Clinical Depression is not something people talk about in first person. It is treatable & preventable but the stigma associated with it that keeps people from getting the best treatment and advice
My experience with disease
I have had a long association with disease, and indeed I have worn my ability to survive, take punishment and endure pain as a medal on my chest. By the time I was 7 I had survived severe rheumatic heart disease. By 30 I had survived 2 heart attacks and a broken back and had demyelination of the brain. By 40 I both my carotids had 50% blockages which makes a stroke imminent. And last year my kidneys started failing — maybe on account of the amount of medication since childhood. Right now I am recuperating from surviving electrocution on an 11,000 volt line 3 months ago and the resulting necrosis it caused in my foot. But I’ve fought it all and I just keep on going. I have no doubt that in 2 months I will reach peak fitness again – I can do 500 pushups, 150 pull ups, 250 burpees and run a 1km flat in 1 go. But all my bravado would not prepare me for something that happened 3 yrs ago — and the disease nobody wants to talk about in first person – depression.
I write about here in detail from my experience. And because it is my nature to understand the world around me. I have not taken one pill or had a test I do not first fully understand. I am no ‘blind’ patient to any doctor. I share my experience so maybe some of you can identify if you need help and seek it. And to debunk the notion that depression is somehow related to ‘will’ and you can ‘will’ yourself out of it. Or that that real ‘men’ can’t or rather shouldn’t have it. It is simply a disease and like all diseases, I’ve had. It happens to men and to women. And it needs a 3 pronged approach to be managed – prevention, diagnosis and treatment.
Interestingly the social stigma associated with depression is not new. Analysis of letters, journals and statements show that Abraham Lincoln had depression, so did Sir Winston Churchill, who repeatedly referred to it as ‘the black dog’. They’re the best examples of people with great character, imagination and ‘will’ who have suffered at its hands.
What caused depression
As we will see in a while depression can have many causes. For me, the sequence of events started in 2013 when a whole bunch of ‘dog activists’ and people they hired started a campaign of arson, poisoning, and intimidation against – VOSD the trust that I run to rescue dogs. Jealousy, profiteering, and extortions had been the motives. At first, it was physical assaults against my people, destruction of vehicles and poisoning of dogs. By the beginning of 2014 I was the subject of attack and it took shape of criminal complaints filed against me in different police stations in Bangalore. I was finally arrested in Sept 2014 and it was front page paid news – for 2 days. What happened then is the subject of a TEDx talk you can watch here.
Their idea was to attack my company TWB_ and defund VOSD (which is today the world’s largest no-kill dog rescue & sanctuary). It looked like it would work. For nearly a year I was running around outside the office. My sales and marketing and delivery were not delivering anything as I battled on many fronts. Our revenue fell by 90% in 1 year.
While we made nothing it was hard for me to let go of the company I had built from scratch on my own. Since we were without revenue, I started taking loans to keep running TWB_. The whole of 2014 the offices were still running the staff still paid as I hoped that in the next quarter I will turn it around. But when in Nov 2014 I discovered that instead of collecting $150K in payments from a single customer that was showing in receivables for 6 months we had not even delivered worth a cent to them I knew the game was over. By the 31 Dec 2014, I was the only employee left in the company.
What happened after that was a bloodbath. I weathered it the best I could and kept fighting on all fronts. Some of the best work that VOSD did was in that time – we created fantastic new revenue streams and brands and slowly as work dried up in Bangalore I immersed myself into creating a much better infrastructure at the VOSD Sanctuary. But by the beginning of 2016, I was tired – and disinterested in pretty much everything around me.
How did I find out I was depressed?
By the mid of 2016, 1.5 yrs into the fightback I was a person I was not. I felt terribly lonely. I felt like I was alone and the world was against me. It felt that this is a never-ending fight one I can’t win. It was a tremendously stressful time. I was living day to day. I did not know where the money for the day would come from. The dogs’ expenses were $500 a day. In addition, there was monthly debt that initially was $50,000 a month!
I kept trying to keep the damage to myself — away from my customers — the few I still had. I was hiding the severity of the situation because I knew even they would leave. At home I’d try to act as normal as possible, I had always protected Helen, my wife, who had never bargained for a life of an entrepreneur, from everything that was unpleasant. After our IOUs at less than $100 a month. For years no clothes or gifts were bought even at festive times.
Slowly I got tired of not just any social engagements I started shunning even business meetings and contact. When I had work I found it very difficult to start because of fatigue and a certain state of mind that said ‘you know what it would not make a difference’. I would not sleep well and yet I would be curled up in a ball a lot of the time during the day.
All that pressure has to go somewhere. If the day passed without any major incident or crisis it was a major relief. If it did not, I still had my drink to drink. I was now drinking because it dulled the world around me, kept me sane. I could not sleep unless I drank a lot. But strangely while alcohol knocks you to sleep when it metabolizes you get up so you actually sleep poorly.
I was always fond of drinking but the cheapest thing I drank for many years was still pretty good scotch. I used to joke that my only expense on myself was alcohol and before the crisis I easily drank a thousand dollars of it (in retail prices) a month. Now as my financial condition deteriorated I could not afford to buy a fraction of it. Helen would keep enough for me for the day to buy a quart of the cheapest local rum and I would buy only for the day because that’s all the money there was.
Music has always been a major part of my life. I’d had to sell everything I could — the houses the cars to repay but I still had this kick-ass music rig which is the price of a luxury car sitting in my living room. But I had completely stopped listening to music – I had given up my biggest pleasure.
My dogs were my only bright spot. But with the pressure, I thought of every illness every death as something I was responsible for and I was inconsolable. I felt so much guilt it became difficult for me to face my own babies. Each weekend, while I sat jobless, I would invent a reason not to go to the farm. Michelle Stewart, who used to volunteer with me at the time, would drive 150 km all by herself for me some Sundays.
I had terrible mood swings. I would plan my comeback in my head and think of how I am going to hurt everyone who has hurt me – and there was relief in thinking of retribution. Anyone I spoke to at the time heard me rant and rave about just how much pain I will give back. But that mania would be followed by utter helplessness. Sometimes when was alone in the house I would sink to the bathroom floor crying — this pitiful cry of a wounded animal.
One day Helen had gone to her parents and I called after her. I started telling her I was sorry for what I had done to her and let her down. I said sorry so many times she froze because she thought I was going to kill myself. I had thought at one time it was perhaps the only option. I went to my balcony but I realized I can’t there was no-one to take care of my dogs and I said I will give myself 1 more day to think. That night I dreamt of my baby Cleopatra at the farm. I got up thinking I am never going to go back to wanting to abandon her. A day later I saw an interview of Boman Irani (who is on my friends’ list since the time his dog was ill and unfortunately passed away). He talked about getting a break when he was in his 50s. It occurred to me to win first you need to stay in the game. I wrote to him a long message about what it meant to me to hear him.
I decided I am not going to be in this place. But what was this place and why was I here?
My 1st breakthrough: Knowing I was depressed
I had stopped watching TV but Helen was watching and I overheard and they were talking about depression. It sounded a lot like what I felt! Did I suffer from it? The first person I asked was Helen and I asked point blank ‘do you think I am depressed’. She said she did not know. I then turned to my only other friend and colleague at the time Sangeeta Velegar. I called her and asked the same question ‘do you think I am depressed’. She replied point blank ‘yes you are’. ‘Why didn’t you tell me?’ I asked. She said ‘I didn’t know how would you take it’. “I’m going to fix it” I remember saying, ”will start with a counselor”.
The counselor was this beautiful old frail bird-like woman with platinum white hair. She came to fetch me at the reception area and she was surprised to see me by myself. She said the stigma was such it is routine for people to sometimes be persuaded for years by the family to see a counselor. She was surprised I had called and made the appointment for myself.
I told her I know I can’t just ‘will’ my way of getting back any more than I can will a fracture to heal. If diabetes can be controlled by lifestyle changes you do that if it requires medication you do that. I’m no professional and can’t diagnose myself but I am not going to prolong my misery.
She asked me what was it that I wanted and I said I wanted to just be back to the man I was – I go after things and get them done and now I’m like this cow tied at the end of a stake waiting my time. I’ve never been the one to be persuaded to talk openly and truthfully to doctors or lawyers. I began this twice a week session with her. It was mid 2016, it had been at it a few months and I was getting impatient. The fog in my head was not lifting. I told her I was frustrated and I did not think it was going anywhere.
So she asked me “what causes you pain?” I’d not thought of it because it was this constant feeling I had never broken it down much. It came from betrayal, from bankruptcy, from lack of control, from many places. She persisted. I had to think long and hard before I said “I am a self-made very proud man. I am now accused of attempting to rape a woman I have never met – I feel humiliated by the police, by the accusation, standing in court. I never took money from anyone and made a multimillion dollar company and now I feel humiliated by ex-employees and banks and other creditors”.
My 2nd breakthrough: I found what was keeping me down
She said “Rakesh you have misplaced emotions. Humiliation was the right emotion if you had misbehaved with her and were defending yourself. Or if you had used the money for personal gain. The right emotion is anger. Find a rage against the situation and do something about it”. It was a like a light went on in my head. I let it sink in.
I asked her to recommend me to a psychiatrist because just knowing the problem would not make it go away. I had been reading about depression in the last few months as well. I called and made an appointment with the doctor she recommended for the same day. They had spoken at length before I met but he too surprised seeing me just walk in. The months of going to the counselor I had started working out and drinking less and I was much fitter but I had was a physical pain that made me run and lift less – an unbearable pain in my legs and it never went away. I could not sleep because of it. I told him about it.
My 3rd breakthrough: Medication
He gave me his prognosis – I have acute clinical depression. He explained what it was, what can cause it to happen and explained briefly the role hormones and neurotransmitters. He explained how the pain was not psychosomatic as I had thought but rather caused because of lack of the feedback loop from the legs with the depletion of the neurotransmitters. He asked me reluctantly if I will agree to be on medication and I almost grabbed the prescription. I was desperate to fix myself.
A few days into the medication I felt different. I was sleeping well, my mood had improved tremendously and the pain in my legs had disappeared. I started putting longer hours, I started working out harder. Over an year I felt I did not need the medication it is somehow slowing me, made the world too rosy. I believe stress is a constant and it is a great motivator, though distress is not. I was weaned of the medication. I went back to became the same edgy type A personality I started with before the crisis. I was fitter and fighting back.
What I learned about clinical depression from fighting it
It is a given that most people will feel low at some point in their lives. Feeling low is not depression. But if you feel low for weeks you need help. Depression is categorized as mild – with temporary episodes of sadness, to severe – persistent depression. Clinical depression is the most-severe form of depression, also known as major depression or major depressive disorder. Clinical depression is evident in a loss of interest in normal activities and relationships.
Symptoms of clinical depression may include:
- Feelings of sadness, tearfulness, emptiness or hopelessness – symptoms that were very pronounced for me
- Anger, irritability & frustration, even over small matters – symptoms that were very pronounced for me
- Loss of interest or pleasure, in social contact, sex drive & hobbies – symptoms that were very pronounced for me
- Sleep disturbances, including insomnia or sleeping too much – symptoms that were very pronounced for me
- Tiredness & lack of energy – symptoms that were very pronounced for me
- Reduced appetite and weight loss or increased cravings – symptoms that were very pronounced for me
- Anxiety, agitation or restlessness – symptoms that were very pronounced for me
- Slow thinking or body movements – symptoms that were very pronounced for me
- Feelings of worthlessness & guilt, fixating on past failures or self-blame – symptoms that were very pronounced for me
- Trouble thinking, concentrating, making decisions and remembering things – symptoms that were very pronounced for me
- Frequent or recurrent suicidal thoughts – symptoms that were pronounced for me
- Unexplained physical problems, such as back pain or headaches – symptoms that were very pronounced for me
Clinical depression can affect people of any age and symptoms are usually severe enough to cause noticeable problems in relationships with others or in day-to-day activities such as work or social activities – symptoms that were very pronounced for me. Symptoms typically improve with psychological counseling, antidepressant medications or a combination of the two, as they did for me.
Triggers for depression
It is often said that depression results from a chemical imbalance in the brain, but that doesn’t capture how complex the disease is. There are millions of chemical reactions that are responsible for mood, perceptions, and how we experience life. There are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, stressful life events, medications, and medical problems. We examine them breifly,
Everyone encounters stressful life events: the loss of a loved one, loss of a job, illness or violence, or abuse. While not everyone who faces these stresses develops a mood disorder stress plays an important role in depression. If the stress is short-lived, the body usually returns to normal. But when stress is chronic changes in the body and brain can be long-lasting causing depression. This is what happened to me
It is well known that depression and bipolar disorders run in families. Studies of identical twins show that if one twin has bipolar disorder, the other has a 60% to 80% chance of developing it, too. These numbers don’t apply to fraternal twins. Genetic makeup influences how sensitive you are to stressful life events. Researchers have identified genes that make individuals more vulnerable to low moods and influence how an individual responds to drug therapy.
Early losses and trauma
Research also shows that early childhood losses and trauma such as the death of a parent, or sexual abuse may resonate throughout life, eventually expressing themselves as depression. It is believed that early trauma causes subtle changes in brain function including changes in the concentration of neurotransmitters and/ or damage to nerve cells.
Some medical problems are linked to lasting, significant mood disturbances. Medical illnesses or medications may be at the root of up to 10% to 15% of all depressions. For instance, an excess of thyroid hormone (hyperthyroidism) can trigger manic symptoms. Conversely, hypothyroidism often leads to exhaustion and depression.
Heart disease has also been linked to depression, with up to half of heart attack survivors reporting feeling low and many having significant depression.
Degenerative neurological conditions, such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, and Huntington’s disease, strokes, some nutritional deficiencies such as B12, certain immune system diseases such as lupus, some viruses and other infections such as hepatitis, and HIV, cancer and erectile dysfunction in men may cause depression. If depression or mania springs from an underlying medical problem, the mood changes will disappear after the medical condition is treated.
This is the depression experienced by some women after giving birth. Postpartum depression has an incidence rate of 10–15% among new mothers and lasts for upto 3 months.
There is no laboratory test that can be used to diagnose major depression. However, the doctor may run blood tests to help detect any other medical problems that have symptoms similar to those of depression. Diagnosis is based on a psychiatrist performing a thorough medical evaluation.
Depending on the severity of symptoms, the psychiatrist may prescribe antidepressant medication and/ or psychotherapy. There is no one drug or dose and so it may be necessary for the psychiatrist to try different drugs at different doses to determine which medicine works best for you.
Selective serotonin reuptake inhibitors (SSRIs) are the primary medications prescribed, owing to their relatively mild side-effects, and because they are less toxic in overdose than other antidepressants. Response rates to the first antidepressant administered range from 50–75%, and it can take at least six to eight weeks from the start of medication to remission. Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is recommended. People with chronic depression may need to take medication indefinitely to avoid relapse.
Biochemistry of Depression: Hormones & Neurotransmitters
When we are under stress the hypothalamus secretes a hormone called corticotropin-releasing hormone (CRH). CRH follows a pathway to the pituitary gland, where it stimulates the secretion of another hormone called adrenocorticotropic hormone (ACTH). When ACTH reaches the adrenal glands, it prompts the release of cortisol (the stress hormone). Cortisol readies the body to fight or flee and the heart beats faster, blood pressure rises & breath quickens. Normally, a feedback loop allows the body to turn off the “fight-or-flight” defenses when the threat passes. In some cases, though the floodgates never close properly, and cortisol levels simply stay high. This can contribute to problems such as high blood pressure, immune suppression, asthma, and depression.
CRH influences the concentration of neurotransmitters throughout the brain. Disturbances in hormonal systems, therefore affect neurotransmitters and vice versa. Neurotransmitters such as Acetylcholine, Serotonin, Norepinephrine, Dopamine, Glutamate & Gamma-aminobutyric acid (GABA) relay messages from neuron to neuron. The release of a neurotransmitter from one neuron can activate or inhibit a second neuron. The neurotransmitter also affects the neuron that released it. Once the first neuron has released a certain amount of the chemical, a feedback mechanism (controlled by that neuron’s receptors) instructs the neuron to stop pumping out the neurotransmitter and start bringing it back into the cell. This is called reabsorption or reuptake.
The brain usually produces adequate levels of neurotransmitters but during depression, receptors may be oversensitive or insensitive to a specific neurotransmitter. Or the originating cell pumps out too little of a neurotransmitter or if overly efficient reuptake mops up too much before the molecules have the chance to bind to the receptors on other neurons. Any of these system faults could significantly affect mood. An antidepressant medication tends to increase the concentration of these substances in the spaces between neurons (the synapses).
Physical Exercise and Depression
Neurobiological effects of physical exercise and major depressive disorder are well established. Research has shown that exercise is as effective a treatment for depression as antidepressant medication or psychotherapy. Earlier it was thought that several weeks of working out was necessary to see the effects on depression, but new research shows that just a single 40-minute period of exercise can have an immediate effect on mood. I know from experience there is simply no drug like exercise.
What made me a little different from a lot of other folks I know is that I could identify something had changed in my mental state and recognized I needed professional help. I felt no shame in accepting it. I actively pursued medication instead of shying away from it and I put myself on a strict exercise program because I learned hard exercise had a lasting effect in improving how I felt and keeping me there. I know that once you have had an episode of clinical depression, you are at high risk and I constantly self check how I feel and change in responses and behavior. I know it is a disease just like the many others I have and I can keep it in check, as I do with the others. I hope you do too.