Unpredictable by Jeferson Roberto Marcelino

UN ER PDICTABLE Depressed m i nds ca n ta ke us away to deep journeys through parallel worlds of mysteries a nd i n ner s t r uggles

CopyrightÂŠ 2017 Taschen All rights reserved. No part of this publication may be reproduced, stored in retrieval system, or transmitted in any means eletronic, mechanical, photocopying, recording or otherwise without permission of copy right holder.

This book is dedicated to everyone who wonder about mental struggles and believe there is an end. Also for my mother, father and family.

TABLE OF

C0NTENTS

PAGE 6

INTRODU CTION

CHAP T ER

C0NFUSI0NS

CHAP T ER

DEGRADATION PAGE 20

PAGE 08

Troubles to concentrate, suddenly irritability or frustration, and calmness. Uncertainty that surrounds a mind with depression.

People suffering from depression run the risk that their brains shrink and will remain smaller after the disease is over.

CHAP T ER

UNSTOPPABLE THOUGHTS

CHAP T ER

CONTROVER SIAL MIND PAGE 4 4

PAGE 32

We don’t always think, feel and behave in exactly the same way, it depends on the situation we are in, the people with us and many other things.

PAGE 56

BIBLIOGRAPHY PAGE 58

COLOPHON

Our minds are vulnerable to negative thoughts, causing us doubt, worry, anxiety and frequently, it’s the same negative thoughts.

DEPRE S SION: UNPREDICTABL E

DEP RESSION MO OD SWINGS

UNP REDI E L B AT C

While DEPRESSION can’t be shooed away like a temporary bad mood, it can be effectively treated. Modern depression treatments include antidepressant medications and short-term, goal-oriented psychotherapy that helps a person learn new coping skills and better ways to address irrational depressive thoughts. Having people around someone who is depressed, people who are supportive and caring, can make a world of difference. If you know someone or suspect someone you know who may have depression, you may not fully understand what they’re going through. That’s okay. They only need you to understand they’re dealing with a real, serious condition that affects everything they do every day. Treat them with care and respect, and be there for them when they need a helping hand. That can make a tremendous difference in their lives.

BUT FOR MOST PEOPLE WHO SUFFER FROM DEPRESSION, IT IS NOT SOMETHING THAT’S VOLUNTARY OR SOMETHING THAT ONE CAN JUST “SNAP OUT OF” OR “STOP BEING DEPRESSED.” IF IT WERE A SIMPLE MAT TER OF “STOPPING” THE DEPRESSION, THERE’D BE NO NEED FOR THERAPISTS, ANTIDEPRESSANTS, OR ANY OTHER TREATMENTS.

IN TRODUC TION

Though public understanding of depression has improved somewhat over the years, we as a society still frequently misunderstand or overlook depression and its symptoms. Because of the continuing stigma, we donâ&#x20AC;&#x2122;t always recognize when people in our lives are struggling with this illness. Worse, too many people go undiagnosed because of erroneous assumptions about how depression manifests and what to look for. This results in a number of people whoâ&#x20AC;&#x2122;s depression is hidden, either from others or from themselves. Especially when a person with depression is undiagnosed, they may develop ways of coping with their problems that conceals their illness from those around them or keeps the person from recognizing their symptoms for what they are. We need to unlearn the assumption that suffering is always clearly visible to us, so that we can better understand and help those who struggle with illnesses that go unseen. Here are some signs that someone might have hidden depression.

01 C0NFU-

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C0NFUSN01S

MIND IS CONFUSION. Thoughts and thoughts â&#x20AC;&#x201C; thousands of thoughts clamoring, clashing, fighting with each other, fighting for your attention. Thousands of thoughts pulling you into thousands of directions. It is a miracle how you go on keeping yourself together. Somehow you manage this togetherness â&#x20AC;&#x201C; it is only somehow, it is only a facade. Deep behind it there is a clamoring crowd, a civil war, a continuous civil war. Thoughts fighting with each other, thoughts wanting you to fulfill them. It is a great confusion, what you call your mind. I cannot tell from your brief question whether your ping-ponging between happiness and sadness is new or has been going on for years. This is a really important question in terms of coming up with the best diagnosis. If you do not have relatively long periods of either depression or mania/hypomania, there is another diagnosis that might be relevant to your condition, and that is borderline personality disorder. This is a chronic condition that affects women more than men and that is characterized by rapid mood shifts between excitement/ happiness and anger/irritability/sadness. These shifts typically occur numerous times over the course of a day. But most people with borderline personality disorder do not have clear manic episodes, although depression is very common. There are other symptoms and behaviors that define borderline personality disorder and if you have many or most of these, then this is likely the diagnosis that most closely fits your situation.

CHAP TER ONE - C ONF USION

BUT IF YOU ARE AWARE THAT THE MIND IS CONFUSION, AND YOU DON’T GET IDENTIFIED WITH THE MIND, YOU WILL NEVER FALL. YOU WILL BECOME FALL-PROOF! People with borderline personality disorder have very intense, stormy relationships with other people characterized by a pattern of being overly idealistic about people at first, followed by disillusionment and then disgust. Part of this pattern is also a terror of being abandoned by others on one hand, and fear of being swallowed up and overwhelmed by them on the other. Other markers for borderline personality disorder include intense anger, a pattern of risky behavior, uncertainty about one’s sexual orientation, chronic suicidal thoughts and a tendency to hurt, typically by cutting. So the fast answer to your question is that yes it is quite possible to have very unstable moods. I worry about your symptoms and want to really encourage you to go to a mental health professional to describe your situation. But if you are aware that the mind is confusion, and you don’t get identified with the mind, you will never fall. You will become fall-proof ! The mind will become impotent. And because you will be watching continuously, your energies will slowly be withdrawn, away from the mind; it will not be nourished any more.

DEPRESSION AFFECTS ALL ASPECTS OF A PERSON’S LIFE They have no motivation and lose interest in activities that were once enjoyable. Depression puts a dark, gloomy cloud over how we see ourselves, the world, and our future. This cloud cannot be willed away, nor can we ignore it and have it magically disappear. 11

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Jun

8 a.m.

EVERY THING IS OK. I’M MAINTAINING

JunI’ VE HAD A ROUGH DAY

11 a.m.

JunSIGNIFICANT LIFE EVENT AND STRESS. IT MAY TAKE LONGER TIME TO COPE.

2 P.m.

JunI’ VE BEEN DOWN FOR A WHILE AND I DON’ T EXACTLY KNOW WHY.

11 P.m.

JunI’M DOING WELL AND I’D LIKE SOMEONE TO KEEP AND EYE ON ME AND CHECK-IN REGUL ARLY.

4 a.m.

JunI’M IN CRISIS. PLEASE COME OVER RIGHT AWAY.

1 a.m.

JunI MAY HURT MYSELF OR OTHERS.

6 a.m.

WHILE DEPRESSION CAN’T BE SHOOED AWAY LIKE A TEMPORARY BAD MOOD, IT CAN BE EFFECTIVELY TREATED Modern depression treatments include antidepressant medications and short-term, goal-oriented psychotherapy that helps a person learn new coping skills and better ways to address irrational depressive thoughts. Having people around someone who is depressed, people who are supportive and caring, can make a world of difference.

10 JunI’ VE HAD A ROUGH DAY

11 a.m.

JunSIGNIFICANT LIFE EVENT AND STRESS. IT MAY TAKE LONGER TIME TO COPE.

2 P.m.

JunI’ VE BEEN DOWN FOR A WHILE AND I DON’ T EXACTLY KNOW WHY.

11 P.m.

JunI’M DOING WELL AND I’D LIKE SOMEONE TO KEEP AND EYE ON ME AND CHECK-IN REGUL ARLY.

4 a.m.

JunI’M IN CRISIS. PLEASE COME OVER RIGHT AWAY.

1 a.m.

JunI MAY HURT MYSELF OR OTHERS.

6 a.m.

CHAP TER ONE - C ONF USION

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COMMON SNO T PMY S DEPRESSION, like any medical disease, requires professional care to be treated properly. It does not just go away on its own in most cases, no more than a broken arm will go away if you just want it to. DEPRESSION is a sense of deep emotional sadness and hopelessness that pervades an individual’s body. People with depression can’t just wake up one day and say, No more depression for me. On the contrary, many people with depression have trouble even taking one step out of bed. The situation described is fairly common but it is not a ver y classic description for depression. Most depressed people feel unhappy all the time. Sometimes they will feel better in the evenings or better in the mornings, but they would not describe themselves as happy one moment and sad the following one. There are two psychiatric conditions which are defined in large measure by moods that shift between happy and sad.

DEPRESSION IS A SERIOUS CONCERN FOR NEARLY 1 IN 10 PEOPLE AT SOME POINT IN THEIR LIVES. NOBODY ASKS OR WANTS DEPRESSION IN THEIR LIVES, YET IT CAN’T JUST BE DENIED OR EXPLAINED AWAY WITH RATIONAL THOUGHT. MOOD SWINGS ARE ANALOGOUS TO A FEVER IN PEDIATRICS THEY INDICATE SOMETHING POTENTIALLY IS WRONG WITH THE PATIENT, BUT ARE NOT DIAGNOSTIC AS AN ISOLATED SYMPTOM.

CHAP TER ONE - C ONF USION

IS IT POSSIBLE TO HAVE MOOD SWINGS WHERE ONE MOMENT YOU ARE HAPPY, THEN THE NEXT YOU CAN BE SAD? IS THIS A SIGN OF DEPRESSION? I DO ALSO HAVE ADD AS WELL BUT CURRENTLY I AM NOT ON MEDICINE.

MOOD SWINGS in children are common, nonspecific symptoms that more often are a sign of anxiety or behavioral disorders than BD. It is a popular term that is nonspecific and not part of DSM-IV-TR diagnostic criteria for BD. The complaint of mood swings may reflect severe mood lability of pediatric patients with BD. This mood lability is best described by the Kiddie-Mania Rating Scale developed by Axelson and colleagues as rapid mood variation with several mood states within a brief period of time which appears internally driven without regard to the circumstance.

The differential diagnosis of MOOD SWINGS is important because they are a common presenting symptom of many children and adolescents with mood and behavioral disorders. Mood swings often occur in children and adolescents with ADHD, oppositional defiant disorder (ODD), developmental disorders, depressive disorders, BD, anxiety disorders, and conduct disorders. Mood swings are analogous to a fever in pediatrics they indicate something potentially is wrong with the patient, but are not diagnostic as an isolated symptom.

SOME PEOPLE MISTAKENLY BELIEVE THAT A PERSON CAN ONLY BE JUSTIFIED IN THEIR DEPRESSION IF THERE IS A CAUSE OR REASON FOR THEM TO BE DEPRESSED If you’re unemployed, just suffered the loss of a relationship or loved one, or just found out you have a life-threatening disease, people react more kindly. They see one’s depression as justified and appropriate. But for the vast majority of people with depression, there is no reason and there is no cause for their feelings.

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CHAP TER ONE - C ONF USION

02 DEGRA-

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n 0 I TA D

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TODAY I AM

FEELING...

CHAP TER T WO - DEGR ADATION

IT’S NOT ONLY MY MOOD D E S S E R P E D S I TA H T Energy levels, motivation, feeling of selfworth and self-restraint are all affected as well. It doesn’t mean I’m lying in bed crying all day, especially as a mom of two young kids. I’m doing my best to be as functional as possible. Instead of sad, I may seem irritable or short-tempered, for which I probably feel guilty as hell. Rapid cycling is a DSM-IV course specifier that indicates mood episodes per year in patients with BD with a typical course of mania or hypomania followed by depression, or vice versa. The episodes must be demarcated by full or partial remission that lasts 2 months or by a switch to a mood state of opposite polarity. In the past, children with frequent mood swings were described incorrectly as “rapid cycling,” but this term has been dropped because it engenders confusion between adult and pediatric BD phenomenology. Patients with BD typically exhibit what is best described as a mood cycle a pronounced shift in mood and energy from one extreme to another.An example of this would be a child who wakes up with extreme silliness, high energy, and intrusive behavior that persists for several hours and then later in the day becomes sad, depressed, and suicidal with no precipitant for either mood cycle. BD patients also will exhibit other symptoms of mania during these mood cycling periods.

SOME DAYS, 24 HOURS I MUCH TO STAY PUT IN, S TAKE THE DAY HOUR BY MOMENT BY MOMENT. I THE TASK, THE CHALLEN THE FEAR INTO SMALL, SIZE PIECES. I CAN HAN A PIECE OF FEAR, DEPR SION, ANGER, PAIN, SAD LONELINESS, ILLNESS. I ALLY PUT MY HANDS UP FACE, ONE NEXT TO EAC LIKE BLINDERS ON A HO

DEPRE S SION: UNPREDICTABL E

Moderate

SEVERE

Rapid mood swings nearly all of the time, with mood intensity greatly out of proportion to circumstances.

EXTREME

Constant, explosive variability in mood, several mood changes occurring within minutes, difficult to identify a particular mood, changes in mood radically out of proportion to some specific circumstances.

CLINICAL POINT

IT’S NOT ONLY MY MOOD THAT’S DEPRESSED. ENERGY LEVELS, MOTIVATION, THE FEELING OF SELF-WORTH AND SELF-RESTRAINT ARE ALL AFFECTED AS WELL. IT DOESN’T MEAN I’M LYING IN BED CRYING ALL DAY, ESPECIALLY AS A MOM OF TWO YOUNG KIDS. I’M DOING MY BEST TO BE AS FUNCTIONAL AS POSSIBLE. INSTEAD OF SAD, I MAY Many mood changes throughout the SEEM LIKE IRRITABLE OR day, can vary from elevated mood to anger to sadness within a few hours; SHORT-TEMPERED, FOR changes in mood are clearly out of WHICH I PROBABLY FEEL proportion to circumstances and cause GUILTY AS HELL impairment in functioning.

Children and adolescents with mood swings typically exhibit a pronounced shift in energy and behaviour from one extreme to another.

CHAP TER T WO - DEGR ADATION

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MY OLDER BROTHER, WHO I ALWAYS LOOKED UP TO, SAW THAT I WAS NOT ACTING LIKE MY USUAL SELF. HE TOLD ME STRAIGHT OUT I SEEMED DEPRESSED AND THAT I SHOULD TALK TO A DOCTOR ABOUT IT. A depressed person’s behavior might be interpreted as melancholy even if that’s not what they’re I HATE GOING TO THE really feeling. Irritability is a frequently overlooked symptom of depression that is also very common. DOCTOR. I THOUGHT, NO This should be understandable, since depression is a WAY AM I GOING health problem you can’t “see” or strictly measure, making it hard to combat. The constant work it takes to keep up all the necessary aspects of life while dealing with depression also drains the person, and leaves little room for patience or understanding. If someone you know discovers they’re clinically depressed and shares this with you, you may initially be confused if their previous behavior didn’t fit the common misconception of the shy, silent depressed person. If they tend to have a short temper and are quick to annoy, that is actually one of the side effects of depression. The main misconception about depression, which has been hinted at in the paragraphs above, is that it’s about “feeling” sad. On the contrary, depression is mostly not feeling anything, or only partially and briefly experiencing emotions. It depends on the individual, but some people with depression report feeling almost “numb,” and the closest thing to an emotion they experience is a kind of sadness and/or irritation. Because of this, appropriately responding to gestures or words of affection will be difficult for them, or they just don’t think about it any more. They may even get irrationally irritated or annoyed with you over it, because it may simply be too difficult for their brains to process and respond to your loving gestures.

CHAP TER T WO - DEGR ADATION

DEPRE S SION: UNPREDICTABL E

DEPRESSION AFFECTS ALL ASPECTS OF A PERSON’S LIFE Though public understanding of depression has improved somewhat over the years, we as a society still frequently misunderstand or overlook depression and its symptoms. Because of the continuing stigma, we don’t always recognize when people in our lives are struggling with this illness. Worse, too many people go undiagnosed because of erroneous assumptions about how depression manifests and what to look for. “IT WAS REALLY HARD TO GET OUT OF BED IN THE MORNING. I JUST WANTED TO HIDE UNDER THE COVERS AND NOT TALK TO ANYONE. I DIDN’T FEEL MUCH LIKE EATING AND I LOST A LOT OF WEIGHT. NOTHING SEEMED FUN ANYMORE. I WAS TIRED ALL THE TIME, YET I WASN’T SLEEPING WELL AT NIGHT. BUT I KNEW THAT I HAD TO KEEP GOING BECAUSE I’VE GOT KIDS AND A JOB. IT JUST FELT SO IMPOSSIBLE, LIKE NOTHING WAS GOING TO CHANGE OR GET BETTER.”

This results in a number of people who’s depression is hidden, either from others or from themselves. Especially when a person with depression is undiagnosed, they may develop ways of coping with their problems that conceals their illness from those around them or keeps the person from recognizing their symptoms for what they are. We need to unlearn the assumption that suffering is always clearly visible to us, so that we can better understand and help those who struggle with illnesses that go unseen. Here are some signs that someone might have hidden depression. Clinical depression affects all aspects of a person’s life. It impairs our ability to sleep, eat, work, and get along with others. It damages our self-esteem, self-confidence, and our ability to accomplish everyday tasks. People who are depressed find daily tasks to be a significant struggle. They tire easily, yet cannot get a good night’s sleep. They have no motivation and lose interest in activities that were once enjoyable. Depression puts a dark, gloomy cloud over how we see ourselves, the world, and our future. This cloud cannot be willed away, nor can we ignore it and have it magically disappear.

CHAP TER T WO - DEGR ADATION

NUMBER OF MOOD CYCLES PER DAY

100

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CHAP TER T WO - DEGR ADATION

DEPRESSION IS LIKE AN ONION. PEEL EACH LAYER AWAY AND YOU’LL START TO SEE WHY SOMEONE IS THE WAY THEY ARE Due to media and cultural stereotypes, most of us have assumptions about how someone behaves and looks if they’re struggling with depression. We imagine someone who rarely leaves their room, doesn’t dress themselves well, and constantly looks miserable, but people with depression do not all behave in the same way.

THINGS IN MY LIFE WERE GOING ALL RIGHT. I HAD JUST GOTTEN MY GED AND WAS STARTING A NEW JOB IN A WEEK. MY FAMILY WAS REALLY PROUD OF ME. BUT INSIDE, I WAS FEELING TERRIBLE.

All people are, of course, different from each other, and the symptoms and coping abilities of people with depression also differ. Many are able to keep up a facade of good mental health to protect themselves, but they aren’t suffering any less simply because they can do this. Similarly, those who are unable to keep up such a facade are not “weaker” than those who can. A prevalent side effect of depression is constant exhaustion. Not everyone with the disorder struggles with it, but it’s extremely common. For those who experience this symptom with their depression, it’s often one of the hardest side effects to cope with. Also, if someone is living with an undiagnosed depression disorder, the cause of their exhaustion can be baffling. They can get plenty of sleep each night and still wake up every morning feeling like they only slept a few hours. Worse, they may blame themselves, believing it to be laziness or some other personal fault that’s causing their low energy levels. This is also a symptom that’s difficult to conceal for those who have been diagnosed with depression but are attempting to keep it from their peers, as it often affects their workload and personal relationships.

CHAP TER

UNST0PPABLE

STHGU0HT

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DEPRESSION IS MOSTLY NOT FEELING ANYTHING, OR ONLY PARTIALLY AND BRIEFLY EXPERIENCING EMOTIONS.DEPRESSION IS JUST AS PHYSICALLY DRAINING AS IT IS MENTALLY DRAINING, WHICH MAKES ENJOYING ALL THE THINGS YOU USUALLY DO DIFFICULT.

CHAP TER THREE - UNSTOPPABL E THOUGHTS

Unless other explanations could equally be possible, an uncharacteristic lack of interest in activities over an extended period of time could be a sign that someone has depression. As mentioned above, depression is just as physically draining as it is mentally draining, which makes enjoying all the things you usually do difﬁcult.

EVERYTHING IS A BATTLE, EVERY BREATH IS A WAR, AND I DON’T THINK I’M WINNING ANYMORE

Previously-loved activities can even lose their appeal in general, because depression also commonly makes it difficult to enjoy or feel fulfilled by much at all. If you have no other way of explaining their decreasing interest, it could be a symptom of clinical depression. Abnormal eating habits mainly develop for two reasons: as a form of coping, or as a side effect of lack of self-care. Eating too little or too much is a common sign of depression. Overeating is often shamed the most, when food can be the one source of pleasure a depressed person is able to give themselves and thus causes them to eat excessively. When a depressed person is eating too little, it’s often because their depression is affecting their appetite and making eating unappealing. It can also be a subconscious need to control something, since they cannot control their depression. If someone is undiagnosed or has not shared that they have depression, people will assume their eating habits are a personal fault and judge them for it, making the person feel worse.

DEPRESSION NEED NOT BE THE LONELIEST FIGHT, BUT IF I DO NOT TELL YOU CAN NEVER REALLY KNOW ME OR

36 DEPRE S SION: UNPREDICTABL E

CHAP TER THREE - UNSTOPPABL E THOUGHTS

THE FIRST STEP IN RECOGNIZING DEPRESSION IN MEN IS DIAGNOSING IT PROPERLY, WHICH MEANS HAVE ACCURATE CRITERIA AND MAKING SURE MENTAL HEALTH PRACTITIONERS KNOW WHAT TO LOOK FOR

I wonder, had I talked with my friend about my own struggle, if he might have said, “Me, too.” Indulging in some magical thinking, I imagine he would be alive today if we had shared our stories. It’s encouraging that new studies are refuting previous ones that showed women to be twice as likely as men to experience depression. For example, a 2013 University of Michigan study concluded, “when alternative and traditional symptoms are combined, sex disparities in the prevalence of depression are eliminated.” In other words, men and women may be equally at risk. The first step in recognizing depression in men is diagnosing it properly, which means establishing accurate criteria — and making sure mental health practitioners know what to look for. The second step, which may be even more difficult, is getting men to speak up about it. Which leads back to my own silence. One reason I’ve been unable to talk about my condition until now is that, as the Cymbalta ad says, “depression hurts.”

I KNOW THAT I MIGHT NOT HAVE DIAGNOSED MYSELF WITH DEPRESSION JUST ON THE BASIS OF THOSE SYMPTOMS. I HAD NO MOOD, CHANGE IN APPETITE, AND NO SLEEP PROBLEMS LIKE GETTING OUT OF BED WAS WHAT WAS DIFFICULT

When I first heard that tagline I rolled my eyes, but I’ve since come to appreciate the copywriter’s genius. Imagine suffering from a bad flu, the kind that seems to have poisoned your blood, physically incapacitating you. For me, depression can feel like the worst flu ever, with no end in sight.

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A DEPRESSED PERSON LEGITIMATELY CAN’T FUNCTION LIKE A MENTALLY HEALTH PERSON A depressed person legitimately can’t function like a mentally health person. There will be things they will no longer be able to do as much of, as often, or at all. Pestering or shaming them about it will only hurt, not help. If they’ve been keeping their depression private, it will be that much harder to deal with others getting irritated with them because they can’t perform at the level that’s expected of mentally healthy people. This is why it’s always best to be understanding with those in your life, both work and personal. You don’t know if someone isn’t just slacking off, but is struggling with a real health problem. Depression can have its ups and downs. If someone has hidden or undiagnosed depression, they might seem like they get random mood swings, depending on if their depression is consistent or not. To you (and to them, if they are undiagnosed), the changes in mood seem without cause, but it’s simply how some people’s depression manifests. If you know the person has depression, it’s possible to falsely believe they’re permanently better because of a few “good” days. While it’s always great if someone has a day that’s better than the one before it, you should always let them tell you what they’re ready to handle and when. Assuming they’ve completely recovered and pushing them too quickly into things might overwhelm them and make them retreat into themselves again. Be supportive of your friends and family who have depression, but let them make the calls.

CHAP TER THREE - UNSTOPPABL E THOUGHTS

BEHIND MY SMILE IS A HURTING HEART, BEHIND MY LAUGH, I’M FALLING APART. LOOK CLOSELY AT ME, AND YOU WILL SEE, THE PERSON I AM, IT ISN’T ME ANYMORE

DEPRE S SION: UNPREDICTABL E

THE SECOND STEP, WHICH MAY BE EVEN MORE DIFFICULT, IS GETTING MEN TO SPEAK UP ABOUT IT. It is tough to talk about when you’re in that much pain. And then there’s the stigma. As much as I understand that illness is illness, whether mental or physical, and that there is a greater openness about depression now than a generation ago, I feel shame. Adolescents today have a reputation for being more fragile, less resilient and more overwhelmed than their parents were when they were growing up. Sometimes they’re called spoiled or coddled or helicoptered. But a closer look paints a far more heartbreaking portrait of why young people are suffering. Anxiety and depression in high school kids have been on the rise since 2012 after several years of stability. It’s a phenomenon that cuts across all demographics — suburban, urban and rural; those who are college bound and those who aren’t. Family financial stress can exacerbate these issues, and studies show that girls are more at risk than boys. The pain of the superficial wound was a momentary escape from the anxiety she was fighting constantly, about grades, about her future, about relationships, about everything. Many days she felt ill before school. Sometimes she’d throw up, other times she’d stay home. “It was like asking me to climb Mount Everest in high heels,” she says.

Experts suspect that these statistics are on the low end of what’s really happening, since many people do not seek help for anxiety and depression. A 2015 report from the Child Mind Institute found that only about 20% of young people with a diagnosable anxiety disorder get treatment. It’s also hard to quantify behaviors related to depression and anxiety, like nonsuicidal self-harm, because they are deliberately secretive. Still, the number of distressed young people is on the rise, experts say, and they are trying to figure out how best to help. Teen minds have always craved stimulation, and their emotional reactions are by nature urgent and sometimes debilitating. The biggest variable, then, is the climate in which teens navigate this stage of development. They are the post-9/11 generation, raised in an era of economic and national insecurity. They’ve never known a time when terrorism and school shootings weren’t the norm. They grew up watching their parents weather a severe recession, and, perhaps most important, they hit puberty at a time when technology and social media were transforming society.

CHAP TER THREE - UNSTOPPABL E THOUGHTS

“WE’RE ALL LIKE LITTLE VOLCANOES. WE’RE GETTING THIS CONSTANT PRESSURE, FROM OUR PHONES, RELATIONSHIPS, AND FROM THE WAY THINGS ARE TODAY”

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YOU DON’T KNOW IF SOMEONE ISN’T JUST SLACKING OFF, BUT IS STRUGGLING WITH A REAL HEALTH PROBLEM I have slogged through a number of difficult situations in recent months, among them the ongoing crises of my elderly parents’ illnesses and the suicide of a friend. I never lost my appetite nor burst into tears, and I didn’t suffer from any of the other typical symptoms of depression. Maybe I was more irritable than usual, a bit more prone to snap. And yes, I buried myself in my work. But I didn’t think I’d tripped down into the rabbit hole of depression. You would think I would have been more self-aware, both personally and professionally. As a health journalist, I have often used my own stories to write about difficult-to-discuss medical conditions, including learning I had testicular cancer at age 26 and my misdiagnosis with H.I.V./AIDS — back when it was a death sentence. But I had never written about suffering from depression, even though it’s plagued me since I first put pen to paper, at age 11, when I started keeping a diary. Still, I’m far from alone. At least six million men in the United States suffer from depression, according to the National Institute of Mental Health. The true number is likely to be even higher, said Dr. Matthew Rudorfer, the institute’s associate director for treatment research, since men are less likely than women to report classic symptoms like low mood, sadness or crying, so they often go undiagnosed. Men, he told me, more often demonstrate “externalizing” symptoms like irritability, anger and aggressiveness, substance and alcohol abuse, risk-taking behaviors and “workaholism.” Oh, that macho thing: Men don’t get depressed; they just work, drink and compete harder. Andrew Solomon, author of the pathbreaking memoir about depression, “Noonday Demon,” told me that ridiculous attitude is part of the mind-set that guys should “cover up our moods with militarism or athleticism.”

CHAP TER THREE - UNSTOPPABL E THOUGHTS

DEPRESSION PRESENTS ITSELF AS A REALISM REGARDING THE ROTTENNESS OF THE WORLD IN GENERAL AND THE ROTTENNESS OF YOUR LIFE IN A PARTICULAR THING. THE REALISM IS MERELY A MASK FOR DEPRESSION’S ACTUAL ESSENCE, WHICH IS AN OVERWHELMING So why speak up now? If there was a specific catalyst, it would be the death of my friend (his family asked me not to disclose his real name), a personal trainer who, one August morning, worked out his regular clients — and then went home and killed himself with a single gunshot to the head.

FROM HUMANITY.

Even with 20/20 hindsight I never would have guessed he was at risk for serious depression, let alone suicide. Just three days before his death, alive with excitement, he’d talked with me about buying his first house and applying for a management role at the health club. Still, as one of his closer friends told me later, “You never know where depression lives.” Most people, even those who know me well, don’t see my depression. I’m a “high-functioning” depressive, for sure, and perhaps an artful one, too, obscuring its symptoms with a mix of medication, talk therapy, exercise and knowing when to close the door on the world. And unlike my surgical scars (thank you, cancer), those left by depression are invisible. Clinical depression affects all aspects of a person’s life. It impairs our ability to sleep, eat, work, and get along with others. It damages our self-esteem, self-confidence, and our ability to accomplish everyday tasks. People who are depressed find daily tasks to be a significant struggle.

CHAP TER

C0ntrover sial

dnim

Steve Schneider, a counselor at Sheboygan ygan South High School in southeastern Wisconsin, says the situation is like a scab that’s constantly being picked. “At no point do you get to remove yourself from it and get perspective,” he says. It’s hard d for many adults to understand how much of teenagers’ emotional life is lived within the small screens on their phones, but a CNN special report in 2015 conducted with researchers at the University of California, Davis, and the University of Texas at Dallas examined the social-media use of more than 200 13-year-olds. Their analysis found that “there is no firm line between their real and online worlds,” according to the researchers. That hyperconnectedness yperconnectedness now extends everywhere, engulfing even rural teens in a national thicket of Internet drama. Daniel Champer, the director of school-based services for Intermountain in Helena, Mont., says the one word he’d use to describe the kids in his state is overexposed. Montana’s kids may be in a big, sparsely populated state, but they are not isolated anymore.

NOBODY GETS EXCITED ABOUT THE FUTURE AT ALL, EVER. THE FUTURE IS SOMETHING WE FIND DEPRESSING AND WORRISOME. DEPRE S SION: UNPREDICTABL E

CHAP TER FOUR - C ONTROVERSIAL MIND

WE’RE THE FIRST GENERATION THAT CANNOT ESCAPE OUR PROBLEMS AT ALL

In my dozens of conversations with teens, parents, clinicians and school counselors across the country, there was a pervasive sense that being a teenager today is a draining full-time job that includes doing schoolwork, managing a social-media identity and fretting about career, climate change, sexism, racism--you name it. Every fight or slight is documented online for hours or days after the incident. It’s exhausting. Steve Schneider, a counselor at Sheboygan South High School in southeastern Wisconsin, says the situation is like a scab that’s constantly being picked. “At no point do you get to remove yourself from it and get perspective,” he says. It’s hard for many adults to understand how much of teenagers’ emotional life is lived within the small screens on their phones, but a CNN special report in 2015 conducted with researchers at the University of California, Davis, and the University of Texas at Dallas examined the social-media use of more than 200 13-year-olds. Their analysis found that “there is no firm line between their real and online worlds,” according to the researchers. That hyperconnectedness now extends everywhere, engulfing even rural teens in a national thicket of Internet drama. Daniel Champer, the director of school-based services for Intermountain in Helena, Mont., says the one word he’d use to describe the kids in his state is overexposed. Montana’s kids may be in a big, sparsely populated state, but they are not isolated anymore.

T gu dr se o ov p It’ of sc 2 of D 2 n ac St S is p pe

In ni w dr m ca E or

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YOUâ&#x20AC;&#x2122;RE SCARED TO TELL PEOPLE HOW MUCH IT HURTS, SO YOU KEEP IT ALL TO YOURSELF AND YOU BROKEDOWN BADLY

SCHOOL PRESSURES ALSO PLAY A ROLE, PARTICULARLY WITH STRESS. A SUICIDE MIGHT HAPPEN ON THE OTHER SIDE OF THE STATE AND THE KIDS OFTEN KNOW BEFORE THE ADULTS.

CHAP TER FOUR - C ONTROVERSIAL MIND

SADNESS IS A SHORT ADJUSTMENT PERIOD. DEPRESSION IS A LONG-TERM ILLNESS

Megan Moreno, head of social media and adolescent health research at Seattle Children’s Hospital, notes a big difference between the mobile-social-tech revolution of the past 15 years and things like the introduction of the telephone or TV. In the olden days, your mom told you to get off the family phone or turn off the TV, and you did it. This time, kids are in the driver’s seat. Parents are also mimicking teen behavior. “Not in all cases, obviously, but in many cases the adults are learning to use their phones in the way that the teens do,” says Moreno. “They’re zoning out. They’re ignoring people. They’re answering calls during dinner rather than saying, ‘O.K., we have this technology. Here are the rules about when we use it.’” She cautions against demonizing technology entirely. “I often tell parents my simplest analogy is it’s like a hammer. You know, you can build a house that’s never existed before and you can smash someone’s head in, and it’s the same tool.” Sometimes phones rob teens’ developing brains of essential downtime. But other times they’re a way to maintain healthy social connections and get support. Nora Carden, 17, of Brooklyn, who started college in upstate New York this fall, says she’s relieved when she goes on a trip that requires her to leave her phone for a while. “It’s like the whole school is in your bag, waiting for an answer,” she says. School pressures also play a role, particularly with stress. Nora got counseling for her anxiety, which became crushing as the college-application process ramped up. She’d fear getting an answer wrong when a teacher called on her, and often felt she was not qualified to be in a particular class. “I don’t have pressure from my parents. I’m the one putting pressure on myself.”

“The competitiveness, the lack of clarity about where things are going [economically] have all created a sense of real stress,” says Victor Schwartz of the Jed Foundation, a nonprofit that works with colleges and universities on mental-health programs and services. “Ten years ago, the most prominent thing kids talked about was feeling depressed. And now anxiety has overtaken that in the last couple of years.” Tommy La Guardia, a high-achieving 18-year-old senior in Kent, Wash., is the first college-bound kid in his family. He recently became a finalist for prestigious scholarships, all while working 10 to 15 hours a week at a Microsoft internship and helping to care for his younger brothers. His mom, Catherine Moimoi, says he doesn’t talk about the pressure he’s under. They don’t have a lot of resources, yet he manages everything himself, including college tours and applications. “He’s a good kid. He never complains,” she says. “But there are many nights I go to sleep wondering how he does it.” Tommy admits that the past year was tough. “It’s hard to describe the stress,” he says. “I’m calm on the outside, but inside it’s like a demon in your stomach trying to consume you.” He deals with those emotions on his own. “I don’t want to make it someone else’s problem.” Meanwhile, evidence suggests the anxiety wrought by school pressures and technology is affecting younger and younger kids. Ellen Chance, co-president of the Palm Beach School Counselor Association, says technology and online bullying are affecting kids as early as fifth grade.

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CHAP TER FOUR - C ONTROVERSIAL MIND

SOMETIMES IT HITS ME OUT OF NOWHERE. ALL OF A SUDDEN THIS OVERWHELMING SADNESS RUSHES OVER ME. AND I GET DISCOURAGED, AND I GET UPSET, AND I FEEL HOPELESS AND ONCE AGAIN, I FEEL NUMB TO THE WORLD

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OFTEN THE PEOPLE WITH THE STRONGEST HEARTS CARRY THE HEAVIEST ONES

Conventional wisdom says kids today are oversupervised, prompting some parenting critics to look back fondly to the days of latchkey kids. But now, even though teens may be in the same room with their parents, they might also, thanks to their phones, be immersed in a painful emotional tangle with dozens of their classmates. Or they’re looking at other people’s lives on Instagram and feeling self-loathing (or worse). Or they’re caught up in a discussion about suicide with a bunch of people on the other side of the country they’ve never even met via an app that most adults have never heard of.

Phoebe Gariepy says she remembers being in the backseat of a car with her headphones on, sitting next to her mom while looking at disturbing photos on her phone on social-media feeds about cutting. “I was so distant, I was so separated,” she says. She says it was hard to get out of that online community, as gory as it was, because her online life felt like her real life. “It’s almost like a reality-TV show. That’s the most triggering part of it, knowing that those real people were out there.” It would be hard for most people to know that the girl sitting there scrolling through her phone was engaged in much more than superficial selfies. Josh, who did not want his real name published, is a high school sophomore in Maine who says he remembers how his parents began checking on him after the Sandy Hook shooting that killed 20 children and six adults. Despite their vigilance, he says, they’re largely unaware of the pain he’s been in. “They’re both heterosexual cis people, so they wouldn’t know that I’m bisexual. They wouldn’t know that I cut, that I use red wine, that I’ve attempted suicide,” he says. “They think I’m a normal kid, but I’m not.” In the CNN study, researchers found that even when parents try their best to monitor their children’s Instagram, Twitter and Facebook feeds, they are likely unable to recognize the subtle slights and social exclusions that cause kids pain.

CHAP TER FOUR - C ONTROVERSIAL MIND

DEPRESSION ON MY LEFT, LONELINESS ON MY RIGHT. Finding disturbing things in a child’s digital identity, or that they’re self-harming, can stun some parents. “Every single week we have a girl who comes to the ER after some social-media rumor or incident has upset her [and then she cut herself],” says Fadi Haddad, a psychiatrist who helped start the child and adolescent psychiatric emergency department at Bellevue hospital in New York City, the first of its kind at a public hospital. Teens who end up there are often sent by administrators at their school. When Haddad calls the parents, they can be unaware of just how distressed their child is. According to Haddad, this includes parents who feel they’re very involved in their children’s lives: they’re at every sports game, they supervise the homework, they’re part of the school community. Sometimes when he calls, they’re angry. One mother whose child Haddad treated told him that she found out her daughter had 17 Facebook accounts, which the mother shut down. “But what good does that do?” says Haddad. “There will be an 18th.” For some parents who discover, as Faith-Ann’s parents Bret and Tammy Bishop did a few years ago, that their child has been severely depressed, anxiety-ridden or self-harming for years, it’s a shock laden with guilt. Self-harm is certainly not universal among kids with depression and anxiety, but it does appear to be the signature symptom of this generation’s mental-health difficulties. All of the nearly two dozen teens I spoke with for this story knew someone who had engaged in self-harm or had done it themselves. It’s hard to quantify the behavior, but its impact is easier to monitor.

EVIDENCE SUGGESTS THE ANXIETY WROUGHT BY SCHOOL PRESSURES AND TECHNOLOGY IS AFFECTING YOUNGER AND YOUNGER KIDS

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Iâ&#x20AC;&#x2122;M JUST TRYING TO SAY THAT IT SHOULD REASSURE US THAT THE INEVITABLE SUFFERING OF BEING HUMAN TO END UP PRODUCING SOME GOOD. OTHERWISE, THE HUMAN STATUS IS STUNNING DEPRESSING ALL THE TIME

CHAP TER FOUR - C ONTROVERSIAL MIND

THEN YOU WONDER, WHAT COULD I HAVE DONE BETTER? Self-harm is certainly not universal among kids with depression and anxiety, but it does appear to be the signature symptom of this generation’s mental-health difficulties. All of the nearly two dozen teens I spoke with for this story knew someone who had engaged in self-harm or had done it themselves. It’s hard to quantify the behavior, but its impact is easier to monitor: a Seattle Children’s Hospital study that tracked hashtags people use on Instagram to talk about selfharm found a dramatic increase in their use in the past two years. Researchers got 1.7 million search results for “#selfharmmm” in 2014; by 2015 the number was more than 2.4 million. While girls appear more likely to engage in this behavior, boys are not immune: as many as 30% to 40% of those who’ve ever self-injured are male. The academic study of this behavior is nascent, but researchers are developing a deeper understanding of how physical pain may relieve the psychological pain of some people who practice it. That knowledge may help experts better understand why it can be hard for some people to stop self-harming once they start. Whitlock, the director of the self-injury research program at Cornell, explains that studies are pretty consistent in showing that people who injure themselves do it to cope with anxiety or depression.

AS THAT WAS STARTING TO

It’s hard to know why self-harm has surfaced at this time, and it’s possible we’re just more aware of it now because we live in a world where we’re more aware of everything. Whitlock thinks there’s a cultural element to it. Starting in the late 1990s, the body became a kind of billboard for self-expression--that’s when tattoos and piercings went mainstream. “As that was starting to happen, the idea of etching your emotional pain into your body was not a big step from the body as a canvas as an idea,” she says.

HAPPEN, THE IDEA OF ETCHING YOUR EMOTIONAL PAIN INTO YOUR BODY WAS NOT A BIG STEP FROM THE BODY AS A CANVAS AS AN IDEA

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BIBLIOYHPARG TEEN DEPRESSION AND ANXIET Y Susanna Schrobsdorff, Time Health October 2016

WHAT IS DEPRESSION? Joseph Bennington-Castro, Everyday Health March 2016

UNDERSTANDING DEPRESSION IN TEENAGERS National Institute of Mental Health July 2014

BIBL IO GR APHY

COPING WITH MOOD CHANGES L ATER IN LIFE Dr. Charles Raison, Depression and Bipolar May 2010

NOT ALL MOOD SWINGS ARE BIPOL AR DISORDER Robert A. Kowatch, MD, PhD , Psychiatry February 2011

THINGS PEOPLE WITH HIDDEN DEPRESSION DO Jane Scearce, Depression and Bipolar March 2011

DEPRESSED? WHAT CAN YOU DO American Psychological Association February 2017

WHAT CAUSES DEPRESSION? Harvard Health Publications September 2015

TEEN DEPRESSION Timothy N. Welbeck, HuffPost April 2016

DEPRESSION STRIKES TODAYâ&#x20AC;&#x2122;S TEEN GIRLS Patti Neighmond, NPR.org April 2017

ALCOHOL AND DEPRESSION Ulifeline.org May 2013

A PATH OUT OF DEPRESSION Stephen Illardi, Experiencelife.com January 2015

WARNING SIGNS & T YPES OF DEPRESSION John M. Grohol, Psych Central December 2016

HOW DEPRESSION AFFECTS THE WORKPL ACE Valueoptions.com February 2013

OPENING UP ABOUT DEPRESSION Steven Petrow, New York Times February 2016

11 WARNING SIGNS OF DEPRESSION Paula Spencer Scott, Caring.com May 2014

DEFEATING DEPRESSION Greg Mazak, DJU Press October 2015

LINK BETWEEN CHRONIC ILLNESS AND DEPRESSION News-Medical.net August 2014 57

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