According to the results of a recently published study, despite an increase in antidepressant prescriptions, treatment is rarely made available to those who need it the most. It goes on to reveal that those who do receive medication for depression don't necessarily need it. Part of this latter problem could have something to do with medical professionals' over-reliance on drug-based treatments versus a more holistic approach that includes diet, exercise, and psychotherapy. Part of it could have something to do with faulty diagnostic processes, leading to overdiagnosis of depression. Screening for depression is, after all, oftentimes conducted within the space of a few minutes via a quick questionnaire that doesn't allow for the nuances between mild depression and more serious psychological distress. Sometimes this even happens during a visit with a primary care physician. The patient mentions she's feeling blue. The doctor—not necessarily qualified to recognize full-blown anxiety or depression—offers the quick fix. Other times, it happens within the space of a single appointment with a mental health professional, after spending just 30 minutes laying out the reasons you were compelled to seek out help.
Sometimes, despite the diagnosis you're given, it's hard to know what you need, or if what you're feeling is a "normal" reaction to the regular ups and downs of daily life, or an "abnormal" reaction. After all, you can easily collect five different diagnoses from as many different doctors.
Many times, whether you really need it or not, taking medication can feel like giving in to a weakness. Like a personal failure.
That's certainly what it felt like to me. With my collection of diagnoses, I wasn't convinced that medication was something I truly needed. I attempted to rationalize: As a white, cisgendered, middle class woman, how broken could I really be? Why couldn't I just suck it up and deal with my emotions like a big girl, without the help of some overpriced chemical cocktail? And so I went on and off my medications, on and off, from my early 20s through my early 30s. I interpreted significant periods of happiness as a sign that I was too healthy to need a pill. And then I'd realize it was the pill that had been keeping me happy all along.
Six years ago, I tossed my leftover Xanax and Lexapro into my bedside trash can for what I thought was the last time. My husband and I had decided it was time to start a family and, though the existing research on the effects of SSRIs during pregnancy was thus far inconclusive, I decided it was best to go without for as long as I could, just to be safe. The clang of my pill bottles against the bottom of my bronze trashcan was like a starting bell. A new beginning. A dare. I was excited to be medication-free. I was excited to be a mother.
It took us three and a half years to get pregnant. And though I did not always manage those years with grace or aplomb, I did not go back on my meds. We were failing at so much during that time. Fertility. Communication. Our marriage. With the dare I had given myself still ringing in my head, I did not want to fail at my own attempt at med-free mental stability as well.
Instead, I started practicing yoga and meditation. I became addicted to them. The way I felt after an intense practice was its own drug, one whose effects I wanted to clutch to my chest lest it begin to dissipate. Eventually, I became certified to teach yoga and, gradually, I stopped missing my medication altogether. By the time I got pregnant, I was a walking advertisement for the mental health benefits of the practice. It was a story I could tell my students about what it could do for them. It was a story I could tell myself about the person I had become. Strong. Sane. Self-actualized.
Until—one and a half years into new motherhood—the story became untrue. My story collapsed around me.
"What is wrong with you?" my husband asked me as my arms trembled and my fingers flexed and I held my head in my hands like someone who could protect myself from what was happening, even though it was happening deeper inside me than I could reach.
"Why are you so angry?" he asked me as I walked briskly into the back room and slammed my fists down repeatedly on our new, L-shaped couch, the impact traveling its way up to my biceps, into my shoulders, but still muffled. Still better than punching a wall or slamming my hand through a window.
"What is going on?" he asked, again, as I screamed my throat raw with an enormous, unending "FUUUUUUUUCK," pacing back and forth between the kitchen and the TV room.
"What triggered this?" he asked me later on, after I had thrown things across our bedroom and rocked my dresser back and forth, slamming it against the wall again and again, finally coming to collapse onto the area rug, knees tucked into my chest, hands clutching carpet fibers, eyes hot and wet and exhausted. He didn't come to me then. He didn't comfort me. There was no hand on my back, pressed firmly against the tremulous rise and fall of my spine. There were no arms around my torso, pulling me close, enveloping me. There was only the cat, looking down at me, concerned, from his perch on the bed, a stable, steady presence. I reached my hand out for him and I placed my palm against the curve of his skull and I ran my fingers through his fur.
You would think that, after eleven years together, he would know: I don't know why I'm angry. I don't know how to label myself. I don't know what story to tell.
But he wants something he can pin it on. A means of absolving the sobbing, heaving, ugly mass of flesh that is his wife, the mother of his one-year-old daughter.
But how do I explain away something as inexplicable and irrational as depression? How do I elicit sympathy when it seems as if there is nothing wrong, except in my own mind? I can look to the things that have happened lately, the things that have caused stress, the small changes and shifts that have forced me to stretch in ways I am unused to. New motherhood. A new job, and all the pressures that come with it. But often, these feel incidental.
On NPR's "Dear Sugar" podcast, Cheryl Strayed and Steve Almond once fielded a letter from someone who habitually lied to the people in her life in order to obtain their sympathy. She spun tales of rape and loss, things that had never happened, things that were so horrific the backlash would likely be huge if she ever admitted to their falsehood.
With their typical openness and compassion, Strayed and Almond surmised that this woman was trying to create a storyline that aligned with the pain and hurt she was actually feeling. She was trying to find a way toward the compassion she needed and, short of concocting sufficiently traumatic stories, she didn't know how.
She knew how stories could absolve her.
She knew how stories could make people understand.
She knew that people needed to know why.
Once upon a time, clinicians used an endogenous/reactive model for depression. Reactive depression referred to depression triggered by obvious external sources. Endogenous depression, on the other hand, referred to depression that arose without any obvious, identifiable cause. It was generally believed to be caused solely by a chemical imbalance in the brain.
Research since then has revealed that things are not quite so black and white. More clinicians are now working from an integrative model, one that acknowledges the myriad factors that can contribute to depression, some of them internal (genetics, biological reactions to past trauma) and others external (lack of sleep, stress, loss, illness, etc.). A recent paper explains depression as a mind-body attempt to conserve energy after "the perceived loss of an investment" such as a relationship, group identity, or personal asset. Sometimes the causes are obvious to the one experiencing the depressive episode. Sometimes, they are less so.
Despite my own grapplings with what story to tell about myself, with what label to use, it's undeniable that depression has always maintained a presence in my marriage. At many points, I have been able to point to the cause: to specific communication issues within our marriage. To my anxiety about marriage in general. To income disparity. To professional failure. To infertility. To exhaustion.
But sometimes, I can't find the root cause of my anger, my frustration, and my general malaise. The depression is something I can't control, because I don't know where it comes from.
And while medication may ease the symptoms of my depression, it can't eradicate it. And even more frustrating, it can't illuminate the cause. Perhaps this—more than anything else—is why I shy away from labels and prescriptions. For others, meds are lifesaving. For me they're a mask.