Joan* was miserable. In the mornings she dragged herself out of bed to put breakfast on the table for her three children. She didn't have the energy to cook, but she knew the importance of a good meal to begin the day, so she managed to put out cereal, milk, fruit and toast. When they were all picked up by their various school buses and carpools, she managed to put the milk back in the fridge, so that it would not spoil. But she left the dirty dishes and cereal boxes on the table, the spilled cereal and toast crumbs on the floor, and stumbled back to bed.
"Something's wrong," her mother told her. "You must be sick. This isn't like you. Do you want me to come take you to the doctor?"
Joan did not want to go to the doctor. She didn't want to go anywhere. She wasn't even sure that she could find the energy to get dressed for an appointment. But with her mother's encouragement, she did go. The doctor asked a number of questions, took blood, and did a variety of tests. There was nothing wrong with Joan physically. The diagnosis was depression, and the doctor suggested she see a psychiatrist for medication. "I could give it to you," she said, "but I think it would be smarter to see someone who is a specialist, who can fine tune the prescription.
It was a difficult moment for Joan. "What do I have to be depressed about?" she asked her mother. "I've got three great kids, a terrific marriage, a wonderful relationship with you and Dad. How can I be depressed?"
In a review of three new books on the state of mental health today, Marcia Angell discusses the huge uptick in depression (as well as other psychological disorders) in recent years. Joan, it appears, is not alone. According to Angell, ten percent of Americans "over the age of six" take antidepressants.
The article - and apparently the books, which I have not yet read myself - takes on the pharmaceutical industry, suggesting that the evidence that medication cures depression is driven by the industry itself. In my own experience, there are certainly times that medication helps. Sometimes it softens the pain enough for a client to engage in the psychotherapeutic process; and sometimes it does the job by itself. Or maybe it's just that the medication makes it possible for someone to tolerate the pain until it goes away - since depression does often eventually go away on its own. There is evidence that talk therapy is effective on its own as well, possibly because it changes the same brain chemistry that medication targets (although Angell's review questions the very idea that depression is related to brain chemistry at all!).
But talk therapy does something that meds can't do - it can help a client figure out what is causing a particular depressive episode, and sometimes understanding what the pain is about is enough to make it lift.
But there is another dimension to the issue of depression. In the July, 2011 issue of Prevention Magazine, author Ginny Graves says that depression serves a purpose in our lives. Graves writes, " ‘Depression may be nature's way of telling you to stop and focus on what's troubling you, so you can move past it and get on with your life,' says Paul Andrews, PhD, an evolutionary biologist at Virginia Commonwealth University. He, along with his colleague J. Anderson Thomson, MD, a staff psychiatrist at the Student Health Services and Institute of Law and Psychiatry at the University of Virginia, have become controversial proponents of an idea that actually dates back to Aristotle, that depression may lead to better mental health."
These authors suggest that depression forces us to go inwards and ruminate on something that is problematic or troubling. In some cases, internally mulling over a painful experience can gradually lead to healing - what psychoanalysts often classify as "healthy mourning." In some cases, however, just what we are mourning is not so clear, and we someone else to help us sort it out. Sometimes we also need the presence of another person to make it safe enough to mourn.
This is what happened to Joan. She went to the psychiatrist, hoping that he would give her something that would bring her energy back. Like her primary care physician, the psychiatrist asked a lot of questions. Besides the excruciating lack of energy, what other symptoms was Joan experiencing? Joan couldn't think of anything. He asked about her appetite. "I can't stop eating," she said. "I always used to have a decent body; but now I'm fat and bloated and miserable. What about how she was sleeping? Joan was tired all the time and could have slept twenty-four/seven; but she forced herself to get up and be available when her children were home. When had she first started feeling this way? Joan had to think about it. Finally she said that she thought it had started sometime during the summer, and had gotten slowly worse over the fall and winter. Before this period of time, the psychiatrist asked, had she felt this way before? No, Joan had always been an energetic, active person. That was why her mother had worried so much about her.
Under the gentle probing of the psychiatrist, Joan started to realize that the loss of energy and all of the other symptoms had begun to sneak up on her as she prepared for the past September, when all of her children were in school for the first time. Now that they were talking about it, she remembered that she had been worried about what she would do with her time. "My oldest is fourteen," she said. "I've been a stay-at-home mom for most of my adult life. And I've loved it every minute. I was happy that my babies were growing up...and I was also so sad..."
The psychiatrist asked Joan if she thought she could go without medication for a little while longer. "I think," he said, "that it would be a good idea for you to talk out some of these feelings. If the talking doesn't start to make you feel better in a few months, then we'll revisit the question of meds."
Joan started psychotherapy. Once a week she met with a therapist, who listened as she talked about how much she loved her children and how sad and empty the house felt without them around. The therapist asked about Joan's interests other than the children, and she asked about her marriage. Joan loved her husband very much, but explained that they had a traditional sort of marriage. "He works long hours, and often even on the weekends. I take care of the house and the children." But they had a good sex life and always had at least one "date night" a week.
It did not take long for the therapist and Joan together to understand the meaning of her depression. She was mourning the end of an era in her life. No longer was she the center of her children's world. Her role as Mom was still central, and she knew her family still needed her - but not in the same way. She began to talk to her husband about the possibility of him spending a little more time with her. He was thrilled. "You've always been so busy with the kids - and you're a great mother, so I didn't want to take you away from them. But I've missed you!!" he told her.
On one of their "dates" he surprised her again. "Have you thought about going back to work?" he wanted to know. "Or maybe going to school to find a new career? You're going to need something to feel involved in - the kids are going to keep growing up, you know."
With her husband's encouragement, Joan began to consider possibilities. As of this moment, she hasn't made up her mind. But she's considering becoming a therapist. "Maybe I can help other people who are struggling with these same issues," she says.
*names and other identifying information have been changed