drip-dropping that leads to their miniscule growth rate and the emergent bony fingers reaching lengths so slowly it goes unnoticed, I miss the sleight-of-hand that clouds the emergence of the expanding vapor cloud, slowing the passage of time, agonizingly.  Finally, the putrid gas begins to emanate gradually as from a sticky, burping tar pit, miring an unfortunate beast in all-encompassing darkness and refusing to let loose its bonds.  The only way to escape is to grab hold a dangling vine to disrupt the force of that sticky goo.  These, verily, will be difficult to shake without assistance– a lifeline of hope.  

The geologic events described above make excellent metaphors for depression and its manifestations, as their personal experience can feel just as devastating as an act of mother nature.  People with depressive tendencies are often unable to notice their ‘darkness’ approaching, or are helpless to stop the progression.  This can lead to the feeling one is falling quickly into the abyss, or, conversely, gives rise to a gradual decline but with the perception that they are helpless to stop it.  Certainly, there are many faces of depression, but speaking from both personal experience with post-partum depression long before I ever had RA-related depression, as well as the clinical experience I have in diagnosing and treating this common mental health disorder, these are the ways I have seen it present most often.  What makes this disorder difficult to treat is patient self-realization and recognition (or lack thereof), societal stigmas against mental health disorders in general preventing people recognizing or seeking appropriate care, and the contribution from not only other medical conditions, but many external factors as well.

Depression is not uncommon in those of us suffering chronic diseases, especially those involving pain, fatigue, loss of control, and feeling complete lack of independence to be able to choose the lives we want to live.  It is often borne out of a sense of loss, even grief and/or mourning over the recognition of one’s previous health status or lifestyle passing out of existence.  Sometimes it seems to emerge from nowhere.  Once it hits, it is critical to treat immediately, because it stands in the way of healing.  Sure, it can take the typical form, crying, isolation, anhedonia (lack of interest in things normally enjoyed), but if you, the reader, have been there, you might know that it is not always so obvious.  It could affect your appetite, sleep cycle, sex drive, feelings of self-worth or any number of things.  Anything in the mind that prevents us living our lives to the fullest is potentially depression, perhaps blended with anxiety.  Fear of the future or the unknown, nervousness that people around know you have unnatural thoughts in your head, the inability to turn your mind off and get a good night’s sleep… these are all very common, but certainly not natural.

I have mentioned before, but think it bears repeating: Learning to cope with a new chronic disease can be a slow process.  Having always been one to pick up on concepts and facts quickly, coping with developing inflammatory arthritis was not even remotely in my wheelhouse, especially after I recognized this was not simply a temporary condition, like reactive arthritis typically preceded by a viral illness.

Finding myself initially in denial coping with my physical limitations, I have been through the entire five stages of grief: denial, anger, bargaining, depression, acceptance.  To be honest, this is an ongoing process.  Sometimes a setback from a severe flare or failure of med management will boot me back a stage or two.  Then there is the ongoing cycle of pain and depression I battle, which I believe independent of those grief stages.  Denial kept me from having the insight into my limitations, and continuing my life just as it had been, business as usual, only served to further my suffering.  In my fatigued state, joint pain notwithstanding, I kept to my usual schedule, poor sleep habits, and continually pushed the busy mom envelope in terms of overwork, over-commitment, and being constantly over-tired.

Ignoring the pain in my hands, starting even months before the arthritis, I kept to my typical computer usage, both at work and at home, unconcerned for my own well-being.  Despite developing tendonitis so severe that my hands would be burning at night, the tendonitis making crab claws out of once-able appendages.  I could barely grip, lift, hold and handle.  I felt my usual piano playing was making things worse, but I told myself I needed the emotional outlet it provided.  I had, after all, only in the prior 12 months, resumed routine practice and revived my slipped skills.  As a classically-trained amateur pianist, with 12 years of lessons and formal music study through a university youth conservatory in my secondary school years, it was unthinkable for me to call it quits.  I had taken a significant break during college, med school, and my early parenting years.  So I did not want to put my passion on hold again. However, I was feeling that things were reaching a critical point, and the stress of it was almost too much to bear.

When we are stressed and more depressed, we feel worse physically.  When a condition flares, that can lead to more depression.  It is a vicious, cyclical pattern.  However, recognizing that we are prone to mental setbacks affecting our progress, trying to be more realistic, knowing our limits and setting clear boundaries to reinforce those limits, are some tools that can help achieve balance.  I attempt to get more sleep, pace myself, communicate my needs to my family, and I have even asked for help from friends and neighbors.  I reached out to others with RA, sought emotional support I could not get from my family, read everything I could to learn how to live with rheumatologic illness, both from a clinical as well as a personal perspective.  These steps helped me to feel less isolated and alone, to feel that my version of depression and cycle of pain was manageable, and that if others, often with even more challenges than I had, could overcome their adversity, then certainly I could, too.  It needn’t come together in an ungainly manner, either.

Make It Personal

Particularly in living with a rheumatologic illness, you begin to doubt that life will ever be normal again, and it gets ahold of you, eats away, such that you find the very motions of life to be overwhelming.  Have you felt that?  That omnipresent dread that a storm, or stress, or lack of sleep, shopping too much, or overdoing it cooking, cleaning, folding laundry, taking a nature hike, going on a museum tour, playing a game, playing with the dog, or the kids, or any number of other triggers could be the thing that takes you out of commission for a time.  It is a horrible feeling to know that the next flare or exacerbation could take you out, unseat your emotions.  What you do next is critical to improving your wellness.

Do you:

  1. Give it time, wait out the storm, because it will subside?
  2. Call a friend or family member for a pep talk?
  3. Speak with a trusted advisor, such as a minister or counselor?
  4. Make an appointment to see your primary care to discuss treatment?
  5. Notify the rheumatologist you think the new medication is affecting your mood?
  6. Check yourself into the local ER or psychiatric ward STAT?
  7. Go on a walk, or do something enjoyable outdoors?
  8. Take a hot shower and let the tears flow, let it out?

Maybe it is one or more of the above, but perhaps the answer is not just in front of you. There is no right answer because not all ‘depression’ is the same.  Not everyone experiences the same emotions or symptoms, and while past societies might have been able to treat their brand of depression or anxiety in a ‘natural’ way- using exercise and sunlight, good nutrition, even ‘natural’ herbs or drugs- it becomes important to concurrently treat in order to achieve the best outcome for healing and living life.  I think if someone is feeling depressed, it is worth mentioning to a trusted person in your life.  Stigma is the enemy of depression.  People just might be able to ‘pull themselves up by their bootstraps’ but then, maybe not.  All too often, we hold it inside, trying to cover it up, hoping we will be able to watch it go floating by in the river of emotions we might experience on any given day.  However, as anyone who has been there knows, it feels awful to suppress those feelings.

Historical Context

Never having been a fan of history in my early years, since it was taught by rote memorization of names and facts, I had a teacher in high school who taught it in a way that it came alive, by reading a mix of historical fiction, texts and essays, and even watching historical movies about the time period we were studying.  Thus, I began to appreciate the value of this knowledge, and became a fan.  I realize how interesting history can be as relates to people, of which I am a student and teacher.  I feel that I am starting to rediscover history on a human interest level, and I find that now I often frame the things I am contemplating or trying to understand in terms of historical context.  We watch an inordinate amount of History Channel programming in our house, because it is interesting, entertaining, and educational, and I do not feel bad about my kids watching TV if they are learning something.  It is said that history repeats itself, and it is clear that this is true, comically, almost, because any student of history realizes how foolish or naive some historical figures were under the lens of modern thinking and advances.  But it is this lens that gives us perspective, and provides the frame of reference for reasons why historical figures might have erred or were unsuccessful.  At the time of the events, their folly was not so obvious to these figures.

Over the decades, even hundreds or several thousand years, there probably has been a significant shift in the incidence of, and consequently the acceptance of speaking about, depression.  It is posited by some medical anthropologists that depression was not as much of a problem in the past as it is today.  Think about it.  If our prehistoric ancestors were depressed, how might they have coped with it?  Did they have herbs or teas they used to get their ‘groove’ back?  Would most seasonal depression have been dealt a blow by the changing of the daylight hours?  Did ancient people have the luxury of falling into a ‘dark place’ with loss of a loved one, feeling themselves the victim of circumstance, or even allow a single day to go by where they were not simply grateful to be alive?  Maybe, if only very briefly.  Could they afford the time to wallow in self-pity, the freedom to sit and mope about their circumstances, the distraction of not being one hundred percent focused on their surroundings to avoid dangers and pitfalls that might be their undoing?

Depressed people would have been more likely to become the prey than the predator, and therefore, would have either become the victim of natural selection, or the genetic tendency towards mental illness would have been bred out of existence.  Finally, did they contend with feelings of inadequacy in coping with chronic disease, daily pain, fatigue, malaise, and poor sleep?  Given the lack of modern medicine, it is much less likely they suffered from chronic disease.  There is evidence they died relatively young from infections, injuries, or inability to cope with any long-term health issues, particularly if painful.  This was possibly related to lack of will, or physiologic inability to cope because of inadequate analgesics, and a greater acceptance of dying- an interesting parallel to make compared to the modern era, where death is feared and fought against mightily, where family members do not so easily accept or let go, and where the dying are not especially supported when their time has come, admonished to ‘fight’ against it, even when every fiber of their being might scream that there is no fight left.  This, of course, depends on the era, the available medicines or technology, and the skill of the healers of the time.  As I mentioned in the last blog, there are some ancient civilizations that were quite skilled in the medical arts, and it is clear that patients recovered from seemingly catastrophic injuries.

The detractors of those who see our remote ancestors as people just as likely as you and I to cope with a long-term condition and capable of becoming depressed, would say that because of their lifestyles, being significantly more physically active as they required and used every hour of daylight to pursue only those activities that would help them to survive another day, they may not have been depressed at all.  We know that exercise, good sleep, adequate vitamins and minerals, including sunlight for the production of vitamin D, are all very effective natural remedies for depressed mood.  Maybe in a well-ordered tribe with many members doing this day-to-day busy work, there might have been some opportunities for sedentary leisure time during the day, and perhaps then more time to think about what brings them personal happiness and self-worth.  Mostly, it is thought leisure was primarily how they spent their nights, only being at rest for significant periods once it was no longer safe to roam beyond the hut or cave for fear of predators, falls, or other potential dangers.  But in an ordered close-knit group, there is less opportunity to spend on one’s own inner thoughts, particularly as there were community activities requiring interactions and less likely to result in remaining isolated or avoiding personal interactions.  Modern society in developed nations, by comparison, almost allows too much free time, and too little time spent in pursuit of activities necessary for mere survival, poor nutrition despite an abundance of food, and much less time in practice of physical tasks.  Therefore, it is quite possible the prevalence of mental illness is greater now.

In more recent history, there has been a terrible stigma about depression and mental illness in general.  Some thought it was a weakness of character, evidence of witchcraft, or possession by evil spirits that lead to mental disorders.  If there has been acceptance directly related to a widening understanding of the brain, that has been more recent, but even that has been ignored and discounted by fundamentalist thinking about resilience and independence.  There are a lot of reasons for this, but at least in the last 100 years, I believe there is the assumption that overcoming adversity was as easy as working hard enough.  However, there has also been a change in the social order that has been influential.  People found that they could, with advances in industry and agriculture, live in relative isolation, and families consisted of smaller and smaller units, living in individual dwellings rather than common and communal living quarters or group of structures compared to prehistoric societies or even close-knit more modern civilizations.  Over several hundred years in agrarian regions abroad or the last couple hundred here since the early settling of America up until more recently, widely-spread family farms, ever-expanding methods of transportation, and the industrial revolution all have influenced this trend.

Once we began to spread out geographically, there was the notion that we must remain independent in everything.  While a remote family farm might be capable of economic independence, it may have been assumed that this was a sign of needing to be, out of necessity, socially, spiritually, and emotionally independent, not fulfilling the previous several centuries’ show of community support.  There were also historical conflicts that contributed, such as civil wars, economic depressions, lack of moral standards, and spy systems, that made people enemies and then resulted in failing to trust in the goodness of each other.  As such, we began to go against human nature, and even the social nature of many mammals and most species of apes.  As we become more advanced, reversing the notions about mental illness, ignoring the societal pressures of independence and self-reliance, and foregoing our inability to trust others, are all ways to fix this issue of mental illness being swept under the rug, and most of these contributing notions are, thankfully, passing out of favor the farther away we get from the last century.  Failing each other by not continuing in the spirit of the phrase ‘it takes a village’, will hopefully become a thing of the past.  It will be best achieved by demonstrating respect to all people, by supporting members of our community with a show of solidarity, organizing meals or household tasks to provide a close friend or neighbor the support they might need to get through a tough time.

 Bringing It Back Around

In my blogging or comments I make online, I must be careful.  As a physician, someone might read what I have written and think of it as free medical advice.  This is a tough spot to be in.  I do always try to remain cognizant of that, and I might be able to guide without necessarily declaring this is my medical advice.  I wanted to talk about depression because I feel it is an important topic, often left off the table in treating chronic disease.  Modern practitioners, in particular specialists, often neglect the influence of the mind-body connection, or they leave it for another specialist to address.  In primary care, I have to keep these things in mind, as my responsibility is to the whole patient as a person, and not just a particular problem or organ system.  Do not mistake my declaration of this to be an affront on other medical professionals or specialities outside of primary care.  They have their place and an important role to play.  The problem comes when the focus is on a narrow topic to address each visit, borne out of the system we have created, where insurance companies and reimbursement become the driving factor, rather than the patient.

I do not believe I am the most gifted at my profession, and I know I am not the smartest internist or primary care provider.  However, I have been told by many patients that I listen better than their previous physician(s), and I pick up on verbal and nonverbal cues that there is often something deeper than what the patient lets on.  I am known for making patients cry, but not because I’m mean or disrespectful.  Rather, the opposite is true.  I see when there is an emotional component to a physical complaint.  Perhaps that is because I have significant personal experience being a patient, have felt I am not being listened to or that my issues were not being fully addressed.  My rheumatologist gets it, and he asks about how I am getting along at work (not just out of professional courtesy or interest), how I am doing with my sleep, or if am coping on a personal level in caring for my family.  In this way, I really get a sense that he cares, that he is not just asking about my physical activity in order to lecture me about it.  He is not judgmental.  He realizes that with a systemic inflammatory disorder, I am coping with more than just arthritis, that every patient has more to contend with than just their physical wellness.

The take home message is to recognize that depression can happen to anyone, and it is more common with chronic disease.  Being on the lookout for it, or asking someone in your life to be your lookout, then being truthful about it, will allow you to seek treatment earlier and recover faster.  Life will go on if you let it, but you must know yourself well to determine the next step, whether that means you can simply emulate ancient societies and get more sleep, sun, and exercise.  Or perhaps you need to speak with your provider to seek treatment advice.  Sometimes we do not always know what is best for ourselves, but the ability to open up, not be ashamed, and to speak with someone in order to partner up and work toward a solution will eventually lead in the right direction.  That self-realization of your limitations and potential to find relief are the things that will likely allow you to heal and keep you from becoming a geologic metaphor.