6 signs of depression

Offenders’ deadly thoughts may hold answer to reducing crime

The findings also have implications for criminal justice and sentencing reform. DeLisi says most of these offenders are psychopaths who are unlikely to be rehabilitated without sustained, intensive treatment. However, treatment is often unsuccessful because of the time and resources required. DeLisi explained that most offenders don’t have insurance, and often fail to maintain their medications once they’re released from prison. The best option is for judges to mandate mental health treatment, including medication coupled with intensive supervision that puts officer safety at the forefront, he said.

“It’s important to understand these offenders because they commit so many more severe crimes, which allows you to do more from a policy perspective,” DeLisi said. “Many of these offenders should probably never be released from confinement, and we may need to rethink sentencing guidelines for these individuals.”

DeLisi believes these offenders may require a “containment” approach used to supervise sex offenders in the community, with the premise that protection of society, not rehabilitation of the offender, is the prominent goal. He says the collaboration with U.S. Probation also identified low-risk offenders who may do better with community-based supervision or sanctions, instead of prison. The team is currently conducting research on the lower-risk group of offenders.

Getting Through the Day When You Have Crippling Depression

By Stephanie Kirby

Updated November 19, 2019

Reviewer Wendy Boring-Bray, DBH, LPC

When you have crippling depression, sometimes just getting through the day is a big challenge. There are days when you don’t even want to get out of bed. When you’re depressed, it’s important not to be too hard on yourself. Even showering and getting dressed are big achievements. It’s okay to ask for help-and know there are treatments (like medication and therapy) that can help you move forward, to doing things you used to enjoy.

Wondering How To Get Through Your Days With Crippling Depression? We Understand. Talk To A Licensed Professional Counselor Today.

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What Is Crippling Depression?

There’s some disagreement on the definition of crippling depression. Generally, crippling depression is clinical depression (also known as major depression or major depressive disorder) that is so bad it affects a person’s ability to function on a basic level. It interferes with a person’s work, life, and relationships.

Are you or someone you know suffering from depression that’s having a negative impact on your quality of life? It’s important to speak to your doctor or a medical professional to get a diagnosis, so you will be able to consider the different treatment options available to you.

Some symptoms of clinical depression include:

  • Feelings of sadness and hopelessness
  • Sleep disturbances (sleeping too much or too little)
  • Weight loss or weight gain
  • Sudden angry outbursts
  • Slowed thought, speech, and physical movements
  • Loss of interest in usual interests or activities
  • Suicidal thoughts and/or attempts

To be diagnosed with clinical depression, patients must report experiencing a depressed mood for most of the day, daily for at least two weeks.

How Do You Get through the Day with Crippling Depression?

When you struggle with depression, life will look different than it does on days that you’re doing well. While each person might respond differently to depression, there are some things you can try that help the majority of people. See which ones help you the most.

Get into a Routine

Trying to follow a basic routine every day (or even five days a week) can give you structure and help you get going even when you aren’t feeling up to it. What makes you feel good and ready to get your day started in the morning? Having your clothes laid out the night before, jumping in the shower, then eating breakfast with a nice cup of coffee or tea?

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Design your routine the way you like it so getting up and going through your day won’t feel like too much of a drag. Make sure you schedule self-care into your week too! Planning a nice long bath to relax after a stressful day during the week can make a big difference in how you feel.

Forgive Yourself

When you have crippling depression, you need to accept that you’re going to have good days and bad days. As much as you might try to plan and prepare, there will be days when you aren’t feeling up to doing anything, and that’s okay. Being too hard on yourself will make things worse. Allow yourself the time you need to feel better and know that tomorrow is a new day.

Sometimes we are way too hard on ourselves and imagine that the world can’t go on without us. You might panic at the thought of calling into work or worry that if you take a nap, you might miss picking up your kids from school. Cut yourself some slack. You might be surprised to find that your boss and co-workers are understanding and want you to get better, or a family member might be more than happy to pick up your kids from school to give you a break.

Have a Support System

A strong support system is an excellent way to complement the treatment for your clinical depression. A support system that consists of friends, family, doctors, and therapists can help you get through your worst depressive episodes and potentially help you keep your depression under control so that future episodes are less frequent, or at least less severe.

Wondering How To Get Through Your Days With Crippling Depression? We Understand. Talk To A Licensed Professional Counselor Today.

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It’s important that your support system is understanding and knows at least a little bit about how depression works. The wrong approach can be less than helpful, which is why it’s important to surround yourself with the right people. Let your friends and family know that sometimes you may just need them to be around, help around the house a little, or listen when you need to talk.

Celebrate Wins (Big and Small)

Just like it’s important to forgive yourself when you need rest, it’s also important that you celebrate wins when you’re feeling depressed. From making your bed in the morning to going to work all week without calling in sick or leaving early, it’s important that you recognize that you can do things despite your depression. You deserve to live a happy life and to celebrate wins, big or small.

When you’ve been doing well for a while, or you’ve been pushing through despite wanting to curl up in bed all day, give yourself credit. Noticing when you do. Experiencing good moments is a great way to turn the focus off things making you feel down. If you only focus on what you do wrong, you’re going to keep yourself in a depressed frame of mind longer.

Physical Exercise

Taking good care of yourself can be hard but it’s important. Take the time to work exercise (enough to sweat) into your day. Like other responsibilities, sometimes we’d rather curl up and watch TV instead of taking time out of our day to work out or do something else that’s good for us. Just remember that a little exercise can go a long way: research shows that physical exercise is an effective form of treatment for depression.

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Keep in mind that exercise doesn’t have to be complicated. It can be as simple as doing five pushups, and 20 sit-ups, and repeating until you start to sweat. Just remember to stretch, and take deep breaths. It’s important to note that this article is not suggesting physical exercise as a form of treatment for depression to belittle the seriousness of depression. It’s because of the well-documented benefits of exercise (for legitimately treating depression) that physical exercise made it on this list.

Working with a Therapist

Working with a mental health professional can be an important part of learning how to overcome depression. Not only can they help you identify triggers, but they can help you learn coping strategies you can use when your depression hits hard.

If you struggle with depression, the last thing you might want to do is drive to a therapist’s office for a session. If that sounds like you, online therapy with BetterHelp could be a great solution. It allows you access to trained professionals right from the comfort of your home. And you can be in contact with them on a more regular basis, which can help during the tough times. Consider the following reviews of BetterHelp therapists below.

Counselor Reviews

“I have only been working with Emily Priestaf for about a week but she has already helped give me ideas on how to help beat my depression and get back into doing the things I love. She is very encouraging and helps talk me through what I’m feeling. Being back in therapy has helped a lot and I couldn’t be more grateful to have her as my therapist.

“Tim has given me some amazing insights to contemplate. He has offered me different ways of viewing my problems and approaching them. He has given me concrete tools to use to manage my stress and improve my depression. He is incredibly responsive and helpful. I’m blown away by how much I like this platform and how helpful Tim has been.”

Conclusion

If you’re living with crippling depression, try implementing the tips above to find what helps you make it through the day. No matter what, you can get through this. All you need are the right tools. Take the first step.

Depression is routinely described as an “epidemic”. The World Health Organisation predicts that the illness will soon be the second-biggest public health risk after heart disease. Young people, as this newspaper reported recently, are more likely to die from depression than from Aids, cancer and heart disease combined. One person in 20 in Britain is now clinically depressed – about three million in total – and one in five of us will suffer from depression at some point in our lives.

Yet I suspect that the true picture is even worse. The statistics all scream about one form of depression, but I believe that there is another form, much less recognised, that affects millions more people, especially men. I first wondered about this in relation to my own breakdown. It happened over the course of just a few days, in the spring of 1996. I went from a high-octane, glamorous life as a New Labour high flyer to being scarcely able to muster the self-confidence to go to the corner shop for milk. It felt at the time as though I was fine one day, and the next completely crippled. But could such a catastrophic depression really have sprung from nowhere?

At first I thought I had a virus, but after a week or so I realised that physically I felt fine. I wasn’t too tired or ill to get up and about, I just had no inclination to do so. I felt bereft, alone (though I wasn’t) and hopeless. I had to recognise the surprising but inescapable fact that I was depressed. I started to tell people, which wasn’t easy, but it did come as a sort of relief. To be fair to the world of Westminster, people were sympathetic, supportive and ready to give me time to recover.

Little did they, or I, know that recovery would take years. For the first two years I eschewed therapy and stuck to medication (first Prozac, then Effexor). This warded off the worst of it and I was able to work in fits and starts. Many the day, though, I would return from lunch with a journalist or some radio or TV gig and collapse in bed with the covers pulled over my head.

Eventually, I gave in to my friend’s urging and went to see a therapist. I started the painful process of examining what had gone so wrong for me, rather than just trying to patch up the wound and soldier on. It was not easy but after two years of once-a-week sessions, I felt I had regained some equilibrium. I had also found something I wanted to do with my life. I wanted to try and help others in the way that I had been helped.

In 2001, I left London for Berkeley, California, where I spent three years training to be a psychotherapist. As I began working with patients in a local community clinic, I noticed a pattern emerging. People would come to therapy with a variety of problems, but, after a few months, it transpired again and again that below the surface was a hidden reservoir of profound melancholia. A depression that they had been hitherto unaware of, except perhaps in the most dim and fleeting way.

I was also struck by the statistic that 70% of people who commit suicide are depressed – that is to say, were showing the classic symptoms prior to taking their own life. But what about the other 30%? Some were doubtless hiding their depression from those close to them, but as anyone who has suffered the illness will tell you, that’s quite a trick to pull off over any length of time. I suspect that their depression was actually masked from themselves.

This becomes explicable if we consider the possibility that not one but two types of depression exist. The classic variety, with its familiar list of symptoms and behaviours – joylessness, sleep problems, feelings of hopelessness and so on – I would call blatant depression. One of my friends said she could always tell if I was depressed, before I had even uttered a word. “It’s in your eyes,” she would say. “They’re dead.” The other type – and the one I believe may be the true hidden epidemic – I would call latent depression. It remains hidden not only from the outside world, but from oneself.

I’ve come across five main ways in which this phenomenon is masked, but in order to understand what may be happening, we need to first understand the true meaning of depression. There is a tendency to consider it just a set of behaviours; symptoms to be ticked off on a medical checklist, but at its cold heart, depression is not a preponderance of certain behaviours or feelings. It is an absence of something – contentment, ease, a sense of aliveness. It is, in fact, a sort of death.

In blatant depression, this is easily seen, and is part of any sufferer’s self-description. But in latent depression, that absence is not expressed or even acknowledged. Instead, it is covered up. Many people with latent depression appear to be functioning very productively, and if anyone asked them if they felt dead, they would think the question absurd. What matters, however, isn’t “feeling” dead, but “being” dead.

Before I became blatantly depressed, I was neither happy or unhappy. My life was a heady mixture of sensation and disassociation, chasing one buzz after another, cut off from any real feelings. In 1998, a scandal known as Lobbygate provoked my deepest slide yet – the one that finally pushed me into therapy. I was taped by an undercover journalist boasting: “There are 17 people who count in this government, and to say I am intimate with all of them is the understatement of the century.” The irony is, I wasn’t capable of being intimate with anyone.

My depression didn’t come out of the blue. It just came out into the open. I had masked it with grandiose, high-powered but self-centred living. Others mask theirs by spending huge amounts of time and energy constructing other ways to suffer, so that the real demon need never be faced. Anxiety, addictions, compulsions (perhaps an obsession with work or shopping), aggression and an emotional detachment from others may all be disguising depression from oneself and the outside world.

Similarly, psychosomatic illnesses, aches and pains, especially backaches, eating disorders and self-harm by cutting all provide ways of converting latent depression into something more visible and, though it is hard to believe, more bearable.

One clue that all these conditions and behaviours may have an underlying connection to depression is that they can often be treated with the very same drugs that alleviate blatant depression. Prozac or other drugs in the SSRI family are prescribed for anxiety, eating disorders, alcoholism and obsessive-compulsive disorder, indicating, at the very least, that there are overlaps in the underlying brain chemistry of these conditions.

These phenomena may not always mask depression, of course. But my own experience, as both a patient and a therapist, makes me believe that latent depression is more common than we think. It may be more widespread, in fact, than its more blatant brother.

However, if the body and mind have devised ingenious methods of keeping you and your depression unacquainted, where is the benefit in digging through a layer of vaguely problematic behaviour – a weakness with credit cards and drink, say – if the prize waiting for you underneath is full-blown depression?

It is a question, of course, of degree: how significant are the effects of someone’s chosen “mask”. Maybe its burden has become too high a price to pay, preventing the finding of fulfilling work; or a successful relationship; or a sense of balance; or just a moment’s peace.

Only by dealing with underlying depressive feelings will the mind be freed from clinging to its old patterns for warding them off. If latent depression is acknowledged and faced up to there is the potential to live in a fuller, richer, more meaningful way. For if depression is not just about a set of particular symptoms but is actually emotional – and psychic – deadness, the possibility held out by change is no less than life.

After a depression it takes a long time to feel truly alive again, and I learned that your life may change quite fundamentally in the process. I am newly back in London, busy setting up my own therapy practice, which will provide treatment for a wide range of emotional and psychological problems, including depression, anxiety, addiction and intimacy issues. It is a far cry from the Westminster and Soho high life.

I haven’t taken antidepressants for the past year and so far have yet to slide back into depression, though on certain days I am conscious of it hovering over me, like a ghost. To make sure it stays exorcised I still see someone – I’m currently undergoing psychoanalysis, which is a deeper, more frequent form of therapy. I want to be sure that as well as avoiding depression’s blatant manifestation I keep its more latent forms at bay too.

DGC started tweeting about her experiences with mental illness in mid-2013, when she was still in college. She now has more than 87,000 followers. DGC interacts with people who reach out to her with questions and concerns about mental health and has become a resource for people struggling against the stigma. Here, she tells her story.

I was always drinking to the point of oblivion. It was impossible for me to go out and socially drink without getting hammered. It got really bad at school, but I would tell myself that I was 21, that this is what people do in college, that self-medicating this way was OK. But in the back of my mind, I knew it wasn’t. Once you realize you’re not drinking socially, and that you’re drinking to make your problems go away, it hits you. I realized over time I would do anything to be happy and that’s what did it. I was totally willing to go through life drunk, honestly. And I was willing to do it forever if it meant that I didn’t have to tell anyone that I was unhappy.

My secret was just that. I was so unhappy, and I didn’t know where to turn. For years, I hid everything from my parents. Nothing was ever wrong, per se, but the unhappiness got worse and worse. I smiled when I was supposed to and functioned like I was supposed to, but I just wasn’t happy. My parents didn’t want to believe that there was something wrong, because I assured them I was repeatedly that I was fine. But they absolutely suspected problems.

I’ve always been close to my parents, but I stopped coming home just because I didn’t want to admit something was wrong. I was afraid of their reactions. They’ve given me an incredible life! They are wonderful parents, but I was just dissatisfied so I shut them out. All my relationships faltered at that point in my life. I shut out friends, too, who knew something was up with me. I surrounded myself with people who faced mental health issues, too, and had not yet come to terms with it, either. I knew that none of it was OK and it made me sick.

Eventually, it broke me. I was on medication for awhile and never filled my prescription when I was supposed to. I would tell myself always, “I’ll do it tomorrow…” But I just kept having bad weeks and never refilled it. The withdrawals from medication that configures your brain chemistry are brutal. I went to my doctor knowing I’d have to start the medication again.

When you go in, they make you fill out basic intake questions. “On a scale of 1-10, how many days do you feel like a failure?” etc. I was relatively honest, but nothing really resonated with me. When I was called in, a doctor I didn’t normally have asked me if I ever felt suicidal before. It was then that I broke. Honestly, I don’t even think I said anything. Right then and there I collapsed to the ground. It was such a blur to me, it happened so fast. It’s hard for me to relive, I guess. I don’t know if I would have committed suicide — that was something that pushed me over the edge because that’s never something you just shouldn’t know. It was a question I thought a lot about, but I always brushed it away as a selfish thought. That was the breakdown that led to my hospitalization.

Until this point, I didn’t receive help in college even though I knew there was something wrong with the way I handled situations and life in general. My partying got a little out of control, but drinking when I was sad to forget my problems was happening all the time. It was an absolutely unhealthy escape. I was under the impression that it would be selfish to get help. Honestly, I was plagued by the stigma that I now aim to end. It scares me to know that there are so many people our age who are in same boat as me. That’s why I knew I had to become so vocal about it.

When I came home after my hospitalization, it took me a long time to tell people. I deleted my Twitter account and deactivated my Facebook. I was so upset and still felt selfish. Within the next few days, though, some of my closer friends and family encouraged me. They helped me understand that this was not something I should be ashamed of.

I slowly got back into social media and let people know what happened to me. Once I started talking about it, the feedback I got was quite surreal. People just email me and say, “I know exactly what you went through,” and “I just need to get this off my chest.” That’s when I started talking about the good and the bad. My followers aren’t looking for advice, necessarily, but I think sometimes they just need someone who can listen or someone who can relate. I realized awhile ago that one of the healthier ways I would self-medicate was by writing. I also realized that when I would tweet anonymously and get this incredible feedback, it was easier to handle. My handle is more of a pen name than anything else.

The worst thing is when someone who is beautiful, successful, and smart decides to end his or her life and people say, “Oh, what a shame. She was so pretty. Why would she do that?” People need to know that depression is not always situational. Sometimes you are born with a biological condition and you cannot help yourself.

I remind people that I am not a counselor. I have no medical or professional experience, but I am merely speaking from my own experiences. I encourage people to get help. It is not as scary as it seems. It takes time to find the right medication and therapist. It definitely took months for me to feel something, to feel happy, but it was worth all the hard work to get there.

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Tess Koman Senior Editor Tess Koman covers breaking (food) news, opinion pieces, and features on larger happenings in the food world.

Talking about suicide can be a scary subject. But the more people are willing to talk with a friend or family member about suicidal thoughts, the more likely they can help someone take positive steps towards healing.

Many people assume that if you ask someone if they have suicidal thoughts, that you can put the idea into their head. This is a myth, and mental health professionals encourage people to ask important questions and gather facts to help someone who is depressed or feels hopeless. When someone is contemplating suicide, their words and actions can give you clues that they are at risk for hurting themselves.

People can become suicidal when they feel overwhelmed by life’s challenges. They lack hope for the future, and they see suicide as the only solution. It’s sort of a tunnel vision where other options seem useless. Having a family history of suicide or impulsive behavior is also believed to increase risk of suicidality.

Other risk factors can include:

  • History of substance abuse
  • Access to firearms
  • Difficult life events
  • Isolation from others
  • History of mental illness
  • History of physical or sexual abuse
  • Having a terminal or chronic illness
  • Past suicide attempts

The more signs you see, the higher the risk there is for suicide. Though talking about dying is an obvious sign, there are many others that can indicate risk. There are emotional, verbal, and behavior clues you can observe.

Emotional Markers can include:

  • Feeling depressed
  • Lack of interest in activities once enjoyed
  • Irritability
  • Anger
  • Anxiety
  • Shame or humiliation
  • Mood swings

Verbal Markers include talking about:

  • Killing themselves
  • Their life having no purpose
  • Feeling like a burden
  • Feeling stuck
  • Not wanting to exist

There are two types of suicidal statements or thoughts. An active statement might be something like, “I’m going to kill myself.” A passive statement might include, “I wish I could go to sleep and not wake up,” or, “I wouldn’t mind if I got hit by a bus.” People often ignore passive statements, but they should be taken just as seriously.

Behavioral Markers can include:

  • Isolating from others
  • Not communicating with friends or family
  • Giving away possessions or writing a will
  • Driving recklessly
  • Increased aggression
  • Increased drug and alcohol use
  • Searching about suicide on the Internet
  • Gathering materials (pills or a weapon)

Older adults also at increased risk for suicide, and they complete suicide at a higher rate than any other age group. They also are especially at risk because they do not usually seek counseling for depression and other mental illnesses. If you see an older adult who stops taking care of their hygiene, is eating poorly, and/or starts giving away their possessions, then you should help them talk to a mental health professional as soon as possible.

Warning Signs For Kids

Many people do not assume that children and teens can be at risk for suicide, but they can exhibit warning signs as well. If a child is talking about suicide or wanting to die, always take them seriously. An event or problem that might not seem like a big deal to an adult can be extremely stressful for a child or teenager. Children and teens might be at risk for suicide if they:

  • Experience bullying
  • Lose someone close to them
  • Experience physical, emotional, or sexual abuse
  • Abuse drugs or alcohol
  • Have a history of mental illness
  • Feel uncertain about their sexual orientation

What You Can Do Today?

If you see a loved one or even an acquaintance or colleague exhibiting any of these signs, you are not powerless to help them. Don’t hesitate to use specific language, such as asking, “Are you thinking about killing yourself?” If the answer is yes or maybe, ask them what they feel most comfortable doing, whether it’s calling a crisis hotline or scheduling a counseling or doctor’s appointment.

If a person is thinking of suicide, it’s also important to ask them if they have a plan. If they say yes, assist them in seeking immediately help. They can simply walk into an emergency room or urgent care clinic, or they can call 911. At any time they can also call 1-800-273-TALK (8255).

Suicide is preventable, and people who feel hopeless can go on to live full and healthy lives. While you can’t control another person’s action, you can be a powerful and intervening force in their lives. So what can you do today to help a loved one choose life?

Last Updated: Sep 9, 2019

In the fall of 2016, I landed a part-time job teaching writing to pre-med majors at Texas A&M University. In 2017, this turned into a dream, full-time position, and it seemed like my life was finally falling into place. Just a semester later, though, at the start of 2018, I experienced the worst panic attacks of my life.

I was holding things together at work, mostly, but a few times each week I closed my office door, turned off the lights, and crawled under my desk to bawl. I constantly suffered near-paralyzing fear, and it was affecting my students. I debated what it would mean to tell my class. Would students no longer respect me as an instructor?

I finally decided to share what I was going through, but, in nearly 20 years of teaching, I’d never been more terrified to be in front of students.

I don’t remember exactly what I said at the end of class that day, but I tried to describe the situation straightforwardly.

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Some of you, no doubt, have noticed that the class isn’t going smoothly. Readings haven’t been posted on time. Due dates for assignments have sometimes been confusing. I haven’t been getting feedback to you as quickly as I’d like. I pride myself on being on top of things, so I feel you deserve an explanation.

The explanation was this: for months, pressure had been building on me from so many different directions that it was almost inevitable that something would give.

Ever since I was a kid I had dreamed of getting a doctorate. I finally accomplished that goal, earning my PhD in biology in 2016. While immensely gratifying, that dream had come with a cost. I’d taken out as much in student loans as many people borrow to buy a house. I had no idea how much my payments might be, and as the date for repayment drew nearer, I couldn’t bear to find out.

Meanwhile, I was just starting to come out of the closet. By the end of 2017, most of my closest friends knew the secret I’d been hiding – even from myself – for 48 years. But many in my family didn’t, and I was desperately afraid of their rejection.

Since adolescence, cycles of anxiety and depression had been part of life, and they were predictable in their progression. If I just waited them out, they eventually dissipated.

While they were miserable in the moment, I’d come to look forward to a kind of rejuvenation I always felt at their end. However long they lasted, once the fog of depression lifted, I would be bursting with new ideas, filled with creative energy and a renewed sense of purpose.

This time, though, there was no end in sight, no resurrection, no rebirth. Death was becoming attractive. I knew I desperately needed help, and I knew it had to be now.

Even though I have health insurance, the demand for mental health services far exceeds supply and, it turns out, the start of the new year is an especially terrible time to seek psychological care. Counselors are busy catching up with clients and post-holiday paperwork. Voice messages never get returned. “First available” was often two months or more away, hardly helpful when I couldn’t see a future beyond two weeks. The choice between suicide and cold calling therapists may seem obvious, but I just didn’t have the strength to be turned away again.

My students were the slender thread that stayed my hands from doing myself harm. What would happen to them if I killed myself? How would my sudden death disrupt their graduation plans? As for my colleagues, they were already stretched thin teaching their own classes. I couldn’t burden them with more.

As hard as I’ve tried not to let my personal life interfere with my professional obligations, as all of you know, sometimes life just becomes too large to compartmentalize.

Before reaching the point where I felt compelled to confess, I had caught a lucky break. A clinic called to let me know that a counselor had an unexpected opening. I just needed to hold on for another week for my first appointment.

The morning of my first session, I was terrified. In fact, I almost ran out of the clinic before I was finally called back to a cozy office.

The counselor introduced herself and started explaining her background and doctor-patient confidentiality while I scratched at a red spot on my thumb, already rubbed raw from a nervous tic I’ve had since I was a kid. I had no idea where to begin, but fortunately I didn’t need to. The counselor had prepared questions and answering them proved comforting – even though it meant divulging things I’d never shared with anyone before. We scheduled weekly sessions, something to hold on to.

I saw signs of improvement over the next couple of weeks – small, silly things to anyone not living in my head. Checking the mail is hardly herculean, but I had avoided my mailbox for two months fearing the bills inside.

Just as things were looking up again, tragedy struck. My dad and stepmom had come to visit me the last weekend in January, an extremely rare treat. We’d had a good time as I showed them my apartment, my new office, and some of my favorite restaurants. They were worried – I’d let slip on social media that I was having panic attacks – but I deftly deflected any conversations that touched on my mental health.

We parted ways in the early afternoon. As they started the 200-mile drive back to Dallas, I hiked in the woods. About an hour later, still on the road, they tried to call me and I knew something must be wrong, especially since my mother, who was living in Nebraska, tried to call shortly afterward.

I found a clearing in the forest with phone service and called my mom. It turned out that my 45-year-old sister, Molly, was in a coma in a Montana hospital, and no one really knew what was happening.

If things were desperate before that call, I don’t know what words would describe the weeks that followed. Grief. Anxiety. Pressure. So much pressure. The dutiful son ripped to shreds from conflicting impulses. Mom all-but-asking me to stay away. Dad all-but-begging me to accompany him to see his daughter one last time.

My colleagues were supportive, offering to take over my classes if needed. I knew they were sincere, too, but that only heightened my anxiety. Academic jobs are hard to find and funding for my position wasn’t stable. What would happen if it looked like I was unreliable?

Even if I’d been able to overcome that set of fears, the logistics proved too much for me to cope with in my emotional state. When your sister lies close to death 1,500 miles away, what is the best time to show up at her bedside? Is it five days into her coma, when she won’t know you’re there but there are still hopeful signs she might recover? Is it on day 11, when her eyes finally open, but she’s at best only dimly aware of what’s happening? Or would it be more supportive to save my limited vacation days to help with funeral plans if it came to that?

Worst of all, I didn’t feel it was right to burden my parents with knowledge of my mental health struggles when they were grieving the impending loss of their daughter.

The facades of health and happiness and professional detachment were collapsing in on me. The only way I could see to relieve the pressure was to let the world see my brokenness. In that moment, how the world reacted hardly seemed to matter. So I explained to my students what was happening.

The day before Valentine’s Day, my younger sister passed away. About two weeks earlier she fell into a diabetic coma and, despite some false signs of hope, she was never able to recover. For over a month of this semester, I have been dealing with overwhelming uncertainty, worry and grief.

I’ve been suffering from major depression and anxiety. I’ve started counseling, and I’m starting to do better. I just felt you should know. As hard as y’all work for my class, I felt you needed an explanation for why you haven’t been getting my best.

Whatever the consequences might be, at least I’d been honest.

To my surprise, far from rejecting me, students stayed after class to tell me how sorry they were. They left condolence cards in my mailbox and sent emails to let me know they were praying for my family. They stopped by my office to check on me. Up to that point, I’d been so caught up in my despair that it never occurred to me that I might be worthy of concern and support. Being accepted despite my flaws touched me in ways that are hard to express.

What happened next, though, transformed me. In their condolences, students shared their own experiences with loss, grief, depression and anxiety – far more than I could have guessed for lives so young.

Encouraged by their candor and support, I continued to open up. For instance, when I started antidepressants a few weeks later, I warned students before my lecture that I might be a bit loopy because I was experiencing distracting tingling sensations. I expected students might look at me as though I were crazy. Instead, I saw heads nodding in recognition. Soon, students showed up at office hours to thank me. They had never heard a professor expose that side of themselves. They saw their own struggles reflected in my vulnerability, and they saw something else, too. They saw hope.

Our students struggle far more than we can imagine. We’re often unaware of their difficulties, largely because we only see them for a few hours each week, often in large groups. At the same time, students are crafting walls of feigned invulnerability and confidence in emulation of the masks faculty wear. From freshman year to full tenure, academic life is lived under constant scrutiny. Is it any wonder we fear revealing anything that might be perceived as weakness?

Since opening up about my mental health, students have given me a peek behind their facades, sharing their stories of grief and despair: the unexpected death of a parent, the suicide of a sibling, paralyzing panic, involuntary commitment to psychiatric hospitals, abusive relationships and more.

Importantly, they don’t view me as a counselor. While a few students have asked what to expect if they enter therapy, not one has asked me to help them work through psychological trauma. That’s not my job, nor is it theirs when I describe my own issues – students understand and respect that.

Mostly, I believe they share their stories because they desperately need to be understood by those who are shaping their lives and their careers. Struggling to succeed while grappling with mental health issues is difficult enough. Keeping that struggle secret – especially from those who evaluate your performance – is exhausting. A barely passing grade separated from a student’s lived experience seems like a mediocre effort. But in the context of crippling depression and anxiety, it becomes a monumental tribute to their dedication, drive and ability. When that same student earns an “A”, a letter grade hardly seems adequate to reflect the magnitude of their accomplishments.

Yes, part of our job as professors is to evaluate students’ performance objectively and honestly, and we do our best to prepare them for the “real world”, which can be unforgiving of mental health struggles. But students already know that life is hard. Far more of them have learned this basic lesson more intimately than anyone would like to acknowledge.

Perhaps, then, as teachers we should include in our lessons that it is possible to be successful even when life is hard. Students need to learn from our example, through our own authenticity, that mental illness does not sentence them to failure. Perhaps, above all, they need to learn that all of us deserve a little bit of grace.

  • This article was supported by the Economic Hardship Reporting Project.

  • In the UK and Ireland, Samaritans can be contacted on 116 123 or email [email protected] or [email protected] In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at www.befrienders.org.

Depression: A Killing Disease

PSYCHED! A PSYCHIATRY PODCAST
with David Carreon, MD and Jessica A. Gold, MD, MS

Depression is a killing disease: the effects of depression on the body beyond suicide

In the first part of this interview, Dr. Charles Nemeroff, Director of the University of Miami Center on Aging and Chairman of the Department of Psychiatry and Behavioral Sciences at University of Miami, discusses depression, including its symptoms, epidemiology, and the link to other physical illnesses like cardiovascular disease and diabetes. In particular, he discusses the role of depression in clot formation and inflammation. He then looks ahead to future studies and treatments that might target inflammatory factors, including stem cells, and argues for psychiatrists to consider obtaining inflammatory marker labs on every patient that they see.

Part 2: Abuse, Attachment, and Resilience: Genes and the Environment

TRANSCRIPT

Welcome to Psyched, a podcast about psychiatry that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.

David Carreon: Hey, everybody. This is David Carreon.

Jessi Gold: This is Jessi Gold.

David Carreon: And this is Psyched, a psychiatry podcast. Today, we have Dr. Charles Nemeroff, the Leonard M. Miller Professor and Chairman of the Department of Psychiatry and Behavioral Sciences at the University of Miami. He was born in New York City and graduated from City College of New York in 1970. He earned his PhD in neurobiology and his MD from the University of North Carolina at Chapel Hill. Dr. Nemeroff has received numerous honors during his career, including the distinguished Menninger Prize from the American College of Physicians and the Research Award from the American Foundation for Suicide Prevention. He’s published more than 1100 research reports and reviews. Dr. Nemeroff, thank you for joining us on the show.

Charles Nemeroff: It’s a really pleasure to be here with both of you.

Jessi Gold: Thank you.

David Carreon: You’ve got an incredible body of work here. We’d like to start the conversation off about depression. For our audience that does have a pretty broad range, what is depression? What is its essence? What does it look like?

Charles Nemeroff: Depression is a syndrome, a collection of symptoms like any disease. It happens to be a very common disorder, so that about 11% of men and about 21% of women in their lifetime will suffer with what we call major depression. The constellation of symptoms, of which you have to have five of nine in the DSM-5 criteria, include such symptoms as sleep disturbance, difficulty falling asleep, having trouble staying asleep, waking up too early, although a small percentage of patients oversleep. A very clear decrease in appetite. Most people, a decrease with body weight loss. Some small number, an increase. Difficulty concentrating, thinking, making decisions.

Obviously, the symptom we worry about the most . . . is suicide. Suicide is the 10th leading cause of death in the United States. It’s the only one of the top 10 causes of death that are increasing in number. All the others, including stroke, cancer, heart disease, are decreasing in number. And we can talk about that, if you’d like.

But depression is this terrible syndrome. Its cornerstone is the inability to experience pleasure. If you think about the worst day of your life, loss of a loved one, lost your job, breakup of a relationship, think about feeling that way every day and not knowing why. There’s a feeling of hopelessness and helplessness associated with depression that, of course, then leads to suicidal thinking.

David Carreon: It’s a pretty devastating condition and something that both Jessi and I have seen plenty of patients with. I guess, from your perspective as somebody who’s done a lot of research in biological psychiatry, what does depression look like in the brain, from your perspective?

Charles Nemeroff: Well, before I answer that, let me just interject a couple of other things about depression for the audience. First, one of the really important facts to know is that depression is a systemic illness. It affects the whole body. Part of having depression is being very vulnerable for other medical disorders, including diabetes, heart disease, certain forms of cancer, stroke. Depression is a killing disease. Not only does it kill you by suicide, it kills you because your life expectancy is shorter because of the biology of the illness. What I mean by that is the biology of depression is not just in the brain. It’s in the whole body.

David Carreon: I think that’s an important thing to emphasize. Certainly, on some popular levels, it’s all in your head, just snap out of it. But you’re saying that it’s something much more than that. It’s not even just in your brain. It’s a widespread disorder across the body.

Charles Nemeroff: Well, first, even if it was just in your brain, you couldn’t just snap out of it. We don’t generally tell patients with epilepsy, “You know, you just ought to stop having seizures.” Right?

Jessi Gold: Right.

Charles Nemeroff: So, this notion that you could snap out of it is just . . . One of the cardinal features of depression is incredible fatigue. I’m always wondering, when people say to severely depressed patients, “You need exercise.” Well, yeah, it’s hard enough to exercise when you’re not depressed, right?

Jessi Gold: Yeah.

Charles Nemeroff: But if you’re morbidly depressed, if you have a Hamilton score of 35, and you’re not sleeping, and you can’t concentrate, and nothing feels good, you think you’re going to go out and run? No. Yes, you’re absolutely right. The notion that you can just get over it, it just doesn’t make any sense.

David Carreon: What are some of the key things? I think we don’t talk as much about the increased risks of dying with depression. We talk a lot about suicide, at least in psychiatry. We don’t talk a lot about some of these other things, things that primary care has to deal with. Do you think that that’s been a perspective that’s been . . . How do you think we got into that way of thinking?

Charles Nemeroff: For many years, I conducted research on trying to understand why depressed patients were at risk for heart disease, myocardial infarction, and stroke. It took almost 20 years of negotiating with the American Heart Association before they were willing to actually list depression as a risk factor for heart disease on their website.

Jessi Gold: Twenty years.

Charles Nemeroff: And the conversation, I wish I had recorded the conversations with leadership of American Cardiology because one of the issues that came up is we were almost there, like 15 years ago, and the then-president of the AHA, who will remain nameless, said to me, “Well, you know, actually, the reason we can’t list it as a risk factor is because you have not demonstrated yet that, if you effectively treat depression, then you can actually obviate the risk.” I said, “Wait a minute, you have genetic risk factors on your website. We haven’t shown that you can modify genetic risk factors, and therefore change risk.” And that was sort of the end of the conversation.

But, in the end, long after I was president of the American College of Psychiatrists, in the end, we managed to get this listed as a risk factor. But there is a general bias about the notion that psychiatric disorders are biological illnesses, and that they have alterations in the body, as well as in the brain.

Jessi Gold: Would you say that the risk factor is just physiologic? Like I have depression, I’m tired, I’m not exercising. Or is there actually something going on in the body and the brain because of depression that’s leading to-

Charles Nemeroff: Oh, there’s no question about it. Many years ago, when you were in elementary school, we published a report showing that drug-free depressed patients have a clotting diathesis.

They have a fundamental abnormality in the platelet clotting cascade, in several steps in the cascade, in the initial platelet activation phase, but also in the final clot formation stage, so that depressed patients simply have a diathesis for forming clots. They’re much more likely to form a thrombus than non-depressed patients.

That’s one abnormality. There are five or six others in terms of oxidative mechanisms. Then the big factor right now, which we and others have spent, now, several years focusing on, is the fact that a very sizable percent of depressed patients exhibit marked increases in markers of inflammation. And inflammation is involved in the pathophysiology of all of the diseases we talked about, right? Diabetes, stroke, heart attacks.

There have been many meta-analyses done that have looked at this already, but the fact of the matter is depressed patients have markedly abnormal inflammatory markers, C-reactive protein, Interleukin-6, tumor necrosis factor. Not all, but clearly a sizable percent.

Jessi Gold: And at a level that somebody who might not understand all those markers would understand what does inflammation … How does inflammation work for depression?

Charles Nemeroff: Well, so the American Heart Association has a cut-off of three for C-reactive protein as a risk for myocardial infarction. A substantial percent of depressed patients have levels of three and above.

Jessi Gold: That makes sense.

Charles Nemeroff: Very clear.

Jessi Gold: Yeah.

David Carreon: I think there’s a lot of popular conceptions and a lot of popular misconceptions about inflammation and anti-inflammatory foods or anti-inflammatory dietary supplements or things like that. What is inflammation at its core level? Why might the body be doing this in depression? What is its purpose or intended outcome?

Charles Nemeroff: We have to remember that inflammation is an evolutionarily important adaption. It’s there because it fights bacterial and viral invaders. It’s there, fighting against certain kinds of cancer. The immune system is an extraordinarily component evolutionarily, and it’s probably partly responsible for the increased survival of our species.

We also know there are a number of inflammatory diseases. The classic ones are sarcoid, Sjogren’s disease, rheumatoid arthritis, lupus, …. We know that these diseases are in fact diseases of inflammation. We also know that Alzheimer disease, stroke, heart disease, certain forms of cancer are unfortunately accompanied by increases in inflammation.

We were the first group to report in the ’90s that depressed patients and depressed patients with cancer showed an increase in inflammatory markers. This has now been confirmed time and time and time again. Why this is the case is a great question. I wish I could answer that. But any more than I can answer why inflammation’s involved in the pathophysiology of Alzheimer’s Disease or epilepsy or stroke or diabetes. We really don’t know why some patients and some diseases are affected with it or not.

What we do know is that patients with inflammatory diseases have high rates of depression, and people with depression have high rates of inflammation. If you give somebody a treatment to increase their inflammatory response, for example, treating someone with malignant melanoma with interferon in order to create an inflammatory response to fight the cancer, one of the major side effects is robust and severe depression in a sizable subset of patients. There is this link.

Jessi Gold: I bet originally when that was determined, people just said that was a drug side effect or something like that, instead of thinking more about the mechanism.

Charles Nemeroff: It was first noted . . . it was really interesting. David Rubinow, who’s the Chair of Psychiatry at the University of North Carolina, was in charge of consult psychiatry at the National Cancer Institute. When they started using interferon for treating certain cancers, he started getting called to come to the clinical center to see these patients who suddenly became severely depressed and suicidal.

I was in a meeting in Luxembourg, of all places, or in Germany right proximal to Luxembourg. There were two suicides of patients given interferon for the treatment of cancer there on the same day. It made it to the front page of the paper.

David Carreon: Wow.

Charles Nemeroff: I looked at it, and I thought, “What is going on here?” That led to our New England Journal of Medicine article on characterizing depression associated with inflammation that was produced by interferon, and then learned that we could pre-treat patients with SSRIs, beginning two weeks before the interferon and ameliorate the depression.

David Carreon: Do SSRIs affect the inflammatory state of the body in non-interferon patients?

Charles Nemeroff: This is a great question, of which there’s very little data. SSRIs have multiple effects, one of which is to inhibit platelet aggregation and coagulation. We’ve always wanted to do a study, giving incredibly doses of SSRIs, like maybe a milligram of escitalopram, to see it if would work better than aspirin at preventing myocardial infarction in the general population because it wouldn’t have much of a side effect, sort of a Framingham-like study. We could never find anybody that was willing to fund such a study.

But it also begs the issue that you asked me that I sort of avoided earlier, which is what about many of the lay public, who believe in anti-inflammatory agents, natural foods, fish oil, etc. and are they effective? It begs the question of whether anti-inflammatories are effective antidepressants, right?

David Carreon: Yeah.

Charles Nemeroff: First, I’m completely agnostic, as far as treatments. I’m just insistent on science.

David Carreon: Mm-hmm.

Charles Nemeroff: I’m willing to test any hypothesis that sounds reasonable, whether it’s an integrative medicine approach, a psychotherapy, pharmacotherapy, food, diet, exercise, as long as it’s a well-powered study, and we can get the answer to the question. And remember that the plural of anecdote is not data. Just because you treated a patient with some regiment and they got better doesn’t mean that this is a controlled study or even a case series, right?

David Carreon: Sure.

Charles Nemeroff: I’m open-minded about this. I’d love to see more studies in this area. We’re embarking on a very novel approach in this area, and that has to do with the following. There have been a few studies of anti-inflammatory agents that were very targeted, in particular, tumor necrosis factor inhibitors. A reasonable hypothesis, because tumor necrosis factor is one of the inflammatory markers that has repeatedly been shown to be abnormal in depressed patients. There are a few tumor necrosis factor antagonists that are on the market approved for other indications—namely, rheumatoid arthritis, for example, and treatment-resistant psoriasis.

There was a study done by Ranga Krishnan at Duke many years ago. Etanercept is a drug that’s used to treat psoriasis. It’s a tumor necrosis factor monoclonal antibody. He infused it to patients with psoriasis and depression, who had failed antibiotic therapy. In a placebo-controlled study, he found that it had anti-depressant properties. It’s pretty exciting.

There was a second study done by Andy Miller, Chuck Raison, and their colleagues at Emory, in which they looked at different TNF Alpha antagonist called infliximab. Interestingly, in the patients with elevated CRP levels, indicative of inflammation, the drug did have anti-depressant properties.

My approach has been that, because multiple inflammatory markers have been shown to be abnormal in depression, I was looking for a more pan-inhibition kind of strategy, one that would quiet inflammation down in a broader way because I was concerned, if you block TNF Alpha, what about aisle 6? What about CRP? What about the inflammatory markers?

As you probably know, there is a huge, burgeoning database on the use of stem cell therapy in regenerative medicine, that you can give intravenous infusions of mesenchymal stem cells derived from bone marrow. These cells travel to sites of inflammation, where they quite down inflammation locally. At Miami, our stem cell institute director, Josh Hare, has done this post-MI. He’s done it in congestive heart failure. He’s done it in frail elderly. He’s done it in COPD. He’s done it in arthritis. You infuse these cells, and they literally go to the hot spots, your knee, your chest.

We’ve done a study in frail elderly. In the study in frail elderly, we saw a six-month reduction in tumor necrosis factor levels after a single infusion of 200 mesenchymal stem cells. No side effects of the treatment at all. And an increase in a sort of crude measure of well-being. They weren’t depressed. And an increase in their capacity in terms of frailty.

The Stanley Foundation has just agreed to fund a pilot study for us, looking at treatment-resistant depression, looking at these patients who are treatment-resistant to, say, SSRIs and have elevated inflammatory markers. We’re going to do that, and I have an NIH application in to look at a very unique population of patients who ought to have robust inflammation, which are patients with comorbid alcohol abuse and depression because both alcohol abuse and depression are associated with robust increases in inflammation. I’m pretty excited about this.

David Carreon: That’s a fascinating approach. Just to kind of think about this more concretely, where do you expect, hope, predict, imagine them to go? If I’ve got an aching knee, it’s going to go to my knee. What is inflamed? Where?

Charles Nemeroff: First of all, we know that peripheral inflammation increases depressive symptoms, both from the interferon studies I’ve told you, but then from a variety of other studies that have been done by Janet Kiecolt-Glaser at Ohio State. She’s shown that artificially increasing inflammation by giving, say, LPS, lipopolysaccharide to college students causes a robust inflammatory response, and their mood plummets.

Stress can do it, as well. I think, by blocking information peripherally, we should, in fact, see a bonafide improvement in depressive symptoms, particularly the cardinal vegetative symptoms. Think about what you feel like when you have the flu. You’re at home, you feel terrible, but you’re not working, but you can’t concentrate. You can’t read, you can’t watch TV, you’re lethargic, you’re listless. That’s sort of part of the depressive syndrome. There may be some cardinal symptoms of depression that respond to this kind of treatment. A big issue, which was cloaked in your question, is is there a direct effect on the brain?

David Carreon: Mm-hmm.

Charles Nemeroff: There’s a huge amount of controversy about this. There’s an investigator at the University of Virginia named Daniel Kipnis that, this year, for the first time, discovered a direct link between the periphery and the brain, as far as the immune system, which had hithertofore not been understood.

It looks like there is a tremendous amount of communication between the periphery and the brain and the immune system. Secondly, you’ll remember from your basic neuroanatomy . . . that there are seven circumventricular organs in the brain that have leaky blood/brain barrier passages that do not have tight junctions separating the brain from the periphery. They are, just to remind you from the Latin, they are the median eminence, the subfornical organ, the area postrema, which controls vomiting, for example. That’s why you vomit when something in the periphery is upsetting you. The organ laminosum, the lamina terminalis. I know you’d like that.

David Carreon: Thank you.

Charles Nemeroff: These areas allow immune cells to enter. Then, lastly, the brain has its own immune system, which is the equivalent of macrophages in the brain, or microglial cells. They also make inflammatory markers.

Jessi Gold: Do you envision that like, I’m working in a hospital, someone comes in with depression, I would be looking at their inflammatory markers to decide treatment in the future?

Charles Nemeroff: First, because a third of your patients don’t have another doctor, you should be doing it anyway because our patients are at risk for heart disease and stroke. I get CRPs on all my patients, just to make sure. And you’d be stunned at how many of them are in the risk range and don’t know it.

But yes, I think this will end up being sort of part of personalized medicine in psychiatry. I think, in psychiatry, we had this notion that monotherapy was good. Then, when the treatment studies like STAR*D came out, we discovered that only 28% of patients treated with citalopram actually got into remission. That’s not a good number.

If you go to an oncology clinic, nobody’s on monotherapy, right? Everybody’s on triple-drug chemotherapy, radiotherapy, whatever. Why would the brain, as complicated an organ as it is, with a syndrome like depression that affects certainly different brain areas, circuits, neurotransmitter systems, why would we think that one antidepressant would bring people into remission?

I think we’re going to see patients show up, you’re going to evaluate them, you’re going to end up getting inflammatory markers, maybe one of these anti-inflammatory treatments will be part of the depression regimen. We’ll find out better whether psychotherapy affects inflammation. It’s not out of the bound of reason that maybe effective CBT maybe helps patients reduce their inflammatory markers. These are all active and important avenues of investigation.

Facebook user Doug Leddin posted a heartfelt video that’s been resonating with people around the world, shining a light on the ordinary men grappling with depression every day of their lives. One MH writer goes under the skin of the biggest problem plaguing men today.

It’s the less severe mental illnesses that are quietly taking their toll

I never had a particularly high opinion of the former Deputy Prime Minister Nick Clegg until I visited a mental health resource centre in South London with him toward the end of last year. As the sole journalist there, I hung back and listened as he talked but mainly listened to the service users there. A pattern emerged of decades of psychotic episodes followed by sectioning followed by release to the care of overworked GPs with little mental health experience, again and again and again.

Afterwards I chatted to Clegg, who had a nice line in unforced posh bloke affability, and quite a tedious one in the intricacies of mental health funding. I took the latter as clear evidence of his sincerity – no-one would get involved with that kind of minutiae unless they really cared about an issue. Both Clegg and his Lib Dem cabinet colleague Norman Baker were passionate on the subject of mental health, and full of big ideas on the subject.

But all their initiatives hit the skids last May when the electorate delivered its own pitiless verdict on Clegg’s political sins, real or imagined. Mental health wasn’t a big concern in the election, but that meeting with service users stuck with me. My own mental health soapbox has been the silence around male suicide, but here was something almost as bad. A wrongly convicted prisoner locked up for 20 years would be a source of national scandal, but we tolerate people with mental health problems being trapped in decades-long cycles of poor care and social neglect. And the cost isn’t just having a crappier life, it’s having a much shorter one. An adult with mental health issues in the UK has the same life expectancy as an adult in Bangladesh.

“When you talk about premature deaths , people immediately think of suicide,” says Chris Naylor, a senior fellow in Health Policy at the health think tank The King’s Fund. “But in the main they are dying of things that the whole population is. Just a lot earlier.

Research published by the mental health charity Rethink bears this out. The problem is particularly acute amongst severe illnesses such as schizophrenia, where patients have double the rate of diabetes, 2-3 times the risk of high blood pressure and triple the risk of heart disease. “These are things which you can actually live with for a long time potentially. But if they’re not managed well they can lead to acute problems you can die from,” say Naylor.

There’s a few factors at work here. One is that when your brain is struggling to cope with the exhilarating technicolour chaos of a manic episode, or the crushing torpor of depression, matters such as eating healthily, watching alcohol units, and getting seven hours sleep are going to fall by the wayside. Smoking also goes hand in hand with mental disorders, and reflected in deaths from respiratory illnesses running at 4 times the rate of the general population. But even in a period of relative equilibrium, people can be reticent about seeking help for a physical illness. Someone who has been sectioned might find their relationship with your GP becoming a little more tricksy.

And then there is the question of the treatment. “Psychiatric medication can cause side effects which affect physical health,” says Stephen Buckley, Head of information at the mental health charity Mind. “Weight gain, lethargy, movement disorders and blood disorders to name a few.”

(Related: The 5 apps you that will improve your mental health)

Patients gain an average of 13lb in their first two months of taking anti-psychotic medication, but the separation between mental health and traditional health services means their weight is often not monitored and there’s little information or incentive provided to shift the excess pounds. While acknowledging these drug therapies are important, Naylor thinks more could be done to look after this group. “People need to be aware of what they’re taking when they’re prescribed these drugs,” he says. “And there are various things out there that can help people to try to keep their weight under control, even if they are taking something that makes it harder.

“It shouldn’t be a fatalistic thing. It’s not like you have to take these drugs and automatically become obese and get diabetes. There are ways of reducing the side effects.”

There is of course a chicken and egg question here, as poor physical heath can often lead to poor mental health, with sufferers of chronic long-term pain and those who’ve suffered heart attacks and strokes particularly vulnerable to depression.” Not everyone in this position will develop a diagnosable mental health problem, but anxiety is rife” says Naylor. “There’s lots of anxiety in people with lung problems. The feeling of breathlessness they experience can make people very anxious, and it can be difficult to tell the difference between what’s a panic attack and something that is actually physical.”

But there’s a final twist to this which preoccupies me, it’s the under diagnosed less severe mental illnesses which nonetheless are taking their own quietly deadly toll. And this is where men, who are almost certainly grossly under-diagnosed for depression and anxiety, are particularly vulnerable. Whilst only 17% of men has received treatement for a mental health issue, compared to 29% of women, the greater likelihood of men to commit suicide, have substance abuse problems or to be a rough sleeper would tend to indicate we don’t feature on the radar early enough.

(Related: 8 daily habits that will fight off mental illness)

The effects of severe mental health problems on health have been reasonably well-tracked, but a couple of years ago researchers from UCL and Edinburgh University worked backwards from 68,000 premature deaths and found that a mild mental illness such as anxiety or mild depression can raise the risk of premature death by 16%. Some of this was attributable to excess smoking and drinking, but the symptoms of depression and stress are closely related. Stress hormones raise heart rate and make blood vessels tighten, putting the body into a prolonged state of emergency. Over time, this can lead to heart disease.

“There’s been a whole field of research over the last 15 years about the biochemical pathways in the body related to stress,” says Naylor. “It’s interesting because it is actually one of the physical ways in which mental and physical health can be connected.”

Our own health service needs to find a better way of connecting physical and mental approaches. But maybe there are some green shoots. New Labour leader Jeremy Corbyn’s first Shadow Cabinet appointments were not perhaps a PR triumph, but he boldly handed the high-flying and resourceful young MP Luciana Berger a dedicated mental health portfolio. A sign perhaps that someone is willing to take on Nick Clegg’s ambition for parity of esteem between the two wings of the NHS?

But in the mean time, we have to take responsibility for our own health. “Being aware of how you’re feeling and building resilience is important in helping you look after yourself,” says Buckley. “If you’re able to notice early on that you’re struggling with feelings of depression, it can be easier to ask for help, or do things to look after yourself.”

(Related: How to tell if your work stress is killing you)

Aficionados of the virtuous messages printed elsewhere in this magazine will be pleased to see that a good diet and a willingness to get sweaty can be a corrective to the blues. Mind’s Food and Mood campaign has long advocated links between nutrition and better mental health, a campaign recently boosted by extensive Chinese research showing evidence that eating fish can cut the incidence of depression. It’s also introduced a new campaign, Get Set and Go, based around sport.

It’s a message that would resonate with Scott whom I met with Clegg at the resource centre. A Tigger-ish and disarmingly candid man in his his late thirties, he talks of how fitness broke a cycle of manic depressive episodes. “I made myself well by getting heavily into running.” He goes on to talk proudly of running from Croydon to the House of Commons to raise awareness of men health.

We don’t have to all take our struggles to the seat of power, but there was much to emulate in his staying power. Maybe there’s a way in which all of us can learn to outrun our own wretched black dog.

Photography by Doug Leddin, Facebook

Mike Shallcross Mike Shallcross is the editor of Independent Nurse, a magazine for those working in healthcare.

How can you help a loved one with depression?

There is no single strategy to help an individual with depression. Knowing the needs and personality of the person with depression can help guide a supportive approach.

A person who thrives on social contact or fears isolation may get temporary relief from spending time with loved ones. If those loved ones are judgmental or unkind, however, the visit may make their symptoms worse.

Below are some ways people can try to help a friend or loved one with depression.

Listen without judgment

One of the most powerful things a person can do is to listen to a loved one and let them air their emotions. A person should avoid telling the individual what to feel or how to solve their problems.

Helping is not about giving advice, as a person may not know the right advice to give unless they have mental health training. Just listening without judgment can make the person of concern feel understood and less alone.

Listening to challenging emotions can also bring up negative feelings in the listener, which can affect their mental health as well.

If helping a friend or loved one with depression is affecting the person’s own health, they may benefit from talking to someone about these emotions.

Talking about or naming depression does not make it worse. Furthermore, mental health professionals tend to agree that directly talking about suicide does not increase someone’s risk of suicide either.

Providing an outlet for difficult emotions may help your loved one feel less overwhelmed.

Reach out to them

Actively reaching out to someone who may be experiencing depression is usually going to be helpful.

People with depression may feel more shame and guilt than others and are less likely to reach out for help themselves because of their negative emotions.

Calling, visiting, or simply texting them will let them know that someone is thinking about them and may encourage them to engage.

Encourage positive action

Share on PinterestEncouraging positive action, such as going for a short walk, may help a loved one cope with their depression symptoms.

It is a good idea to ask someone what they find helps them feel better. This might be watching a favorite movie, going for a short walk, exercising, or cooking a healthful meal. Try encouraging them to do these things, even if they feel like it is impossible. Offering to do something with them may be most effective.

It can be helpful to suggest strategies that might provide the person with a diversion. This approach can also offer the individual an outlet to talk or just be with someone who cares about them. An example of this is offering to take them to dinner or a movie or planning an afternoon together.

If someone with depression feels unable to do these things, let them know that taking it easy is okay, too. The idea is to support the loved one.

Learn more about depression

People can read blogs, books, websites, message boards, and other resources to learn more about what it feels like to have depression. These information platforms can also explain the various treatments, therapy methods, and other factors that may be helpful.

Researching the subject can enable someone to understand better what their loved one is going through.

If a person has experienced depression themselves, they should not assume that their experiences are the same as their loved ones. Each person with depression faces their own journey with challenges that will be unique to them.

Help them get help

It can be a good idea to encourage the person experiencing depression to seek professional help.

Find ways to make this help more accessible for them, such as by offering to contact an insurance provider to determine how much coverage they have for therapy or offering to drive them to their appointment.

If someone is unsure where to get help, the National Institute of Mental Health provide resources and links where people can find support for mental health and crises. Otherwise, people can contact their or their loved one’s healthcare professional for information.

Offer support

Offering support with activities that the individual finds overwhelming or unbearable is a good strategy. An example is offering to take their kids for an hour or two, so they can get some rest or go to therapy. If they feel overwhelmed by daily tasks, someone can ask about helping with laundry or hiring a cleaner.

It is simple to reassure the person that depression is treatable in most cases, even if it feels unbearable. One strategy is to reassure them that they are not alone and that their depression should start to get better with time and treatment.

Look after yourself

Caring for someone with depression can feel overwhelming and be exhausting. It is important to remember that an individual cannot cure somebody else’s depression. Also, their loved one’s depression is not their fault, and they can only do so much.

To avoid burnout, people should make sure they create boundaries and look after their own mental well-being. This can include seeking counseling or talking to friends about what they are experiencing, taking time to themselves, and engaging in relaxation methods.

What Is Crippling Depression?

On a popular thread discussing crippling depression, one woman used her story to exemplify the condition.

“Everything seemed difficult,” she wrote.

She opened up about losing her job because she was unable to perform, neglecting basic hygiene and bills, feeling physically ill and contemplating suicide, among other issues.

“I would call it where you literally don’t want to do anything,” wrote another participant. “You are basically confined to your bed, without eating, without drinking and just want to wither away in your self-pity.”

Therapist Christine Fuchs learned about crippling depression through her work and offered similar descriptions. She listed a pervasive and significant decline in functioning in all areas of life. The illness makes people feel like “everything is overwhelming.”

Crippling Depression Defined

Crippling depression is clinical depression (major depressive disorder) that is severe to the point of limiting basic functioning, including the ability to work and live normally. Some of those afflicted experience episodes that last for a few weeks or months, as in after a loss or the death of a loved one. In other cases crippling depression is resistant to treatment and becomes a lifelong struggle.

Everyone who has lived with crippling depression has a unique experience, but there are some common threads such as difficulty sleeping or getting out of bed. When describing his period of crippling depression, mental health writer Stefan Taylor mentioned dropping out of college and “laying in bed all day.”

Is Crippling Depression the Same as Major Depressive Disorder, or Something More?

Some mental health professionals and people who live with depression believe crippling depression is simply a synonym for clinical depression or major depressive disorder. It is true that many have used the term this way, sometimes without being aware of its more popular meaning.

Sometimes popular phrases used to describe mental illness do not come from research, universities, or mental health organizations. Instead, people who live with certain disorders use unofficial terms to express levels of severity and describe how symptoms are affecting their functioning. Crippling depression is a perfect example of this phenomenon.

Nonetheless, there is evidence that what people call “crippling depression” is significantly different than other forms of the disorder. Both the Mayo Clinic and National Institute of Mental Health do not specify an inability to work, for example, in their definitions of depression. These organizations seem to acknowledge the fact that every mental illness has degrees of severity.

Sufferers often live with moderate depression and experience symptoms that qualify for a diagnosis but do not noticeably impact daily functioning. Others cannot work full-time jobs or attend school. The term, “crippling depression,” came from the need to define this distinction.

A Symbol of Accepting Depression as a Disability?

Traditionally, people have used variations on the word, “crippling,” to describe physical disabilities such as the inability to walk, speak, or hear. Most people have accepted these types of disabilities as legitimate and deserving of support. The government often provides benefits to disabled people, especially those who request assistance because of the difficulty they have maintaining employment.

Describing oneself as “crippled” — or even “a cripple” — isn’t necessarily pejorative either. In her famous personal essay, “On Being a Cripple,” Nancy Mairs illustrated her life living with a case of multiple sclerosis that robbed her of the full use of her limbs. She chose to identify as “a cripple” and stated she wasn’t ashamed of the label.

Lately an increasing number of employers, mental health professionals, and organizations, including the World Health Organization, have acknowledged depression as a disability. Similar to Mairs, sufferers often declare they have crippling depression and believe such language is both appropriate and accurate. Some people use the term crippling depression to describe when they believe their symptoms have crossed the threshold from a manageable mental health condition to a disability.

How the ‘I Have Crippling Depression’ Meme Raised Depression Awareness

On July 17, 2016, YouTuber Ian Carter, whose channel name is iDubbbzTV, published a video that begins with him jumping into a wheelchair and saying in a silly voice, “I have crippling depression.” The video quickly went viral and became a popular, lasting meme.

There were many commenters who thought the joke was insensitive and offensive. Several responded by writing about how they had depression and believed it was a serious matter.

Before the meme took off, the internet interest for “crippling depression” was relatively low, according to Google Trends data. Once most viewers lost interest in the original video and memes, the frequency of the term plummeted dramatically. Nonetheless, the popularity level stabilized to a range that was about five times greater than in previous years. It is possible that the joke caused more people to use the phrase and galvanized those who felt that it was a legitimate term for a distinct mental health issue.

We Need to Be Accepting of Crippling Depression

Clinical diagnoses are useful and preferable, but people have the right to apply unofficial labels to their illnesses. We need to be accepting of the fact that some people feel that clinical terms do not fully or accurately describe their experience.

If you think you might have crippling depression, consider seeking mental health treatment such as psychotherapy. There are also many online resources that offer advice for dealing with depression. To be there for loved ones who might have the disorder, read up on how to support someone with depression. The illness is much less crippling when you have support and loved ones to lean on.

Have You Heard the One about My Crippling Depression?

Comedy

Mental illness almost killed North Shore comedian Gary Gulman. Then it made him famous.

By Jack McCallum· 12/2/2019, 11:03 a.m.

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Photo by Chris Buck

On the evening of October 11, 1993, 23-year-old would-be standup comedian Gary Gulman, a towering, well-put-together man from Peabody who had failed as a tight end at Boston College and was in the process of failing as an accountant, stepped onstage at Nick’s Comedy Stop on the edge of what used to be known as the Combat Zone. His first joke went like this: “I guess you saw that Michael Jordan retired from basketball,” a nervous Gulman told the Monday-night audience, inflated by the club mandate that each comedian bring along at least three friends. “He had accomplished everything there was to accomplish in basketball…plus, he knew he wouldn’t be able to concentrate with Joey Buttafuoco behind bars.”

A beat. Silence. He could almost feel how much the room hated the joke. Then, a sickening idea flashed through his mind: Oh my gosh, I was really wrong about my talent.

He told a second joke—a routine about Seinfeld’s Kramer calling a foul on Jerry during a pickup basketball game. It got laughs, and so did the third. The rest of the set went well, and Gulman knew that his accounting career would soon be in his rearview. He would quit his job at Coopers & Lybrand (now PricewaterhouseCoopers) and pursue comedy full time. From the vantage of the tiny stage at Nick’s, the future looked bright.

Now, 26 long and sometimes painful years later, Gulman is finally finding the success he had dreamed of, but he can still remember that disastrous first joke. “It’s a classic Letterman setup where you say a funny name and add a weird twist,” he tells me, spreading his arms in a sweeping shrug. “But it bombed. People hated it.” Vividly reliving his lows is something Gulman has always done because, as he spent a quarter-century building his rep with long-form, tightly constructed, mostly apolitical PG-13 narratives, he also harbored a secret of which only his family and a few close friends were aware: He suffered from debilitating bouts of anxiety and depression that at times made him suicidal. These feelings go back a long way. In second grade, he wrote a story called “The Lonely Tree,” and in middle school, after failing miserably for his synagogue team during a basketball scrimmage— “I shot 0-for-chai,” he says, spitting out the guttural Hebrew word for 18—he remembers wanting to kill himself.

Gulman delivers that line, and dozens of others, in a similarly self-deprecating fashion that hides the existential misery of depression, in The Great Depresh, his comedy special now available on HBO. About a year ago, Gulman decided, through some combination of self-examination, managerial coaxing, and maybe even professional necessity (after all, standups need material), to open up onstage about his mental illness. The philosopher Arthur Schopenhauer—no standup he—would have counseled Gulman against it. “If I maintain my silence about my secret it is my prisoner,” Schopenhauer wrote. “If I let it slip from my tongue, I am its prisoner.” A few members of Gulman’s audience who caught a tryout version of the HBO show would concur with the dour German. “I didn’t come to hear a comedian talk about his damn depression the whole night,” said one man as he stormed out of a show in Wilmington, Delaware, several months ago. Gulman recovered quickly. “Man, I’m sorry I comped that guy,” he quipped from the stage.

It’s undeniable that what Gulman does in The Great Depresh, and is now doing onstage during a tour of comedy clubs, is doubly dangerous for a performer—laying bare his inner darkness while also brush-stroking a coat of dark gray over what is normally an hour of escape. But this fine irony is also undeniable: As Gulman runs through the field of mental land mines that preceded his 2015 descent into almost two years of soul-crushing despair, his worst bout yet with the confounding disease, it becomes clear that what he once held inside has finally set him free.

If this is Gulman’s moment, it may be one for the rest of us, too. “Everyone feels some sort of depression in their lives,” says comedy giant Judd Apatow, who coproduced the Gulman special. “Depression is a discussion people want to have. And now Gary is the one you want to have it with.”

Gulman is the youngest of the three sons of Phil and Barbara Gulman. He is 13 years younger than his brother Rick, a semiretired CPA who lives in Florida, and 10 years younger than his brother Max, who owns an interior-decorating company and lives in Newton. Phil left the family when Gary was one-and-a-half (though they remained fairly close until Phil’s death in 2015), so part of Gulman’s evolution as a comic is predictable—the young cutup bartering for love and attention at the dinner table. Gulman is also part of a strong Jewish-comedian tradition. “I grew up watching David Brenner and then all those other Jewish comedians came along, like Garry Shandling, Richard Lewis, Paul Reiser, and, of course, Seinfeld,” says Gulman, 49. “I connected with their neuroses and all the observational stuff.”

He also feels attached to a long line of Boston-area comics, but pays particular homage to two who are not widely known out of the area: Don Gavin (“a Robert Klein type who could really write”) and Paul D’Angelo (“extremely helpful to me when I was starting out”). Gulman saw Lenny Clarke (from Cambridge) several times when he was at Boston College; vividly remembers his mother taking him to see Jay Leno (Andover) at a Beverly theater (Gulman can still recite verbatim one of Leno’s jokes from that night, about Nancy Reagan); and traipsed around with Dane Cook (Arlington) on Cook’s 2006 HBO docu-series Tourgasm, though Gulman, who was in the middle of a depressive state at the time, clearly looks like he’d rather be somewhere else. He attended BC at the same time as Burlington’s Amy Poehler (“She did mostly improv and we didn’t know each other well”) and remains closest with Lexington-born Pete Holmes, who says that he “sat shiva” with Gulman during his most recent and challenging depression.

There may not be one single Boston style of comedy, Gulman says. “But what I do think is that Boston, this area in general, is just such good inspiration for us. The way we work is kind of—it sounds crazy—but kind of a Larry Bird thing, you know, being so intense on the court, so serious, so centered on getting it done. That Boston work ethic is what propels so many of us.”

The sports metaphor is apt. Gulman has long drawn material—not to mention a volcanic level of anxiety—from sports, into which he was, well, directed because of his 6-foot-6 height. At first, Gulman gravitated toward basketball because, as he says in The Great Depresh, “It’s the only sport where if somebody so much as slaps you on the wrist, they stop the game, separate everyone, let you make two easy shots, while everyone else is forced to watch quietly…as if to say, Think about what you did.” But his sporting life, as well as his inner life, was altered dramatically when John and Joe Taché, twin brothers who coached at Peabody Veterans Memorial High School and called themselves “The Jetsyns” (“They thought they were out of this world,” Gulman says), happened to catch him dunking in gym class. They relayed the intel to the football coach, and Gulman was all but forced onto the team for his senior year.

Gulman’s size and natural ability helped him shine—an article in the Salem News by the late Bill Kipouras labeled him “Mr. Raw Potential”—and he came to the attention of Boston College coach Jack Bicknell, who sent assistant coach Pete Carmichael to Peabody for a recruiting visit. Next thing you know, Gulman, after one reluctant year as a high school football player, was an Eagle, though he viewed himself more as a pigeon. “Two years prior, had coached Heisman Trophy winner Doug Flutie,” Gulman says in The Great Depresh, “and then two years later he’s recruiting future participation-trophy advocate Gary Gulman.”

The central contradiction was that Gulman looked like a football player (he added 10 pounds of muscle before college and in 1989 reported for his first preseason training camp at 265 pounds) and sometimes performed like a football player (in most physical tests, he was surpassed only by future NFL star Mark Chmura, BC’s first-string tight end). But it was illusory, for inside he felt intimidated, anxious, and desperately alone to the point that he contemplated suicide.

It was a stroke of luck that, during the not-always-enlightened ’80s, Gulman opened up to Thomas McGuinness, a BC counselor who provided him with some simple advice: You could quit, you know. Appearing many years later as a guest on the The Hilarious World of Depression podcast, Gulman broke down when he discussed how with that simple message—Stop trying to force yourself into being something you’re not—McGuinness had sprung him from the prison of someone else’s expectations. (Citing confidentiality, McGuinness, to whom Gulman remains close, would not comment.)

Gulman didn’t see action during his freshman season, but decided to keep going and entered BC’s 1990 Spring Game full of hope and determination. Well, not really. What Gulman desperately wanted was a sign that he should quit. And he found it early on, after missing a block that enabled linebacker Mike Marinaro to crash into Glenn Foley, the prospective starting quarterback. “Jack Bicknell came running across the field and smoke was coming out of his ears,” Gulman remembers. “He really laid into me. On the one hand it was terrible, but on the other I thought, This is my sign. I’m sure it was self-fulfilling, but it still was dramatic. That Monday, I went into his office and quit.”

Gulman kept his scholarship, earned good grades even as he hit the local comedy clubs—including Giggles, the Comedy Connection at Faneuil Hall, and Dick’s Beantown Comedy Vault—and graduated with a degree in accounting. Then he took a job with Coopers & Lybrand, told a mediocre Joey Buttafuoco joke, and was on his way.

Sort of.

Over the past two decades, Gulman has made a solid living from club appearances across the country, residuals from TV and movie appearances, and the royalties from five comedy albums. He has developed both a steady following and the respect of his peers by turning himself into an oversize, 21st-century Mark Twain, spinning out long disquisitions on “the hierarchy of cookies” (“I never saw a fig outside of a Newton in my life”), the vileness of Blockbuster (“Why is this a new release…because it’s in color?”), and the disappointment of viewing The Karate Kid as an adult (“I don’t remember rooting for the Cobra Kai, but this time around I was like, ‘Ugh, just take him out’”).

Gulman’s stuff was funny, and, sure, sometimes silly, but he delivered it all with the precision of a Swiss watchmaker. His six-minute riff on an imagined documentary about the group charged with assigning distinctive two-letter abbreviations to each of the states—the problems begin with Alabama and Alaska—has become a comedy classic. “This is one of those rare…perfectly written, realized, and executed comedy routines,” Patton Oswalt posted on Facebook after seeing the bit on Conan. Gulman avoided easy targets, breezy one-liners, and dick jokes. He burrowed deep, even if his material came packaged with a goofy smile and an I’m-just-up-here-having-fun attitude.

Religion and Judaism were—and still are—major topics for Gulman, who was influenced, he says, by the Jesuit intellectualism at Boston College. Some of his Jewish material is quick-hitting, such as the absurdity of installing breakaway rims in Jewish community center gyms (“In the history of the NBA, only four people have smashed a backboard, and not a one was a 10-year-old Jew”). In a somewhat more reflective set, he suggests that the Old Testament should be renamed “He’s Just Not That Into You” and says he finds the New Testament to be a refreshing sequel. “I like to call Jesus the ‘Frasier of Nazareth’” is one of his favorite jokes. “I love it when I can combine all my obsessions into one piece,” Gulman says, “and I’m obsessed with both Jesus and Cheers.”

Still, if you charted the success of Gulman’s 20-year career, it would be more or less a straight line. He never broke through in even a Dane Cook way, never mind a Seinfeld way. “It’s always some kind of combination of luck and timing if you hit it big,” says A-list director and producer Apatow, whose credits include Knocked Up, Trainwreck, and Girls. “Some comedians get pilots and take off. Okay, that didn’t happen with Gary. But however far Gary’s star rose was due to one thing—the quality of his work.” Gulman heard and appreciated the encomiums, but over time, he wanted more—a wider audience and an upward bump from the B-list.

Gulman was sure that he had the ammunition to make the jump as he prepared for a 2015 special at the Highline Ballroom in New York City. “I remember thinking, This is when I’m going to break through enough that I won’t have to worry about selling tickets, that I won’t have to be concerned about whether the audience is half- or three-quarters full,” he says. “I thought it was my best work, but the reception was lackluster. It just didn’t work. And then it took a year to sell the special to Netflix and it didn’t get a good reception there, either.” He started to doubt himself. “I started to worry I wasn’t going to be able to come up with a new hour, and I’d turn into one of these comedians that I dreaded becoming, the one who sees his audience dwindle because he’s doing the same act every year.”

No one is sure if a single event is needed to trigger a depressive incident, but Gulman is positive that his Highline show had a major effect. Soon after that, his father died, and that threw him for a loop, too. “So it was a combination of a number of things,” he says, “that sent me into a depression that lasted pretty much from the summer of 2015 until the fall of 2017.” It was the mother of all depressive spells, his worst yet. He worked only sporadically during this period, and one night, after a gig in Denver, the urge to end the pain almost got the better of him. Alone in his room, Gulman held a butcher knife over his wrists and contemplated using it. “Comedians are known for being slobs,” he says, “so what would the poor cleaning woman think when she came in Monday morning and had that to contend with? So I backed off.”

Lines like that are Gulman’s way of coping—take the pain and marinate it in mirth. But it was no joke. Gulman was scared. Those close to him were scared. Everything in his life was tinder to his mental illness. He was only six months into an exclusive relationship with Sadé Tametria, a budding comedian, when she found herself living with a man who spent most of his days crying, sleeping, or combining the two. “There was a point when I honestly wondered if Gary would come out of it,” Tametria says. “My philosophy became: Make the best of every day because I don’t know how long I’m going to have him.”

Gulman canceled most of his bookings. He endlessly juggled prescriptions, consulted with shrinks, and studied the shade angles and wind currents of Manhattan street corners because he thought he might soon be living on one. On two occasions—once for three weeks and another for one week—he checked in to the psych ward of New York-Presbyterian/Weill Cornell Medical Center, where he underwent electroconvulsive therapy (ECT), once a reliable cinematic horror vehicle but now considered the gold standard for treatment-resistant depression. “I was contemplating retiring from comedy, and then I thought about it some, and realized that retirement is a bit pretentious for what was going on,” Gulman jokes in The Great Depresh. “Johnny Carson retired. Michael Jordan retired. Gary Gulman, you’re giving up.”

At a loss for how to help him, Tametria eventually made the suggestion that he move back into his mother’s house in Peabody. “Gary was having a hard enough time pulling himself together without all the stress and economic anxiety of living in New York City,” Tametria says. “Money seemed like the one thing we could control.” They moved out of their midtown Manhattan apartment and got rid of their furniture. Tametria went home to spend time with her mother in Georgia, and Gary Gulman, all 6-foot-6 of him, decamped to his boyhood bedroom, stomach-roiling football photos all around.

Gradually, Gulman’s depressive fog began to lift, and at this writing it has stayed lifted. When you meet a person plagued by depression, it seems axiomatic that some of that nuclear-grade angst, some of the darkness, would have to show through, but that isn’t the case with Gulman. Over the course of three meetings in New York City, the only portrait that emerged was that of a joyful man at the top of his professional game, voluble and eager to engage, a Regular Guy with a fanatical interest in basketball.

There was no single dramatic aha moment in his recovery, and he believes that the latent effects of the ECT were a major factor. After 11 months, from June 2017 to May 2018, he left the safety of his hometown and moved back in with Tametria to an apartment in Harlem. With his depresh in remish, he began writing, took a couple of gigs, and began to talk onstage about depression. He sent some of that material to his manager, Brian Stern, who suggested that Gulman build an entire show around it. A well-known director, Michael Bonfiglio, came aboard, and he got his better-known friend Apatow on board, and next thing you know, Gulman had the potential for a hit. “It was like HBO granted us a Make-a-Wish,” Tametria says.

So The Great Depresh was born, and, in a way, so was a second career—and maybe a second life—for Gulman. “A lot of times comedians don’t get big right away,” Apatow says, “but they keep digging deeper and deeper and revealing more about themselves, and that’s what Gary has done. This is his moment.”

The Great Depresh begins with a short, sad scene filmed two years ago at the Comedy Studio (it was still in Harvard Square then) during a period when Gulman could barely get out of bed. He had asked for the spot because he thought it might help him, but he’s clearly lost, describing himself as being at “a cosmic bottom” while a dead-silent audience tries to figure out what the hell’s going on.

In retrospect, the Comedy Studio appearance was in fact a beginning, the first time Gulman not only talked in a serious way about depression, but also viscerally demonstrated its toll. Lord knows that comedy and depression are no strangers. Last year’s “Spark of Madness,” one of the eight episodes of CNN’s documentary series called The History of Comedy, was devoted to the mental-health struggles of comedians. So many celebrated standups—Richard Pryor, Robin Williams, Sarah Silverman, Woody Allen, and Ellen DeGeneres among them—have talked about their struggles with depression, anxiety, and feelings of helplessness. “I despised myself pretty much close to getting out of the womb,” Richard Lewis, one of Gulman’s heroes, says in the documentary. The Australian monologist Hannah Gadsby has circled around the subject of depression, as well as autism, in her recent HBO specials.

Yet it is Gulman who seems to have found the ideal space—considering his affection for millennials, he might even call it a safe space—to talk about a mental illness that affects an estimated 11 million Americans. His long standup background allows him to shift gears between light and dark with an abject professionalism. As Kathryn VanArendonk of New York magazine’s Vulture put it in her review of The Great Depresh: “It’s affirming without being trite, and it’s warm without being simplistic.”

Gulman has managed to serve up an essential PSA dressed in comedy clothes. We learn things in The Great Depresh, among them the benefits of the horrifying-sounding ECT treatments and the you’ll-get-through-it mundane horrors of prescriptive side effects. “I will take impotence and diarrhea simultaneously,” Gulman says in the special, “if I can smile at a sunset!”

He offers advice, in his non-pedantic fashion, to those with depression—get out and interact even if you don’t feel like it; there is hope; you’re not alone—and, offstage, feels comfortable enough to have begun a kind of comedic advice column on Twitter. I found that when I stopped using any swears the audience greatly appreciated it. Being Gulman, he also reliably responds to most people who tweet at him.

Another reason The Great Depresh is a hit is Gulman’s essential likeability. He has long come across as The Guy You Root For. “I would hear that Gary was in a difficult period, and I saw how it affected everyone who knew him,” Apatow says. “And when you started to hear, ‘Hey, Gary is coming out of it,’ you saw how happy that made everyone, the love they have for him.”

But the real reason The Great Depresh succeeds is that it speaks to our times, a 74-minute window into the national zeitgeist. We are divided, upset, anxious, sad, and, yes, depressed, and along comes this good-looking, appealingly earnest ex-jock-in-disarray telling us that he feels depressed and anxious and alone, and that he’s been struggling his whole life with those feelings, but maybe, just maybe, you can come out on the other side.

And so, on January 18 it will be a different Gulman who takes the stage for two shows at the Wilbur from the lost soul who lifelessly occupied a stool at the Comedy Studio. He has new material, a role in a hit movie (he plays a comedian in Joker), and a new outlook on life, sprinkled, though it must be, with caution. “You can never say you’re cured with this disease,” Gulman says. “It can sneak up on you. But I know I’ve moved forward, with help from Sadé and a lot of other people. It’s really meant something to me when people come up after a show and say, ‘I really appreciate you talking about depression. It’s going to be very helpful.’”

Gulman says he prepares for his Boston appearances throughout the year. He expects to see friends he hasn’t seen since grade school and kids he taught at Peabody High School during a substitute gig he took to supplement his comedy income during the late ’90s. When he’s in front of a hometown crowd, Gulman says, he feels like “the best version of myself.”

But, really, there is no new version of Gulman, no Gary 4.0 or whatever the number might be. He is the sum and substance of all that tenebrous history, all those moments when he felt that he was lost, and all those times, too, when he climbed his way out. He has shown us the hurt and how it can get better, but we also sense that, for Gulman, as for many of us, life is a tightrope walk, and the time he gives us onstage is less a performance than a communion of common souls, all of us searching for the light.

To reach the National Suicide Prevention Lifeline, call 1-800-273-8255. You can also text a counselor at 741741.

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