My goal for the next post was to write about my experience in Rwanda, however, a story came out in the news this week that is important to share and discuss. Amy Bleuel, the founder of Project Semicolon died on March 24, 2017 from suicide as confirmed by the organization. Project Semicolon is an advocacy campaign meant to bring attention to mental illness, specifically depression and suicidality. It began in 2013 when Bleuel asked people through social media to draw a semicolon on their skin and post pictures. The symbolism was drawn from how semicolons are used in writing; they are not the end of a sentence, but a continuation of the author’s thought. Project semicolon encouraged those with mental illness to persevere, using the slogan, “your story is not over.” The best article I found describing her story came from the Washington Post.
As I was reading articles and comments, I came across some statements that are good for discussion and offer a chance to dive into the research literature about Depression. But I think it is important to first discuss exactly what Depression is before we dissect some misconceptions, which I will do in a follow-up post. I write it with a capital “D” because I am using it as a medical term, not colloquial and want to emphasize that point. More properly I should say Major Depressive Disorder. Very often people who do not suffer from Depression use the term to mean “the feeling of sadness,” however they are not synonymous.
Let’s start off with a pretty blunt statement: Depression is a mental illness. It is a pathological dysfunction of the brain, every bit as real and physical as a person with diabetes suffers the consequences of a dysfunctional pancreas. It can be debated whether Depression is over-diagnosed, medications are offered too easily, people confuse momentary sadness with a disease, but I assure you, Major Depressive Disorder is real. And it accounts for a significant burden of disease, both in the developed and developing world. You have encountered many people with Depression in your life, most likely without knowing it, and you will no doubt encounter more.
This link from the World Health Organization (WHO) is a quick introduction to some facts about mental illness. I encourage you to peruse both the US Centers for Disease Control (CDC) and WHO websites on Depression.
In terms of disability, depression accounts for the highest burden of disease around the world[1]. In the USA, lifetime prevalence of major depression is 17%[2], meaning over the course of one’s life, 17% of people will meet the criteria of Major Depressive Disorder at some point. Depression and mental illness in general are significant risk factors for suicide, which happens almost 40,000 times per year in the USA[3]. Suicide is the second leading cause of death for people aged 10 – 35 behind unintentional accidents such as car crashes. Over a twelve-month period, 17% of high school students seriously consider suicide and 8% will attempt.
Now that we have discussed some epidemiology, let us talk about the diagnosis and the experience of depression. There are many flavors of depression (bipolar disorder, dysthymic disorder, etc.) but Major Depressive Disorder is defined as having discrete moments in life that meet criteria of depressive episodes. These episodes include most, but not always all, of the following, and must last longer than 2 weeks: feelings of sadness, guilt, worthlessness, hopelessness; anhedonia (inability to find joy in things normally joyful), difficulty concentrating, difficulty falling asleep or staying asleep (or the opposite, sleeping all the time), weight loss (or weight gain), suicidal ideation or thoughts of harming oneself. Often these symptoms are triggered by an event, but sometimes they start randomly. The point is that these symptoms are not a normal reaction, and certainly not normal to occur randomly. In medical terms, the depressive episode is pathological. A healthy person will not suffer a true depressive episode. Someone suffering from a depressive episode is having a brain malfunction, just like a child with asthma can suffer an exacerbation due to malfunction of the small airways in the lungs. If an individual suffers a first depressive episode, they have a greater than 50% likelihood of a second occurrence sometime during his or her life. Therefore, a first depressive episode, while it should be treated by psychological and psychiatric therapy, does not necessarily lead to a diagnosis of Major Depressive Disorder, and therapy is often temporary. However, someone suffering a second episode has a greater than 80% chance of a third, and the relapse rate continues to increase with each subsequent episode[4]. These people are the sufferers who must be followed closely and with care. They may require lifelong medication and psychological therapy. They must make changes to their lives to promote healthy behaviors, both body and mind. In these people the burden of disease can be severe: Job-loss, school drop-out, difficulty with relationships, and even death.
But what does depression feel like? There are two insightful TED talks that do a great job of explaining what it is like to experience Depression. One is by a university professor who has written extensively on the topic (The Noonday Demon, winner of the Pulitzer Prize), and the other a young comedian. It takes about 45 minutes to watch them both and I hope you will give them a view.
An insightful documentary comes from the Junior Committee of the Central Ohio Chapter of the Alzheimer’s Association discussing both Alzheimer’s disease and mental illness in Columbus, Ohio.
So here is what we know: depression (and mental illness in general) is real; it is an enormous burden on our society; it is often stigmatized preventing people from seeking the help they need; it can ruin lives; and it can kill. But it is also preventable and treatable. One can even argue that Depression gives a person unique insight and perhaps a strength through suffering. I was particularly moved by stories of Abraham Lincoln and Winston Churchill, both sufferers of extreme Depression. One historian argued that Lincoln’s melancholy fueled his passion for social justice and created in him an urgency to change the nation. Churchill famously called his Depression his “black dog.” He would go through periods where he would cut himself off from the world, deeply in despair, and contemplating suicide. Then he would emerge with vigor and boundless ideas; an unstoppable force. The concept of the “black dog” materialized his depression such that he could grasp it, point to it, and blame it for his despair. The “black dog” was always at his heals, but if he made it tangible, gave it a name, he could attempt to tame it, battle it back if it went for the throat. Depressive episodes may offer an empowering space for self-reflection and perhaps lead to wisdom and strength.
Reader, I challenge you to read more about mental illness and understand its burden of disease. Know that many of your family, friends, and colleagues suffer from these diseases; and too many of them suffer silently. Mental illness is a sickness, not a weakness. If you suffer from mental illness remember Amy Bleuel and her wisdom; your story is not over.
If you are in immediate crisis, go to your local emergency room or call 911. To find mental health providers near you visit the map at Project Semicolon.
[1] Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Vos, Theo et al. The Lancet, Volume 388 , Issue 10053 , 1545 – 1602
[2] Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Arch Gen Psychiatry. 2005;62(6):593.
[3] The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. Murray CJ, et al. JAMA. 2013;310(6):591.
[4] Burcusa SL, Iacono WG. Risk for recurrence in depression. Clin Psychol Rev 2007; 27: 959–85.