What do you say to people who ask if you’ll eventually stop taking medication?
“I say to people that they don’t expect a diabetic to stop taking insulin, or someone with a heart condition to stop taking blood thinners. I have a chronic, lifetime disease and the only responsible thing for me to do is stick with my medications.
People wonder about medications’ long-term effects on the brain. I explain that while the medications’ effects appear to be reversible as soon as you stop taking them, the long-term effects of having repeated depressive episodes appear to be absolutely dire. There is lesioning of the hippocampus, and brain cells die. And this is in addition to the havoc that such repeated episodes cause in your daily life.
Imagine you have heart disease. You’re prescribed medication, you do better for a while, so you stop the meds. Then you have another heart attack, so you go back on the medication to get better. Twelve heart attacks later, what kind of shape are you in? It’s obviously crazy. If you have recurrent depression, you are not being “courageous” or “genuine” to go off your medication. You’re being foolish.
Can you explain the importance of balancing therapy and medication?
Different treatments work for different people, and I am open to the endless possibilities out there. But for most people, a combination of medication and therapy is the surest-fire way to handle depression.
The medication alleviates the worst symptoms and lets you function again. It makes life and the world bearable. But once you have emerged from the horror, you need to learn skills for managing the illness. You need to understand where it comes from. You need to make your peace with the idea that you cannot be fully yourself without the use of medications or other support structures.
And you need someone capable who can keep an eye on you. Ideally, you also need to understand the structure of your own personality and who you are; this gives you a feeling of peace and allows you to get through a difficult time with dignity.
By his mid-twenties, Solomon established himself as a multi-disciplinary wunderkind, earning international accolades for his work as a novelist, journalist and historian. After the death of his mother, the then 31 year old Solomon descended into a major depression, rendering him unable to work or even care for himself. He was helped by a combination of medications and talk therapy. This experience formed the bedrock for his National Book Award-winning “Noonday Demon: An Atlas of Depression”, a tour de force examining the disorder in personal, cultural, and scientific terms.
Professor Mitchell, what is the difference between being depressed and just feeling bad about yourself?
Sometimes it’s easy to tell the difference; sometimes you’re not certain. I look for clinical indicators of depressive illness: whether the person’s life is becoming impaired by these bad feelings, when it’s starting to interfere with people’s sleep, appetite and weight, when it’s interfering with their work and concentration, they’re having suicidal thoughts, they can’t buck up. Those symptoms help me to sort out whether it’s just life problems or whether it’s more.
So depression is an illness?
Yes. Even though there are both psychological and physical parts to it, it makes sense to think of severe depression as an illness. There are good medical and psychological treatments that can help people get out of it.
What proportion of the population is depressed?
Figures vary, but over a lifetime about 15% of the population are prone to getting depression on at least one occasion. So it’s relatively common. Some people only have one episode, but for at least half of those who suffer depression once, it is a recurring experience.
Is depression the sort of thing that certain personality types are likely to suffer?
I think that’s true. Anybody is vulnerable to becoming depressed, if things get difficult for them, but some personality types are more prone than others. For instance, if you tend to look for your own failings and weaknesses, if you expect disasters, you are prone to becoming depressed. People who have fragile self-esteems are prone; people who are excessively perfectionistic can be thrown when things don’t go quite right; people who have long-term high levels of anxiety.
Can you describe what it is like to be depressed?
Patients find it quite hard to describe. They often use analogies, like there is a ‘black cloud’ or a ‘weight’ on them. They say that they just can’t enjoy things any more, that they can’t get the drive to do anything; they stay in bed because they just have no energy or enthusiasm. They tend to ruminate and think about their failings, their hopeless situation. But many people find it hard to communicate the experience; even very articulate people have told me how difficult it is to communicate the experience to other people.
On the other side of the fence, what is it like to be close to someone who is depressed?
I think it’s very wearing. It never ceases to amaze me how couples stay together, particularly when it’s prolonged. Even with the best of good will and human kindness, long-term depression can be a very tiring experience for a spouse or close friend. You may get little response from a depressed person, little enthusiasm, withdrawal. They don’t want to interact socially and sometimes they can be quite irritable. Within a marriage, tension may be increased because the depressed person has no interest in sexual activity. So these things exacerbate the problem.
I sometimes hear it said that depressed people ought to just ‘snap out of it’. Can they do that?
Not when the depression is severe in the way we have been talking about. If someone can snap out of it, usually they have by that stage. In general, a depressed person doesn’t like the experience and if it was a matter of just getting on and doing something, they would have tried it. Sometimes people need to learn psychological ways of getting out of the depressed state. But sometimes there is a biochemical process going on that means the person isn’t physically able to snap out of it, without professional help.
Often there is a mixture of the physical and the psychological. It’s very rarely one or the other. The more I see depression, the more I see a complex interplay between personality, the biology of our brains and our life experience.
So depressed people can’t snap out of it, but they also can’t explain very easily what is actually troubling them. It’s a very frustrating illness!
Absolutely. It’s hard for people who haven’t dealt with it professionally to have any idea what it’s like to be depressed. So people have this difficulty understanding it, and this tendency to think that the person should be able to get out of it, and the depressed person has difficulty explaining the experience and feels frustrated and stigmatized when people are telling them to snap out of it, because they know they can’t snap out of it. There is enormous tension.
I suppose the big question is, for both the depressed person and those around them, can depression be cured?
Most people with depression can either be cured or significantly helped by available treatments. These days, we have very good treatments. We can’t help everybody, but we can help the vast majority of people we see.
Is it always a long-term cure, or can it happen quickly?
It varies. Often within a few weeks many people have benefited significantly. Some forms of depression require more long-term psychological treatment, others respond very quickly to medication. And there are grades in between.
Is depression like alcoholism, where you can get it under control but never really be beyond its reach?
For most people, that’s probably a realistic comparison. I tell people that they are always going to be prone to becoming depressed, so they need to be wary about relapses in the future. They need to be sensible about their medications, learn techniques to help them, think about whether there are aspects of their lives that they need to change. We can’t always prevent future episodes, but we can usually make them less likely.
The poet Les Murray recently has been very public about coming out of his depression. It’s interesting that some of the best poetry is written by people who have been depressed. Look at William Cowper, a Christian poet and hymn writer who wrote some of his most moving material during periods of profound depression. So depression can be both creative and destructive.
This raises an important issue for Christians. How do we connect our mental and our spiritual lives?
Cowper became very doubting at times, during his depression. One thing many Christian patients say is that God seems very distant during such periods. I’ve come to accept that as part of the depressive experience rather than a problem with their faith. I’ve seen people with a very deep faith, who yearn to be close to God, and who when depressed feel very barren and remote from God. For instance, J. B. Phillips, the Bible translator, was profoundly depressed for much of his adult life. He has described this sense of distance from God.
That is very distressing for Christians. They begin to worry that it is a lack of faith or lack of spiritual growth. But having seen it enough, I think it is just an expression of the depressive experience. Many Christians also feel that depression is a sign of weakness, of spiritual inadequacy, and they have a strong sense of guilt. Unfortunately, I think that often the church, explicitly or implicitly, has encouraged that—that if you have depression, it’s a reflection on your spiritual life. This adds an incredible burden to people who are already feeling guilty and self-critical. It’s a bit like Job’s encouragers, who basically made him feel worse.
Why does there seem to be a large number of depressed people in our churches?
It’s often the more sensitive people who become depressed, and there are often a lot of obsessional and sensitive people in churches. My experience is that there is a lot of depression in our congregations and that we don’t handle it at all well. We often infer, explicitly or implicitly, that the Christian shouldn’t have the experience of depression—that it’s not part of the victorious Christian life. And that causes enormous guilt and makes people less likely to talk about it. I think we have a lot of silent suffering going on in our churches. People just aren’t getting helped, because they feel guilty about having depression. We need to bring out into the open the fact that depression is a common experience, even within the church. And that being a Christian doesn’t stop you from getting depression. And that having depression is no more a failing than having diabetes.
In general, the church deals very badly with mental illness. In the middle ages, it was considered demon possession; in the late 20th century it’s considered a symptom of spiritual inadequacy. But it isn’t necessarily either of these things.
Are people in very demanding ministries especially prone?
They are prone; I don’t know about especially. They are in line for so many of the factors that contribute to depression: burn-out, demoralization, excessive demands, not looking after your own emotional needs, not having time to yourself. I see some of the casualties, and often by then it’s too late because someone has resigned from the ministry or become completely disillusioned. And it’s all too hidden, too hush-hush. We’re dealing with it no better than the secular world; in some ways we’re doing worse.
What then are the ways that a depressed person can be helped, both by individuals and by the church?
Well, especially in the early days, one can be supportive, help people get back into their lives—those normal things of friendship and support, being a sounding board, willing to listen to difficulties. These things might be sufficient to alleviate the early experience of depression.
But if we’re looking at a fully formed depression that’s been going on for a while, the person should be encouraged to seek proper professional help. That doesn’t always mean a psychiatrist; it might mean a GP or a counsellor. Just someone with the skills and training to help. So that’s the first thing, when the support networks have been stretched to the limit.
While that process is happening, it’s important to be around for the depressed person, accepting the fact that it might be a frustrating experience until that person picks up. Not feeling that you have to do everything yourself. There has to be a point where a friend accepts that they can’t provide everything the person needs. That point is usually indicated by signs like someone crying constantly, their work falling apart, withdrawing inexplicably, perhaps losing weight. These things indicate that the depression is getting severe.
Finally, do you think depression has become more of a problem today than it used to be?
It’s an area of debate. There’s no doubt that depression has always existed. The old Greek medical writers are clearly describing patients with depression. There was a book written in the 17th century called The Anatomy of Melancholy which described what we would call depressed patients. So it goes back through the ages; it’s part of the general human experience.
The issue is whether it has become more frequent. People have looked at the occurrence of depression in groups of people born in different decades in this century, and the frequency of occurrence seems to go up as the decades continue. People born in the 60s are more prone to depression than those at similar ages, but born in the 30s. Now, the significance of that is debated. It could be that people in recent decades simply have become more willing to admit to their depression, hence the higher rate of reports. Or it could be true that it is becoming a more common experience, and presumably that reflects changes in society. What those changes are is a very difficult question to answer.
So it’s hard to say whether the loneliness of urban living is a major factor?
Well yes, and it’s a very interesting area of debate. The World Health Organization has released predictions of the impact of different illnesses over the next century. They are saying that depression will be the 21st century’s most disabling condition, in terms of the impact on the individual, frequency and cost to society, on a worldwide basis. That survey included all medical conditions, including cancer and heart disease. So there is a recognition that it is a very prevalent condition, and that it is a very disabling condition to have. Whatever is causing it, we’re going to have to deal with it.
Philip Mitchell is a Professor at the School of Psychiatry, Prince Henry Hospital in Sydney, Australia.
NAMI’s Interviews With Danielle Steel & Kay Jamison
Last year, Steel published His Bright Light, a memoir of her son, Nick Traina, who committed suicide at age 19 after a life-long battle with bipolar disorder (manic depression). More recently, Jamison has published Night Falls Fast: Understanding Suicide, combining research, clinical expertise and personal experience to explore one of the world’s leading causes of death.On February 8, the Senate Appropriations Subcommittee on Labor, Health, Human Resources, Education & Related Agencies will hold a hearing on suicide prevention that will include testimony from best-selling author Danielle Steel and Professor Kay Redfield Jamison, author of several academic and popular books on mental illness.
Interviews with Steel and Jamison have appeared in “Spotlight,” a special supplement to The Advocate, the quarterly publication of the National Alliance for the Mentally Ill (NAMI). Conducted by NAMI executive director Laurie Flynn, they offer a possible preview of Steel and Jamison’s testimony on Tuesday. Excerpts follow below.
NAMI’s Interview with Kay Jamison
Spotlight (Winter 1999/2000)
NAMI: What do we know about the linkage between suicide and mental illness?
Jamison: The most important thing to know is that 90 to 95 percent of suicides are associated with one of several major psychiatric illnesses: depression, bipolar illness, schizophrenia, drug and alcohol abuse, and personality disorders. These are obviously treatable illnesses. Another thing people don’t think about enough or emphasize enough is that because cancer and heart disease hit older people, they are seen as lethal illnesses. Because the age of onset for mental illnesses is very, very young, people don’t tend to think of mental illnesses as the potentially lethal illnesses they are. It’s important for people to understand that they have an illness to begin with and then that they get good treatment for it.
NAMI: You have spoken specifically of suicide and college students.
Jamison: Yes. Suicide is the second major killer of college aged kids. It’s the second leading killer of young people generally.
NAMI: You also have pointed out that, worldwide, suicide is the second leading killer of women between ages 15 and 45. These statistics are staggering, yet most people don’t seem to be aware of it.
Jamison: Absolutely. Across the world. There are almost two million suicides a year worldwide. I think people just don’t have any sense of the enormity of it. Suicide unfortunately has been so individualized and, because of the early suicide movement in this country, so separated from mental illness. People working in the field of suicide concentrated on existential factors and vague sorts of things, when in fact the underlying science is very clear that they’re associated with a few mental illnesses.
NAMI: Knowing what we do about illness and its treatability allows us to be able to discuss preventing suicide.
Jamison: Right. [U.S. Surgeon General] Dr. David Satcher’s emphasis has been very strong on three fronts. One is public awareness. Secondly, intervention and all that’s involved in making doctors and others more able to ask the kinds of questions needed to uncover mental illness. And then, thirdly, to support the science that’s necessary to study suicide.
NAMI: What else can policy makers and public officials do?
Jamison: I think we have to have public officials talking about it. When you have someone like Jesse Ventura out there saying these outrageous things-I think it’s really beyond the pale-we’ve got to have the president of the United States saying look we’ve got a real epidemic here, and there’s something we can do about it. People are dying from not gaining access to treatment-or from having three days in the hospital, and then going out and dying.
NAMI’s Interview with Danielle Steel
Spotlight (Winter 1999)
NAMI: “His Bright Light” is a very personal story about a very painful subject, the mental illness and death of a child. What did you hope people would learn by sharing your story?
Steel: I hoped first of all that people would come to know my son, and learn what an extraordinary person he was. I wrote the book to honor him, and to share with people what a remarkable person he was, in spite of his illness. I also wrote it to share with people the challenges we faced, so that they feel less alone and less isolated with their pain, in similar situations. I wrote it to give people hope and strength as they follow a similar path to ours.
NAMI: What did you learn from this painful tragedy?
Steel: I’m not sure yet what I learned from the tragedy, except that one can and must survive. But from his life, I learned a great deal about courage and perseverance, and love.
NAMI: Lots of people in America might be facing signs of a mental illness in one of their children. What about Nick’s behavior made you realize that it was more severe than just the normal growing pains of a child?
Steel: Nick was different. Always. His moods were more extreme. I sensed from early on, that despite his many wonderful qualities, there was something very wrong. I knew it in my gut, as I think many parents do.
NAMI: How long did it take for Nick to be diagnosed as manic-depressive and receive treatment for that condition?
Steel: Nick was not clearly diagnosed as manic depressive until he was 16, a good 12 years after we began the pursuit of the causes for his ‘differences’. He received no medication until he was 15, and did not receive the most effective medications until he was 16. A long and very painful wait for all concerned!
NAMI: Prior to knowing of Nick’s manic depression, what did mental illness mean to you? Did you associate stigma with mental illness?
Steel: I don’t think I realized, before Nick, that one could still be functional, or seemingly functional, if mentally ill. I thought of it as something totally incapacitating, and of people who were shut away. I don’t think I realized how intelligent and capable mentally ill people can still be. I’m not sure I did associate a stigma with mental illness. It just seemed like a sickness, and not necessarily a shameful one. I just thought of Nick as sick, whatever it was called, and wanted him to be cured.
NAMI: How did Nick deal with the knowledge that he had a mental illness?
Steel: For a long time, Nick himself was in denial about his illness. And eventually, he accepted it. In the last year, he told people he was manic-depressive. Before that, when he felt ‘normal’ on medications, he believed he was cured. He had a hard time accepting at first that he would be manic-depressive all his life.
NAMI: Are schools able to cope with the mental illness of a child?
Steel: In most cases, I don’t believe they are. It is a huge challenge for all to meet, and certainly hard on the other kids to have one child acting out. We were very lucky, in Nick’s high school years we finally found a wonderful school that understood the problem, accepted him as he was, and was willing to work with him in a framework he could cope with. They were remarkably flexible and creative. But for most schools, it’s asking a lot to expect them to adapt to a mentally ill child.
NAMI: If you could tell a family member who is caring for someone who is mentally ill one thing, what would that be?
Steel: Never give up. Get the best help you can. Keep trying, keep loving, keep giving, keep looking for the right answers, and love, love, love, love. Don’t listen to the words, just listen to your heart.
NAMI: What do you think support groups like NAMI can do for families coping with the mental illness of a loved one?
Steel: I think groups like NAMI can provide support, both emotional and practical—the knowledge that you are not alone. And resources, where to go, who to talk to, what works. You need all the information you can get, and it is just about impossible to do it alone.
NAMI: Stereotyping the mentally ill as violent and dangerous is pervasive in America. How do we change this perception?
Danielle: Information. Obviously there must be some mentally ill people who are violent and/or dangerous. But I suspect that most are not. Nick certainly wasn’t either of those, he was gentle, loving, smart, funny, compassionate, extremely perceptive about people, and very wise. I cannot conceive of Nick as ‘dangerous,’ although ultimately he was a danger to himself. But for the most part, I think the turmoils of the mentally ill are directed within and not without.
NAMI: What do you think the average American should know about mental illness?
Steel: I think most people should know how common it is…I also think people should know how serious it is when it goes untreated. And how potentially lethal it can be. It is vitally important to get good treatment, the right medication, and good support. If you let a bad cold turn into bronchitis and then pneumonia, without medication, it can kill you. If you do not treat serious diabetes, it can kill you. If mental illness goes untreated, it can kill you.
NAMI: We know that having “hope” is important to battling any disease. What hope do you see for people with mental illness?
Steel: I see a huge amount of hope. The medications today can give people whole, happy, productive lives. There are lots and lots of people with mental illness holding down good jobs, even with important careers, happy family lives, and doing great things. It is possible to lead a good and happy life if you are mentally ill. If those who are doing just that would speak up, it would give great hope to all those who are still groping their way along in the dark.
NAMI: What is Nick’s legacy?
Steel: Nick’s legacy is the love we had and have for him, the word we have spread of what a terrific person he was. In his lifetime, he touched countless lives, with his warmth, with his mind, with his music, with his words. Through his experiences, others have and will learn. Through the Nick Traina Foundation, hopefully we can bring help to others, in his name.
Many Christians are still afraid to let God love them as they truly are, says the former priest, sober alcoholic, and author. This is just a small excerpt of an interview given by Mr. Manning to Christianity Today.
What is premise of this book about trust?
The basic idea is in one sentence: The splendor of a human heart that trusts and is loved unconditionally gives God more pleasure than Westminster Cathedral, the Sistine Chapel, Beethoven’s Ninth Symphony, Van Gogh’s Sunflowers, the sight of 10,000 butterflies in flight, or the scent of a million orchids in bloom. Trust is our gift back to God, and he finds it so enchanting that Jesus died for love of it.
It’s what Jesus said we need to bring into the relationship.
Yes. Childlike surrender and trust, I believe, is the defining spirit of authentic discipleship. The supreme need in most of our lives is often the most overlooked: an unfaltering trust in the love of God no matter what goes down. I think this is what Paul taught when he wrote in Philippians 4:13, “There is nothing I cannot master with the help of the one that gives me strength.”
But how do we know if we’re really trusting? Most people would say they trust God.
The dominant characteristic of an authentic spiritual life is the gratitude that flows from trust—not only for all the gifts that I receive from God, but gratitude for all the suffering. Because in that purifying experience, suffering has often been the shortest path to intimacy with God.
I’d also add that biblical trust grows out of love. My trust in God flows out of the experience of his loving me, day in and day out, whether the day is stormy or fair, whether I’m sick or in good health, whether I’m in a state of grace or disgrace. He comes to me where I live and loves me as I am.
In John 17:26, Jesus says, “Father, I have made your name known. I continue to make it known. And I pray that the same love with which you love me may be in them and I in them.” The very same love that the Abba has for Jesus is the same love he has for us when he’s in our hearts. The problem is most of us aren’t aware of it.
So part of this is an attention problem?
I believe that the real difference in the American church is not between conservatives and liberals, fundamentalists and charismatics, nor between Republicans and Democrats. The real difference is between the aware and the unaware.
When somebody is aware of that love, the same love that the Father has for Jesus, that person is just spontaneously grateful. Cries of thankfulness become the dominant characteristic of the interior life, and the byproduct of gratitude is joy. We’re not joyful and then become grateful, we’re grateful and that makes us joyful.
But there’s suffering, too. In your book, tucked away between talking about gratefulness and beholding God, you talk very personally about how, if we’re truly going to learn to trust God, we can’t avoid the personal suffering.
When I was outside an alcohol and drug rehab center in New Orleans, and I was clutching a pint of Taaka vodka, what I did not want was the lifesaving treatment of detox in a 28-day program.
I kept on drinking, a drunken child crying out, “Jesus, where are you?” How do we experience trust in the midst of pain, suffering, heartache, and throbbing despair? I mean, is it possible to endure and eventually move beyond the bleak and melancholy landscape of evil and destruction, back to the experience of God as unconditional love? That’s the problem I ask Christians. Do you trust that God loves you? Everybody says, oh yes, I’ve known that for a long time. Then just watch the way they live. There’s so much fear, so much anxiety, and so much self-hatred. The best definition of faith I ever heard was Paul Tillich when he said, “Faith is the courage to accept acceptance.”
Meaning? Faith is a code to accept that Jesus knows my whole life story, every skeleton in my closet, every moment of sin, shame, dishonesty, degradedness darkening my past. Right now he knows my shallow faith, my feeble prayer life, my inconsistent discipleship, and he comes beside me and he says, I dare you to trust. I dare you to trust that I love you, just as you are and not as you should be, because you’re never going to be as you should be.