Some thoughts about living with depression

2014-05-07 14:11

A fair number of people I know have long-term depression, and it can be hard to deal with. For them, obviously, but also for me. And of course, then they feel bad because it’s hard for me and that makes them feel horrible and worthless (see also: depression). And I want to try to help.

That turns out to be hard, because the things that people usually want to suggest to help with depression don’t actually help at all. And they can even make it worse. And after a couple of recent experiences some friends have had, and written about, I thought I’d try to write up some information aimed at the people who are trying to live with someone who has depression. (Not necessarily “live in the same building”, just the people who are a part of your life.) This isn’t exclusively aimed at non-depressed people, but my experience is that they are a lot more likely to need it.

Depression is a long-term disability.

For some people, depression is temporary. That’s rare. For most people, depression is going to be a long-term disability. And there’s two key pieces of information here. First, depression is likely to be long-term. Like, life-long long-term. It may go into remission, but it’s very likely that it will also come back. Secondly, it’s a disability. Depression doesn’t just make you unhappy, it prevents you from doing things.

Mental health issues are especially troublesome in that you don’t look sick or injured. If someone’s got a badly-mangled leg, it can be pretty easy to see by looking at it that they can’t plausibly be expected to walk on that. But if someone’s depressed, you can’t tell just by looking, and the ways in which they fail to act can’t be obviously distinguished from “just lazy” or “just stupid”.

Unfortunately, this gets us to one of the most severe ways in which other people will, while doubtless meaning well, severely hurt their depressed friends and loved ones: Accusing them of being lazy. This does not help. And it’s not just that it doesn’t help; it’s that it feeds directly into the nasty feedback loop in which feeling bad about who you are makes the depression stronger and the disability more severe.

Someone pointed out: “Major” depression is fairly often shorter-term. However, this doesn’t necessarily change the claims made above. First, many people have only “not-very-major” depression. Second, even if a lot of cases are shorter in duration, your chances of encountering a longer-duration case are better simply because you have more opportunities to do so.

Depression is, very often, a physical disorder

Yes, depression is a “mental disorder”. But when we say “mental disorder”, that doesn’t mean that it’s purely a matter of cognition, and if you just did things differently you’d be fine. Mental disorders are disorders which happen in the brain, but the brain itself is a physical thing. Mental health issues are often related to chemical imbalances, and sometimes adjusting chemicals can help. But it’s very, very, rare for them to completely solve a problem like depression, and they can have pretty significant side-effects. The fact that many people will stay on an anti-depressant which eliminates their sex drive should give you some idea of just how much depression sucks, though.

Getting antidepressants working can be pretty difficult, even if they do eventually work out. Generally, assume it will take at least two weeks, and usually a month, to try a single specific dosage of a single specific medication and see roughly what it does. Each attempt to adjust the dosage will take that long again. It can take a while at a given dosage level to observe effects, or side-effects. And if you want to change from one medication to another, you may need to taper off the old medication (reducing dosage gradually over weeks), then start the new one at a low dosage, and gradually build up to the desired dosage. So you could easily spend six months without any effective/functional medication at all in order to see whether a different medication might work better. You can’t just try them for an afternoon to compare.

And, of course, something can stop working after ten years and no one knows why, but now you get to start the entire long trial-and-error process over. Are the new meds giving you insomnia, or are you just having trouble sleeping because you’re stressed from worrying about whether the new meds will work? You don’t know!

One of my friends was on medication (depression-related) which made him hypoglycemic and caused him to gain 50 pounds. Doctors, of course, told him to exercise more and “eat six small meals a day” — a course of action entirely incompatible with his disabilities. Finally he got to a doctor who had at one point actually read the list of side-effects, observed that weight gain and hypoglycemia were common side-effects, and suggested trying a different medication.

So, when you’re about to express your frustration with someone who’s depressed and is just not doing anything about it, stop and think about how you’d handle a comparably severe physical injury or disability. If you have to wheel a friend around in a wheelchair, you quickly notice how inconvenient this is. You suddenly become aware of all the stairs and escalators you weren’t thinking about before, for instance. But you tend to intuitively grasp that your friend is not being unable to walk because they’re rebellious, or just to spite you, or anything like that, so you’re not likely to blame them. But if someone’s depressed, the fact that you can’t clearly see the boundaries of what they can and can’t do may make it feel like they’re just being lazy. Only, the chances are, they’re not.

It’s true that not everyone needs, or significantly benefits from, medication. These are two separate issues; some people don’t need medication, some people would be a lot better off if there were any that worked for them, but there isn’t. Also, medication is often a very useful tool for improving things enough that someone can work on the more fundamental changes that will allow them to progress to not needing medication. So some people really will be better off without medication, or will make good progress without it; this all goes back to “this is not a simple fix that eliminates the problem”.

Ego depletion and emotional energy

One major aspect of depression is a tendency to tire out easily. Tiring out in and of itself is not unique to depression; all humans tire out in similar ways, just not as quickly. So a little discussion of how this works might help understand what’s happening with depressed people. (For another way of talking about this, you may appreciate spoon theory, which provides another nomenclature.)

The official fancy term for this is “ego depletion”. This is the general term for the thing where your ability to “force yourself” to do things gets used up. This is not unique to depressed people. In fact, it’s not even unique to humans. Dogs and cats also experience the same thing. There’s a particularly elegant experiment demonstrating this in dogs. A brief excerpt:

They had their canine participants sit and stay for 10 minutes, which seems like a very long time indeed (even for the owners). The dogs were then praised and given a treat. Then they received a toy from which ordinarily another yummy treat could be extracted, and the dogs had experience doing this. For the experiment, however, the toy was sealed and the dogs struggled in vain. The finding of interest was that after having gone through the taxing sit-and-stay exercise the dogs were quick to give up on the toy. Dogs that did not experiences the prior strain of having to stay in place were more persistent. A second experiment showed that if the sit-and-stay dogs received a shot of a glucose drink, they persisted with the toy as long as the control dogs did.

What this tells us is that something is happening when we expend mental effort to control our behavior. There is a kind of effort involved. So if you’ve had the experience of having unpleasant experiences accumulate until you just can’t take it anymore, now you know why. You’re burning through a resource that takes time to recover. And working through unpleasant tasks is one of the things that burns this resource. So’s confronting things you’re afraid of. So are lots of things. And most of us can, on occasion, reach our limits. There comes a point where I’m not tired, I’m not sleepy, I’ve just been Doing Things too long and now I need to take a break.

In depressed people, the effort required to do things is significantly higher, or the overall amount of effort available to spend is lower. (I don’t know which.) The net effect is that the amount of Do Things available is more limited. I might be able to go run three or four errands in a day; a depressed friend might be lucky to make two. I’ve known people who can apparently run errands pretty much all day, stopping only when they are physically tired from all that moving around.

There’s a secondary effect, though, which is that once you know you have a very limited budget for doing things, you tend to start conserving it. You avoid doing things you don’t really need to do, because you can run out and if you haven’t managed things like “eating” yet, that can kill you. (And yes, people do die from inability to keep up with their basic self-maintenance tasks.) And to an external observer, this can look like laziness; after all, we know you can do these things, but you won’t do them, so presumably you’re lazy. But that misses the point; what is the cost of doing them? What is the other thing that won’t get done if I do this one first?

Long-term prognosis

In general, depression doesn’t get cured. Depression gets treated, and that treatment is usually life-long. Assuming reasonable health care options (hah), people have a good shot at ending up with medication which makes them functional enough to survive, and can be pretty happy. But even with that, they’re still disabled. Most people wouldn’t take the fact that someone in a wheelchair was laughing and apparently happy as evidence that they weren’t disabled and should be expected to start running again. But people frequently take occasional moments of happiness in depressed people as evidence that the disability is gone and we can expect you to just be normal again. And again, it doesn’t work like that. And this is another way that people can be pretty hurtful, because as soon as you latch onto that happiness as evidence that the problem is solved, you’ve made that happy moment a source of guilt and stress and shame. Which usually at least solves the problem that someone is visibly being happy even though they’re disabled; they’ll stop being happy. Whee. You win.

This isn’t to say things can’t be livable, or even pretty good, but it’s really important to not spend your time waiting for them to get completely better and not be bad again. And, especially, not to place that expectation on someone who’s already probably pretty thoroughly overloaded and doesn’t need anything more to deal with.

Try to avoid the thing where someone mentions a breakthrough in therapy, or is trying new medication, and a week later you’re expecting them to be All Better. It’s not like that.

Things that don’t help.

I’ve mentioned a couple of things already, but there’s a few things I want to stress particularly that you should work hard to avoid.

  • Any variant whatsoever on “cheer up” or “you shouldn’t be depressed” or “you have nothing to be depressed about”. Depression is a disorder. It’s not intended to be, or portrayed as, a well-considered and strategically-valid response to one’s life experiences. You don’t need a “reason” to be depressed any more than you need a “reason” to have cancer.
  • Explanations about what the real world is like. The overall evidence is that depressed people tend to have a very good idea of what the world is like, and how inhospitable it’s going to be to them if they don’t magically get better. Reminding them does not help. It doesn’t help, because the information can’t suddenly change their characteristics. Telling someone who can’t walk “well, you should try walking, because you’re in front of a bus” will not help them any. This isn’t much different.
  • Accusations of laziness. For one thing, they’re false. For another, they’re hurtful. And last but not least, you are frankly completely outclassed; you cannot even hope to be nearly as hurtful and false as the things they are saying to themselves every hour of every day. Leave that to the experts, and spend your time trying to be supportive and recognizing the efforts people are making, even if those same tasks wouldn’t be hard for you.
  • Cheerful enthusiasm and encouragement can easily go horribly wrong. Be wary.
  • Talking a lot about how much frustration, pain, or stress they cause you. Again, they already know. They’d have done something about it ages ago if they could.
  • Empty praise or encouragement. Either they’ll figure out that you’re lying, or they’ll feel even worse because they’re not as good as you apparently expect them to be.
  • Have You Tried? The odds are that whatever you’re about to say will be something that they have tried, or that they can’t try. This is one of those experts-only things; if you aren’t intimately familiar with the situation you are almost certainly going to make things worse through any sentence starting this way.
  • Talking about other people who have it worse. This tends to come across as insulting. Furthermore, it’s usually based on the false premise that “depression” is about a response to your circumstances, rather than a mental disorder.
  • Explaining that the depressed person “needs to try harder”. One of the major components of depression is dysfunction in the part of the brain that does “trying”. Telling them to try harder is like telling someone to outrun the inability to move their legs.

Things that help.

(The temptation to leave this section blank was successfully resisted.)

Patience. Kindness. Acceptance. Helping out by chipping in with things you can do to help them catch up on the backlog of things they can’t do.

Some of the feedback loops that make depression toxic and dangerous can be significantly mitigated if you’re trying to do things for other people instead of yourself. I know people who are depressed who help each other out with chores, and get a lot more done than either of them could do for themselves. Even if you’re not depressed, helping a depressed friend out with some things, and asking them for favors, can result in them being more successful than they would be trying to do things for themselves.

Concrete praise for specific accomplishments can be useful, depending on the person. The problem with empty praise is mostly that, well, it’s empty.

Try not to let the depression dominate your interactions. There are going to be days when they aren’t showing much sign of difficulty, and then, hey, run with it. Try to avoid being yet another therapist when not being asked to.

How to tell whether praise is empty.

I’ve had a couple of people ask about this. And it is sort of tricky. The basic idea of empty praise is that it’s not really connected to things you’ve done. Praise for who you are may or may not really qualify, but very often does. But if the praise has no connection at all to anything you’ve done, that’s empty praise. As a quick starting point: If you’re thinking of saying something, try to imagine someone it wouldn’t be true of, or different choices the person you’re talking to could have made so that it wouldn’t be true of them. If you can’t, you’re not actually offering meaningful praise. Even if you are, it might still be sort of pointless. And if someone’s really struggling, you can have the additional problem that even things that maybe really are hard work for them will sound sarcastic if you comment on them.

If you’re not sure, usually, you are better off avoiding trying to give praise, because it’s not generally all that helpful. Note also that sometimes commenting on a thing without praising it can be more useful; “I can tell you’re really working at this” is at least as useful as “wow, you are working on that so hard! You should be proud!” and often better.

Peter Seebach

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Comment

  1. I think people often confuse depression with pessimism and grumpiness. Correct me if I’m wrong, but it sounds like depression is primarily a low-energy state, similar to a normal person having too little sleep or blood sugar. I know that I’m incredibly grumpy at night, when I’ve expended my energy and decision-making capacity for the day. Depression sounds like that, only all day long.

    One technique that a lot of people at my church are using to combat pessimism and grumpiness is once a day to make a short list of things they are thankful for. Even just one thing. Counting their blessings, as it were. It trains the mind to look for good things throughout the day, and therefore have a more positive outlook.

    Of course, that’s no cure for depression, but it might help as a palliative against some of the ancillary symptoms, and might help to reduce the negative feedback loop.

    Dave Leppik · 2014-05-08 09:11 · #

  2. Yeah, depression is more low-energy than pessimism or grumpiness. It’s also strongly characterized by a general failure of the feedback loops where doing things successfully makes you feel better, and by difficulty with the transition from intent to action.

    seebs · 2014-05-09 11:48 · #

  3. Another thought for those wanting to help: ask your depressed friend or family member if they can think of something you could do that would help. Not everyone will be able to answer—some feedback loops will make this into a “trap”, so approach with caution. But, for instance, I know I am very bad at moving to a next step—if there are papers to go through, just looking at the stack is overwhelming. But if someone is there to say, okay, first you have to sort through them. Put bills here, records to file here, junk mail and trash here, and anything else (correspondence, etc) here. Then I can do that, and go to them when I’m done and say okay I’m done. And they can say okay, now we take this pile and go to the filing cabinet and put it all away. It sounds extremely juvenile, but part of that “trying” block is that EVERYTHING requires so many decisions (down to which stack to deal with first) that the prospect is overwhelming and I just can’t scrape up the energy to do it. And the task, left half-done, will leave more of a mess than if I never start. So it goes undone. Anyway, all that to say, helping break tasks into extremely simple steps might be helpful—or not. Always, always, ask.

    — That Girl · 2014-05-09 21:43 · #

  4. A lot of good stuff here. Another possibly helpful source of information for the non-depressed to understand the depressed is the game Depression Quest.

    Jack Maney · 2014-05-23 09:16 · #

  5. I want to remark on some things here. First though; thanks. So many people simply do not take any time at all to understand mental illness. Worse is the stigmatising others for it. Then it is made worse still because a lot of the stigma are based on misinformation, lies and assumptions – extreme assumptions.

    Now then:
    “Someone pointed out: “Major” depression is fairly often shorter-term.”
    Except that major depression is a disorder itself; as in that is the name of it. I’ll not get in to this part much, but as for the criterion is concerned, it (like other illnesses of this type) is of at least a duration (it varies from illness to illness). Only some (not many) will list no more than (and that isn’t to say once the time has exceeded that it suddenly wasn’t there – it is a subtle difference). Two examples: brief psychotic disorder and schizophreniform (no, not schizophrenia; schizophreniform). That aside, depression is hardly short term. Guess what people? Major depression isn’t one of those illnesses (that define short term duration as such). Try again. In addition, anyone who has short term major depression, that never returns, probably didn’t have major depression to begin with (and if they did it most certainly wasn’t severe). This claim is mostly assumption and misinformation (and in some cases lies). In other words: these types of claims are harmful and further add to stigma (because it is also claimed that they’re lazy/selfish/other nonsense).

    “Depression is, very often, a physical disorder”
    Indeed. And schizophrenia is for a long time known as a biological disease. And other mental illnesses also involve genetics; that is to say, there are alleles associated with certain mental illnesses (I have to clarify that because some might take it as only some involve genes; they all do in some way or another even if that is simply predisposition). There’s also the fact that any one illness will make other illnesses worse; any help in one problem will help others (even if it doesn’t seem like it). More importantly, here, I want to remark on some of your other statements in this section.

    “Generally, assume it will take at least two weeks, and usually a month,”
    Generally, yes (there are exceptions, though).

    “Each attempt to adjust the dosage will take that long again.”
    Not necessarily the case; you should at least wait it out before deciding it isn’t helpful, true, but it actually depends on how the drug works (and acts). Actually, you can extend this: even if you think you’re feeling better, it might be that you’ll continue to feel better still, as the time goes on.

    “It can take a while at a given dosage level to observe effects, or side-effects.”
    True although side effects can show sooner (and see above). What you say about drugs stopping working: also very true. Unfortunate but very true. And as for your point about weight gain; yes, there’s a lot to that one and also your remark about blood is true (although it can be worse, I will not get in to that).

    “And if you want to change from one medication to another,”
    Depends on the drug and also dose (or drugs and dosages involved). But yes, there’s times you do need to do this and it is important to note that some things might seem silly, unimportant, and any other things, but some of these issues are very important and this is an example of such; so do not just disregard what you’re told by your doctor.

    “You can’t just try them for an afternoon to compare.”
    So true and so unfortunate. There’s another key thing here: while certain things can occur outside your control, if you change more than one medicine (for example) at the same time, how do you know what is doing what? This also goes, I might add, for other medical decisions unrelated to mental health.

    “In general, depression doesn’t get cured.”
    This applies to other illnesses, mental and otherwise. You only treat. Even cancer can return. Even if you eradicate something more or less, it too can return. Ebola anyone? One example of many others.

    Lastly, as for disabled or not, I want to finish with some remarks on me personally:
    I have a history of psychosis (I’ll spare the details) and this is unrelated to my also major depression (yes, depression can cause it, and yes it is certainly extreme enough to have, but we know this is not the case with me). That itself is rather enough to tell others some things I simply cannot do (some might have difficulty thinking of things but there are many things nonetheless). Yet I can laugh about pretty much everything, including things most would find rather wrong to laugh about (and worse is making jokes about, often). But more so than that, I can laugh at myself (and I do a lot of that). It is therapy. I can also (and do without fail) make others laugh, regardless of the circumstances, very easily. But make no mistake: I don’t know happiness, not at all. Neither do I know healthy. Never have. Being able to laugh is not indicative of not being depressed. Yes, being unable to laugh can be one way depression shows itself but there is not a correlation; being able to laugh does not mean you’re not depressed and being unable to laugh does not mean you are depressed. I try to remember that things can always be worse (in my case they have been by a lot) and to only worry about now; anything else will not help you and can make things worse. Perspective is hard to keep in mind but when you can it is very helpful.

    Sadly, this very truth is here though: those who would do best to understand these things, won’t care – they’ll ignore, assume and still stigmatise others. But I commend you for this. That’s why I decided to respond, truthfully. Thanks.

    — Cody · 2015-03-17 14:57 · #

  6. Im hella forwarding this to my whole clade. It is good thinks.

    A thing that can be helpful for depression is helping basic self-care be a thing. Depression is a disease that specifically attacks your ability to do things that make the depression better. So things like showing up with food and watching the person eat it, or hassling them until they get into the shower even if it feel pointless and too difficult, or making them go outside even if its only to stand by the street for five minutes, those can be lifesavers.

    — Lissiel · 2015-09-22 10:48 · #

 
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