Dense and Depressed

dense-titleHires_Descent_BozorgniaPhoto: “Descent” by Behdad Bozorgnia, MD, MAPP

It wasn’t until I was six months into my second depressive episode that I discovered depression existed. I didn’t know it was a real disease. I didn’t know that my grandmother got electroconvulsive “shock” therapy in the 1950s.  I only knew something was terribly wrong when I sat crying for 20 minutes in front of a pile of laundry one morning because the thought of choosing clothes and going through another day was so daunting.

At age 24, I moved back in with my parents to take pre-med science classes. Everyone said medical school was a bad idea – too hard, too expensive, and definitely too long – I’d be 35 and in crippling debt by the time I finished fellowship!

They were right about the costs. I made a hard choice and thought I was paying the price. Who wouldn’t be sad in their parents’ basement after living in New York City and India? Who wouldn’t be constantly exhausted or have trouble concentrating when taking organic chemistry, physics, and biology simultaneously?

My symptoms were normal reactions to stress – I told myself this again and again – until they weren’t.  Crying at the gym isn’t normal. Rehashing your life choices for hours a day isn’t normal.  Deciding not to see your friends anymore isn’t normal.

Somehow, I made it to Student Health and was referred to a therapist. She was an obese black woman who grew up in the inner city. I arrived at the first session thinking the whole thing was a mistake.  How could she understand me? Is this really the treatment I needed?  

I was wrong. She was smart, kind, and funny and had no problem understanding me. It was exactly the treatment I needed. She was just beginning her career, recently engaged, and filled with hope and enthusiasm. For a few sessions, I took great comfort in her warmth and wisdom.

After winter break, the clinic director asked to speak with me. I honestly thought I’d be told that my treatment was ending because my problems weren’t that bad. I already felt guilty about using resources that could probably be better spent on others, like my lab partner who was being forced to marry her cousin in Pakistan.

“Your therapist is dead,” the director told me. She said some kind words, but that was the only part I heard. My therapist was in her 30s and wasn’t sick, but she got a pulmonary embolism flying to the Middle East for a trip she’d been planning for years. She never got to take that trip, get married, or have a career after a decade of training.

All I could think was: it should have been me. Life is terribly unfair. I’m taking up space in this clinic and this world, crying and worrying, and contributing nothing of value. So, I quit therapy and it never once occurred to me that my guilt in accepting medical care and in being alive were symptoms of depression. I continued the antidepressant I had just started, finished my classes, and after more needless suffering, the depression slowly got better.

Writing this now pains me. How could I have been so dense? How could I have thought that the healthcare system would view my depression as unworthy of treatment, especially as a young, insured person with no medical history? And in what world would a broke student living in a basement be considered too privileged to treat?  

I didn’t know about depression because no one talked about depression. I didn’t talk about it either. I worked desperately to hide it and nobody was the wiser, while the cycle of secrecy and shame about psychiatric conditions continued.

A decade later, the cycle still continues. As a psychiatrist, I have evaluated many students in the ER who are frantic about their futures, feeling like failures, not sleeping, socially isolated, racked with guilt, and totally unaware that they are depressed and it is a real and treatable illness.

I tell them everything I wish someone told me: depression is wildly common, probably in their own families and definitely at Penn, it’s not their fault, it will get better, and to not make any big decisions until it does because they simply can’t see things clearly right now. If they don’t believe me, I cite studies and statistics until they do.

I tell them they can grit their teeth, and they will improve whether or not they get treatment, but untreated depression is more likely to come back and will be worse and harder to treat if it does. They are on a long hike with a 60 pound backpack they don’t need to carry. I can help them take it off. I ask them to tell me every reason they can think of why their lives are worth living to underscore why their depression is worth treating.

Becoming a psychiatrist was like opening the floodgates to stories of friends, family, and, of course, patients about the elaborate lies they told and steps they took trying to hide mental illness. They postponed their weddings, missed funerals, and lost their jobs in flares of depression, mania, anxiety, and PTSD, too afraid to seek psychiatric treatment or even admit they needed it. It shouldn’t be like this.

We need to talk about mental illness until it’s no more taboo than the flu, screen for it, treat it aggressively to full remission, and demand insurers pay for it with true parity to other medical conditions.

Lisa Jacobs is a third year psychiatry resident at Penn and the founding editor of the Penndulum.

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