A few thoughts on depression

This post isn't about economics at all, just to warn you.

Like everyone else, I'm very sad to hear about the suicide of Aaron Swartz, the gifted programmer and activist. I had heard of him a few times, but never really knew all the things he did. I wish I could have known him. Really, that's the worst thing about people dying...all the living people who will never get to benefit from their continued existence.

What do I have to say about Swartz' death? Well, maybe a little bit, since Swartz is said to have suffered from clinical depression. I do know a little bit about this topic, since I myself have struggled with depression for over a decade. Mine was first triggered by the sudden death of my mother in 1999, although I also have a family history of depression on my mom's side (the Swartz side, ironically, though I don't think Aaron and I were related). 

Obviously, everyone's experience of depression is different, so I don't intend these thoughts to be a universal guide or general theory. Also, bipolar disorder, or "manic depression", is another thing entirely. But that said, here are my thoughts on depression.

1. Depression is not sadness. During the most intense part of a major-depressive episode, what I've felt is nothing at all like sadness. Mostly, it's a kind of numbness, and utter lack of desire and will. Underneath that numbness, there's the sense that something awful is happening - there's a very small voice screaming in the back of your mind, but you hear it only faintly. There's an uncomfortable wrongness to everything, like the world is twisted and broken in some terrible but unidentifiable way. You feel numb, but it's an incredibly bad sort of numbness. This is accompanied by a strange lack of volition - if a genie popped out and offered me three wishes at the depth of my depression, my first wish would be for him to go away and not bother me about the other two. Looking back on this experience, I've conjectured that part of depression might be like some kind of mental "fire sprinkler system" - the brain just floods the building completely to keep it from burning down.

Depressed people often remark that it's impossible to remember what depression is like after it's over, and impossible to imagine feeling any other way when you're in the middle of it. Therefore, most of what I'm saying here comes from things I wrote when I was in the middle of major depressive episodes. I think my most colorful description was that depression was like "being staked out in the middle of a burning desert with a spear through your chest pinning you to the ground, with your eyelids cut off, staring up at the burning sun...forever." 

2. Coming out of depression is the most dangerous time. Coming out of depression, I've found, is like having your emotional system turned back on. But when it's turning back on, it sputters and backfires. You feel incredibly raw. You have days where you feel elated, like you're walking on air. And you have days when you feel black despair, rage, hysterical sadness. These latter are the only times that I've seriously thought about harming myself. And I've done a few...unwise things during these periods.

One of the most common negative episodes, for me, is what I've heard people call the "spiral" - a flood of negative emotions makes you feel like you're bringing down the people around you, which triggers more negative emotions, etc. I often experience this when coming out of depression. It comes on very rapidly. If you see this happening to a depressed person, get them away from large groups of people and high-energy social situations, as fast as possible.

3. Depressed people don't need good listeners, a sympathetic ear, or a shoulder to cry on. Most of the time, when our friends are having life problems, what they need is a sympathetic ear. They need someone to listen to their problems, to understand and accept the validity of their feelings, and to empathize. So when our friends have depression, the natural urge is to sit there and listen, and ask "What's it like?", and "Why do you feel that way?", and to nod, and make a concerned face, and tell them you understand (even though you don't), and to give them a hug. This is a good impulse, but when the person is depressed rather than sad, it's a completely misplaced impulse. This is not what depressed people need, and although it doesn't hurt them, in my experience it doesn't do them any good at all. One reason is that depressed people tend not to think that anyone can really understand what they're going through (and in fact it's very hard for a non-depressed person to understand, thank God). Another is that, while for a normal sad person, getting negative thoughts out in the open helps expunge them, for depressed people airing the negative thoughts just forces them to think their negative thoughts, without expunging them. Another is that the emotional disconnection that I mentioned in point 1 tends to short-circuit the warm, good feeling that usually comes from someone being sympathetic and friendly toward you.

4. Depressed people do need human company. For some reason, human company helps. In fact, it is the single thing that helps the most. But not the kind of company a sad person needs. What a depressed person needs is simply to talk to people, not about their problems or their negative thoughts or their depression, but about anything else - music, animals, science. The most helpful topic of conversation, I've found, is absurdity - just talking about utterly ridiculous things, gross things, vulgar offensive things, bizarre things. Shared activities, like going on a hike or playing sports, are OK, but talking is much, much more important. I really have never figured out why this works, but it does.

And of course, relationships are very, very important. Friends, I think, are the most important, because friends offer opportunity for understanding and positive interaction without much feeling of obligation or shame (see point 6). Family and lovers are important, but really, the friendship component of these relationships has to dominate, so the depressed person doesn't constantly think negative thoughts about how they've let you down. Essentially, to help a depressed person, friends need to become a bit more like family, and family a bit more like friends. Also, you should realize that just because your depressed friend or family member is unresponsive, that doesn't mean that you aren't doing him or her a lot of good.

5. Cognitive behavioral therapy really works. I've taken one antidepressant drug (Lexapro), but it did nothing perceptible for me. (This is not to say that antidepressants in general don't work; for that, ask PubMed. This is just about my personal experience.) What has worked for me is cognitive behavioral therapy. The "cognitive part" is the most important. Basically, depressed people have negative thoughts that they can't get out of their head; cognitive therapy teaches you to habitually identify, examine, and correct these negative thoughts. That really helps; once those negative thoughts aren't always racing unnoticed through the back of your mind, your brain has a much easier time repairing the damage done by a depressive episode. Also, "behavioral" therapies can be important for improving your lifestyle. 

Cognitive behavioral therapy is best done by a counseling therapist, and there are many good therapists, but also many crappy ones. It is easy to see who is good and who is crappy, but since depressed people have low volition, sometimes they need a push to ditch a bad therapist and keep looking for a good one.

6. Depressed people may need a new "narrative". I've also called this a "new perspective", but I think the word "narrative" fits better. I've discussed my "narrative theory of depression" at length with psychotherapists. Keep in mind that this theory of mine might be wrong, and even if it's right, it might only be right for a subset of depressed people!

Basically, I think that the most important repetitive negative thought that afflicts depressed people is negative self-evaluation. You think, in a very detached, dissociated way, "The person who I call 'me' is a worthless person." And I think that the main criterion that we use to evaluate people is the narrative; a story that seems to unify and make sense of a person's life. Obviously, this is not a realistic or accurate method; human beings are not consistent, we are not simple, and we don't make sense. The narratives that we construct for ourselves are mostly bullshit. We construct them out of a need to make sense of the world, not as rational scientific theories that best fit the available data. 

I feel like most people construct a narrative of their life that is basically positive. People tend to think that they are good, and also talented and special, and that their life is progressing toward some purpose. We are each the protagonist in our own story. This narrative gives them motivation, and also the overconfidence they need to take risks and exert effort (Ha! I managed to slip in a behavioral econ reference after all!). People also strive to fit their positive narratives. The part of people that conducts self-evaluations - the "internal performance review" component of the psyche, if you will - observes how well the person is living up to the positive narrative, and tries to correct deviations.

But sometimes, for some reason, people become fixated on a negative personal narrative. Instead of the protagonist or hero of the story of your life, you become the villain, or the tragedic failure. Instead of Luke Skywalker, you become Oedipus. And because we construct our narratives to have false consistency, the negative narrative starts to color absolutely everything you do. You start to see every action you take as backed by bad motives, or as doomed to failure. You perceive every emotion as base and reprehensible. The "internal performance review" part of yourself, whose task it usually to keep you toeing the line of the positive narrative, begins to throw up its hands and wish that it could just get rid of you completely.

Obviously, this could lead to some very bad things.

I believe that many depressed people are constantly afflicted by the crushing negative feedback of a negative personal narrative. And I've found that the biggest single thing that helps people out of depression is the scrapping of the negative narrative and its replacement with a positive alternative narrative. This is usually possible, because narratives are mostly constructed out of bullshit - replace the bad bullshit with good bullshit, and you win. But that is much easier said than done.

If you have depressed friends, you can, in theory, help them construct a new, positive narrative for themselves. But this is a very difficult thing to do, because a coherent, believable narrative is a rare thing, and you never quite know what will stick and what will be rejected. The good news is, if you try and fail, your depressed friend will be no worse off. Remember, depressed people are weak-willed, they have low volition and little initiative; to help your depressed friend construct a new narrative, you have to be pro-active. You've got to spontaneously volunteer positive perspectives on his or her life, without being asked to do so. 

This goes against our social instincts, since with a normal, non-depressed sad friend, doing this is kind of a mean thing to do; the friend just needs you to listen and understand, not to contradict, reinterpret, and dismiss their pain. But a depressed person is not sad, and what they need is very different from what a non-depressed sad friend needs. I'm not saying you should be an aggressive jerk, and berate your friends for thinking negative thoughts. Nor am I saying you should project fake sunny optimism about your friend's life. It takes a lot more honesty than that, not to mention finesse and creativity and careful guesswork about the nature of your friend's "negative narrative". So go slowly and carefully.

As for what kind of positive narrative to help your depressed friend construct...well, this will be very different for each person, and it will depend on what kind of negative narrative they've constructed for themselves. In general, though, I'd say that it's good to reinterpret past "failures" as necessary steps on the road to future successes. And it's important to emphasize how much potential the depressed person still has in their future - like in the movie City Slickers, when Billy Crystal convinces his depressed friend that he gets to have a "do-over" in life. In general, if you can help a depressed person visualize a different and positive future, he or she will entertain the notion that his or her past "mistakes" might have just been "Act Two" in a three-act romance, instead of the final act in a Greek tragedy.

Now, I am not saying that construction of this "new narrative" is a cure for depression. It is a complement to things like cognitive behavioral therapy, constant low-pressure human interaction, a healthy lifestyle, etc.

7. Depressed people always need to be vigilant against a relapse. Depression is like cancer - once you have it, it remits, possibly forever, but you are never "cured". Relapses are not certain, but the danger will always be there. Therefore, after recovering from a depressive episode, a depressed person must change his or her life completely and permanently. The things that you did to get out of depression, you must never stop doing for the rest of your life. You must permanently place a greater emphasis on human contact and on meaningful, positive, healthy relationships of all kinds. You must constantly think about what makes you happy and how to get it, and you must constantly take steps toward a positive future that you envision for yourself. If you allow yourself to coast, or get stuck in a rut, you will fall back into the pit and have to start all over again. And if therapy helped you, keep going to therapy forever. What's more, if you get out of depression, do lots of things to remind you about what got you out of it. Turn it into a story of personal triumph, and repeat that story to yourself. And never forget to solidify, cement, embellish, and elaborate a positive narrative of your life.

Anyway, that's the short version of my thoughts on depression. The long version could fill books. Maybe someday it will. In the meantime, remember, depression is real. It's among the worst things that can happen to you. But it is beatable.