A depressed day

I jolt awake at 5:45 a.m., thrust into consciousness to escape the dark vapours of a nightmare already dissipated. My tank top is soaked, cool against clammy skin pruned from a night spent sleeping in sweat. I shuffle through the bleary dawn light, change into dry pyjamas, and head downstairs to the couch. If I change where I sleep, sometimes it’s enough to push away the night terrors and nightmares. This isn’t one of those mornings.

I dream I try to die by suicide, but I still botch it. After a doctor tends to me, I spend the rest of the dream with garish black stitches displayed for anyone to see. Luckily, I hear my partner’s footfalls on the stairs when he heads downstairs to make coffee, saving me from the dream. I wake for good.

Still lying on the couch, I fall into reality with a weighty thud I recognize as depression. I’ve felt this way for the past few days, and a night of broken sleep and awful dreams doesn’t shift the feeling. I haven’t sat up yet but already I feel like crying. It’s going to be one of those days I have to drag myself through—tasks that normally interest and excite me are chores today. My future, no brighter or duller than a week ago when I was feeling fine, seems particularly bleak today. I tell my partner it’s another depressed day.

While I’m fairly critical of the Diagnostic and Statistical Manual of Mental Disorder (DSM), also known as psychiatry’s bible, it doesn’t do a bad job summing up the symptoms of major depressive disorder (MDD), which include:

• A depressed mood

• Loss of interest or pleasure in almost all activities

• Significant unintentional weight loss/gain or decrease/increase in appetite

• Sleep disturbances, fatigue, or low energy

• A sense of worthlessness or excessive guilt

• An inability to concentrate or make decisions, and suicidal ideation or attempts.

To be classified as MDD, symptoms must cause significant distress or impairment for at least two weeks, are not due to substance abuse or a medical condition, are without a history of mania or hypomania, and can’t be better explained by other psychotic disorders.

I’ve lived with MDD for as long as I can remember. In elementary school, teachers used to ask me why I never smiled, and why my younger brother seemed so much happier than I did. Back then, I didn’t have the vocabulary to explain how I was feeling. I couldn’t put into words the toll even the most mundane activity took on my small body. I felt dead, drifting through space, unattached and going through the motions expected of me, but never really engaging. It was like I was lost in a dark swamp, muck pulling my feet into place, the oppressive humid air smothering me, unsure if stepping forward would lead me out or further into the bog.

As a child, I had no idea how to manage my depression. It smothered me until I was so desperate to escape it that I felt death was my only way out. At six, I tried to die by suicide for the first time. As the years passed, my depressive episodes didn’t diminish, but my ability to manage them did. Since depression played such a significant role in my life, I eventually learned that the more I tried to resist it, the more likely I was to spiral into crisis. The bog became familiar territory—a terrain that though daunting had become almost homey over the years. I knew eventually my depression would lift, so I learned to get comfortable with it.

PLEASE Skill

I settle onto my balcony stoop with my coffee and start the cognitive work a day like this requires. I catalogue my vulnerability—factors that are likely influencing and impacting the depth and severity of my feelings—using the dialectical behaviour therapy (DBT) skill, PLEASE (a weird and imperfect acronym):

• Treating Physical iLlness

• Eating a balanced diet

• Avoiding mood-altering substances

• Getting a balanced Sleep 

• Getting Exercise

Studies have shown that poor nutrition, lack of sleep, and inactivity can all contribute to depression. In this case, I recognize my poor sleep, being on the second day of a particularly nasty period (and the associated PMS), and an empty stomach are all collaborating to make me highly vulnerable to my emotions. I’m still in pain, and it sucks, but by stepping back from my feelings, I’ve introduced some perspective and understanding into my day. I’ve also reminded myself of the skills I can use to reduce my emotional vulnerability and dysregulation.

Reflecting on the PLEASE skill gives me the motivation I need to drag my ass through my morning routine—I brush my hair and teeth, take a washcloth to the ranker parts of my body, and (most importantly) take my antidepressants. I don’t have the energy to shower, plus the layer of grime feels more protective than cumbersome, so I let myself off the hook. Out of necessity, I work from home so I can get away with a grubby day.

Building Mastery

I don’t always feel like this when depressed, but today my intuition tells me maintaining a sense of routine and building a sense of accomplishment will be the most helpful to me. This is also the first part of the DBT skill, PLEASE, or ABC PLEASE. The “A” stands for accumulating positive emotions, the “B” stands for building mastery, and the “C” stands for coping ahead. I focus on building mastery or engaging in activities that will give me a sense of accomplishment to combat helplessness and hopelessness.

I know my depression (and myself) well enough that I recognize it will be easiest to tackle the tasks I’ve been dreading the most, or I’m likely to put them off again, which will only perpetuate feelings of worthlessness and uselessness. First on the list is a call to the Canada Revenue Agency (CRA), which has owed me some money since March. Dealing with the slow-turning wheels of democracy can be maddening at the best of times, and the role the CRA plays in perpetuating the cycle of poverty for people with low income and mental illness is enough to send me back to bed. Ideally, I would have had breakfast to reduce my vulnerabilities before I made this call, but even after so many years living with depression, I still don’t always handle it gracefully. However, it seems that fortune’s wheel has finally rolled around in my favour, and my money is allegedly going to be released (I still have my doubts). I cried while I was on the call but I hung up feeling that some of the despair around my financial straits has shifted. Had I avoided this task, I likely would have spent the rest of the day wallowing in self-pity. Taking care of it gave me the sense of accomplishment I need to keep going.

I continue to build mastery and a sense of accomplishment by checking off a few of the easier tasks on my to-do list (practicing my Ukrainian and Spanish, and writing something simple I’ve been looking forward to). I give myself permission to postpone the tasks that seem too much in the moment and are most likely to bring me down, derail my productivity and diminish my sense of mastery. I finally eat breakfast—again, noticing and dealing with a lack of appetite when depressed is not my strong suit. In the past, I’ve turned to meal replacements like Ensure when my MDD makes meal prep impossible.

Getting Back in Touch with the Body

Despite the day’s small victories, I’m still struggling with my connection to reality. When depressed, it’s easy for me to automatically slip into dissociation. Dissociation is basically a break in how the mind handles information. In my case, I feel disconnected from my thoughts, feelings, and surroundings. When feelings seem too distant or difficult to access, sometimes the easiest way to get back in touch with them is through the body. I try to exercise daily but when I’m this blue anything overly strenuous feels about as possible as sprouting wings and taking flight. Instead, I turn to a restorative yoga session designed for depression. I find restorative and yin yoga to be the most helpful in treating depression as these types of yoga are very soothing to the nervous system. The class I select is full of gentle supported inversions that meet my energetic limitations and help to physically shift my perspective. I’m reminded during the session that painful experiences can lead to positive transformation—the gentler version of lesson I picked up through dialectical behaviour therapy (DBT): sometimes, the only way out of hell is through it. By the end of the class, I’m closer to seeing this depression as a healing opportunity, not a problem to be fixed, and I understand the only way to shift the feeling is by experiencing it fully.

Accumulating Positive Emotions

Following my yoga session, I’m ready to practice the “A” of ABC PLEASE—accumulating positive emotions with a focus on the long-term (a good exercise as depression tends to send me backwards into the past). To accumulate positive emotions, I have to start doing what I need to build the life I want right away. I identify a few values that are important to me—being productive and being part of a supportive community—and pick the latter to work on. A goal related to this value is to do a better job cultivating my relationships, and the smallest action step I can take toward this goal is simply socializing. 

I start with my partner but his day isn’t going so well either. My instincts tell me I should focus all of my energy toward lifting his spirits; however, I’m still running on next-to-empty emotionally and have to take care of myself before I can help anyone else. I call my grandmothers to achieve my action step. Since my emotional sensitivity means my moods are very likely to be impacted by the emotional states of others, I guide my calls toward happier topics. My Granny’s soothing and reliable advice and my Grandma Kath’s open and empathetic heart are exactly what I need. I want to keep engaging with others, so I message some friends I feel really comfortable with. I feel satisfied with the action step I have taken toward being part of a supportive community, and am ready to try being productive.

I cruise through some Instagram stories of artists and writers who I find inspiring and gather some of the necessary energy to write as my first action step. It works, and I’m able to start drafting this newsletter (so meta). Although I give myself permission to cut my daily word count in half, I end up exceeding it. I do have one work-related call I have to manage, but it’s with a person who I feel comfortable with, otherwise I might have cancelled it. On days when I’m depressed, recognizing and reinforcing my boundaries can be more restorative than trying to steamroll through my to-do list for productivity’s sake.

My mood is still tenuous enough that when I head upstairs for another attempt at an encounter with my partner, it proves difficult. He’s battling his own bad day and though my whole heart wants to help pull him through it, I feel the fog of depression grow thicker when he vents about his frustrations. A tightness grows in my chest, and I recognize a panic attack is coming. Since neither of us is in a place to help each other, I ask my partner for a little space so I can re-centre myself and come back to the conversation with a little more room for him. Luckily, he’s very understanding, and we live in an apartment that stretches over two floors, so I’m able to pop on some Seinfeld (go ahead, make your Newman jokes), distract myself from my feelings for a bit, and return to a deactivated emotional state. Though I still can’t fix my partner’s mood when we have another conversation, I have a lot more space to listen to his feelings without taking them personally and getting upset.

To keep my emotional vulnerability low, I make a real effort to eat and prepare what I call a “snacky dinner”—cut up vegetables, cheeses, and crackers—all I can manage tonight. I avoid drinking. Though I might occasionally have a beer (or two) with dinner when I’m this depressed, I recognize alcohol is only going to make me more emotional, impact my sleep, and lead to turmoil I’m in no place to manage. As evening settles over the day, I check in with my emotional state. Accomplishing reasonable but necessary tasks has improved my self-esteem, which has extended to my mood. I managed a potentially emotionally reactive confrontation with my partner relatively gracefully, which also helped with my self-worth. I’ve been able to shift my perspective around depression to a gentler understanding that it might be necessary for me to experience it in order to move forward. 

Hopefully, a look into my depressed day will help you identify strategies to manage your own.

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Mad History

This issue: A brief history of electroconvulsive therapy (ECT)

I’m a person with lived mental health experience who tends to view electroconvulsive therapy (ECT), or shock therapy, as a form of medical abuse. As bad as my depression gets, you couldn’t bribe me with all of the money in the world to allow someone to mess around inside of my (already delicate) brain. However, many medical professionals and patients consider it an effective treatment for severe depression, and one that’s still in use today. In fact, a 36-year-old American woman recently made news for being the first person to receive an electrical brain implant to treat her severe depression.

ECT works by using electricity to induce seizures. Back in 1934, Ladislas J. Meduna, a Hungarian-Jewish psychiatrist and neuropathologist, theorized that seizures could be used to treat psychiatric disease. He induced a generalized tonic-clonic seizure into a catatonic patient who, after several treatments, was soon able to walk, speak, and feed himself; however, Meduna’s technique took minutes to work, during which time patients would experience a profound sense of terror. Seeking to improve on his technique, a team of Italian physicians led by Ugo Cerletti and Lucio Bini, started electrocuting dogs from mouth to anus before determining it was probably better to focus exclusively on the head. Their first human patient, a 39-year-old man diagnosed with schizophrenia, received 110 volts of alternating current for 0.2 seconds to successfully induce a seizure. After ten treatments, the man was able to return to his family and his job in the community.

From there, the technique spread through Europe and North America, where it was first used in 1940. Early use of ECT was physically dangerous—patients were awake during the procedure, felt the pain of the electricity, and broken bones were a common result of seizures. Today, those dangers can be mitigated through the use of anaesthesia and muscle relaxants (though a 2010 review of 14 Asian countries found that 56 per cent of patients received the treatment without these). By the 1950s through to the 1960s, ECT was being used to control difficult patients and “treat” homosexuality. With the rise of the anti-psychiatry movement in the 1960s and 1970s, ECT use declined in North America; however, it returned in the early 1980s to treat severe depression. Though there are advancements in how ECT is administered today, researchers still aren’t sure exactly how it works to improve depression, the treatment can cause permanent memory loss and brain damage, and its efficacy is debated even among medical professionals.

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Recommended Reading

Depressed and Anxious: The Dialectical Behaviour Therapy Workbook for Overcoming Depression and Anxiety
By: Thomas Marra

Most of the strategies I used to get through my depressed day are informed by DBT. Marra’s Depressed and Anxious breaks down exactly how to use DBT skills like mindfulness, emotional regulation, distress tolerance, and strategic behaviour to treat depression and anxiety. And, for days when even reading seems like too much, there’s a handy, “Symptoms and How to Treat Them” section that guides a reader through helpful DBT skills based on the symptom they’re experiencing.