For Steven, a “bender” began with a scenario like this: He would be watching a movie at his girlfriend’s apartment. Then the thought hit him: He had done something wrong at his job—or just something inadequate. Steven works in finance, in security and regulation compliance; there are always things he could have given more scrutiny.
“My girlfriend would be talking, but I wouldn’t hear what she was saying,” says Steven (who requested that his last name and location be withheld because he feared possible termination from his job). “I would just be thinking, 'You are lazy. You are stupid. You can’t pretend anymore. You are a piece of shit and you don’t have a plan.’”
He would leave his girlfriend’s place and text his dealer for an eight ball of cocaine. They’d meet at a bar. He’d snort up. He’d move through bars throughout the night, winding up at shadowy dives that are open almost until dawn. Sometimes, he and whichever woman was also around for last call would have a quickie. Then at 7 am, he would restart the motions of normal routine, even going back to work if it was weekday.
“These self-destructive patterns, they are comforting in the moment,” Steven says. “A hundred times over: escapism and numbing.” He kept this up for spats of three of four days until his bank account ran dry. If his girlfriend found out, that was good—even altruistic—in Steven’s warped view: He was convinced he was worthless and “the greatest thing I could do for her was prove she shouldn’t have a lover like me,” he says.
Steven experienced a particular kind of depression known as "agitated depression" that isn't signaled by the slumped shoulders, flat faces, and placid sitting in an armchair seen in the “before” part of commercials for antidepressants. Instead, agitated depression manifests as a continual state of unrest, often with insomnia and suicidal thoughts, and sometimes the onset of psychotic symptoms.
Those with agitated depression experience the intense hopelessness and self-criticism that are hallmarks of major depression. But instead of being ground down into inactivity and passivity, they are sparked by an impulse do something, anything—even acts of self-destruction—to react to the discomfort and dodge the pain. The response can range from shuffling around in a room in a huff to rock star-like drug and alcohol binges.
“A lot of times, the agitated piece vastly overshadows the depression piece,” says Alex Dimitriu, a psychiatrist and sleep medicine specialist at Menlo Park Psychiatry and Sleep Medicine in the San Francisco Bay Area. “They can’t stand still and they are amped. This person also reports low mood and depressed mood. This can be a critical moment: The agitation is screaming for attention. They can’t sleep. They can’t stand still. That freaks people out.”
Psychologists and the compilers of the Diagnostic and Statistical Manual, the American Psychiatric Association’s bible for defining mental illnesses, have waffled about how to define agitated depression and similar terms. Agitated depression, or “melancholia agitate,” was once described as a “mixed state,” in which some symptoms of depression exist with those of other psychiatric ailments, but it’s since been axed from the DSM.
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Agitated depression does not respond well to common antidepressants and shares traits with bipolar disorder, including racing thoughts and spurts of determination. Some psychologists feared mistreatment and misdiagnosis by putting its symptoms firmly under the major depression banner. Yet awareness of agitated depression as a subtype of depression continues among mental health professionals and appears everywhere from the medical literature to best-selling celebrity memoirs.
As Bruce Springsteen wrote in his—surprisingly frank—2016 memoir Born to Run, “I had an attack of what was called an ‘agitated depression.” Springsteen describes a time in 2014, when he was touring behind the album High Hopes. “During this period, I was so profoundly uncomfortable in my own skin that I just wanted OUT. It feels dangerous and brings plenty of unwanted thoughts. I was uncomfortable doing anything. Standing…walking…sitting down…everything brought waves of an agitated anxiety that I'd spend every waking minute trying to dispel.” Springsteen wrote that he “was not hyper,” but “too depressed to concentrate on anything of substance.”
As a man in his 60s, the Boss is among the types prone to agitated depression, says Melissa Deuter, a psychiatrist in San Antonio and author of Stuck In the Sick Role: How Illness Becomes an Identity. “When I see a 60-year-old who seems agitated, I wonder how long it has been building up,” Deuter says. The agitated symptoms tend to accumulate in the psyches of those “who might not be comfortable being sad,” she says. Men, particularly those from cultures and eras where mental illness is stigmatized, might funnel their depression into irritation and rage, having never developed other psychological release valves.
Agitated depression is also prevalent among people with motivated personality types. “For people who are activated by mood, that increased energy can turn into a negative direction,” says Gianni Faedda, a psychiatrist at The Mood Disorders Center of New York who has written about the evolution of psychiatry’s understanding of unconventional kinds of depression. “One woman [I treated] felt like there was a wolf in her body.”
Steven says that he felt “wired to self-destruct” from a young age. “I’ve thought about killing myself every day since age five,” he says. This was not caused by a negative experience; he says he had a normal childhood. “I think it’s just brain chemistry.” But he’s never been one to mope. Instead, as an adolescent, he punched walls and smashed objects.
As an adult, the rage was focused inward. He was unable to forgive himself for flaws and social transgressions. He was once out drinking with a female friend and made “a joke that referenced her body.” They got into an argument. He got defensive. Instead of calling to apologize, he contemplated suicide for days after. “I was incapable of doing anything else besides picturing her wanting me dead,” he recalls. “I spent a whole week picturing my own suicide.” And he self-medicated with drugs and alcohol. Now in his early 40s, Steven has stabilized with the help of therapy and a network of understanding friends. “I’ll be in therapy for the rest of my life,” he says.
For clinicians, agitated depression presents challenges: First, they have to rule out bipolar disorder, a.k.a. manic depression, which can also include symptoms of high energy, sleeplessness, and loss of touch with reality, with depressive episodes of low energy and motivation. The key difference is that bipolar disorder is defined by rotations between highs and lows. Agitated depression is unipolar and manifests as one package of symptoms, but it can look a lot like a stage of bipolar disorder.
Faedda says it’s important to look at patient history, which he says is a dying art amid the trend of 15-minute psychiatrist visits for medication management. “We can distinguish mental illnesses based on their course,” he says. “I need to ask what was happening two years ago because two years ago, you may have been presenting differently.”
Selective serotonin reuptake inhibitors (SSRIs), most commonly prescribed type of antidepressant, can be hazardous in cases of agitated depression. Suicidal ideation is an adverse effect of many. For agitated patients, already at greater risk for suicide, this effect may push them to attempt the act, Dimitriu says. “Some of these medications improve energy levels because they improve mood,” he says. “You have the energy to take action.” That makes him cautious to take out some of the more common tools in a psychiatrist’s belt—Celexa, Paxil, Lexapro, Zoloft, Prozac—for an agitated patient.
Deuter says that older types of antidepressants, like monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants, may be more useful. Tricyclic drugs are particularly helpful because their main mechanism is a mood stabilizer. For agitated patients, there is probably a long road with multiple coping strategies ahead. “There are therapy support groups, lifestyle changes, and self-care,” Deuter says, adding that exercise and heathy eating in particular can boost the body’s regular emotional regulation systems. Agitated depression is not an easy or pleasant condition, even by the standards of depression.
“When someone reaches that level, they probably cross from mild [depression] to moderate and severe,” Deuter says. “By the time someone looks agitated, they’ve probably developed a severe mental health problem."
Now in his early 40s, Steven said it took some time to understand he was experiencing depression.
He once described feeling of guilt over not being prepared for a meeting to a friend as “intense self-hatred.” “She told me, ‘That’s depression. That’s what depression makes people do: only see the bad things about themselves and none of the accomplishments.’”
Steven has stabilized with the help of therapy and a network of understanding friends. “I’ll be in therapy for the rest of my life,” he says. His conclusion? “Depression isn’t sadness. Depression is rage. It starts off with being pissed at yourself. To deal with that, I got drunk and banged a stripper. I had to take a lesson and I decided that was not the kind of thing I could keep doing.”
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