The Writing Desk of Jakebe Rabbit

On the weekend before last, I walked all night to raise money and promote visibility for suicide prevention and related issues. There were more than a thousand people with me, all dedicated to this cause because they had been touched by mental illness and the havoc it can wreak over the lives of people who cope with it and the people who form their support network. It was a sobering thing, knowing just how many people were directly affected.

Walkers wore honor beads to show their connection to suicide. Green meant you had a personal struggle or attempt. Gold meant you lost a parent; white meant you lost a child; orange meant you lost a brother or sister. Red is for losing a spouse, purple is for losing a friend or other loved one. There was a rainbow of colors over a sea of blue shirts that day, and the sheer variety of people wearing green beads really blew me back. There were old hippies, young video game nerds, intellectuals and business-people, homemakers, people of color, couples and whole packs of others. I could look at someone, see their green beads, and know that I'm not alone in what I survived. So many people from so many different walks of life also deal with depression and the suicidal ideation that can be a part of it. It was inspiring, but also surprising.

We don't talk much about suicide or the conditions that lead to it -- namely, deep depression and anxiety. I can understand why. Mental illness is something that can be very hard to wrap your brain around; one can understand it logically, or have an idea of what it's like through metaphor. But when you're dealing with a loved one who feels like they're only burrowing deeper into a hole you're trying to pull them out of, it can be exasperating, confusing and make you feel hopeless.

Why do we do that when we're depressed? What's actually going on when people like me are in the worst of those troughs? I wanted mainly to try and explain things on a few different levels -- what physically or chemically happens to the brain; what it feels like to me personally when it does; how it looks to our support networks; and what the depressed and their loved ones can do to help manage their condition before, during and after episodes. This might take me a little while to do, and it'll most certainly take multiple posts. I want to make sure that my information is correct and any recommendations made are helpful, but also please keep in mind that I'm not a mental health professional. I have intimate knowledge about this, but I'm not trained to deal with it any way.

Depression (or major depressive disorder, or chronic depression) is a mood disorder often characterized by deep feelings of sadness, hopelessness, numbness, loss of interest and lethargy. People within a depressive episode can appear sad or empty to the point of near-catatonia; angry or irritable; entertain irrational thoughts or worries that leads to catastrophic imaginings; be unable to sleep, or sleep too much; appear tired or "slowed down", so that thinking and speaking are noticeably delayed; appear distant, aloof and/or unable to explain what's going on. There are a lot of other symptoms, of course -- depression isn't a "monolith" illness, and everyone's relationship with it will differ depending on physiological and environmental factors.

So what's going on in the brain that depression manifests with such different symptoms? Why do some of us get really sad and still while others get agitated, angry or paranoid? Why is it so difficult to treat depression with medicine or lifestyle changes, like so many other illnesses?

That's a difficult question to answer, simply because so little is known about the physiology of the brain and how it relates to mood. The brain is a frighteningly complex organ that is really a bundle of inter-related systems working together to do amazing things -- if any one of them runs into a problem, it can cause changes that are hidden through some dependencies and rise in others. The simple fact of the matter is we can't pinpoint to one part of the brain and say with certainty that this is the part that causes mood disorders.

What we do know is that there does seem to be a genetic component, and parents can pass depression and other mental illnesses to their children. For example, my biological mother was schizophrenic and the children of schizophrenic people are at a higher risk for chronic depression. There is also a physiological component that might take a bit to explain.

So, our moods are actually electrical and chemical messages that travel through our brain. What happens is an electrical message is sent from a neuron, travelling down the long trails called dendrites to the end of the branch. Think of it like a rural family walking down a long dirt road to put a message in a mailbox. That message can be anything from "This thing you're touching is very hot." to "You are getting sleepy." That message changes from an electrical stimulus to a chemical when it reaches the mailbox, and that chemical is called a neurotransmitter.

Receptors at the end of dendrites for other neurons are specially formatted for any of the 30 (identified) neurotransmitters; when those receptors pick up the neurotransmitter, it converts the chemical message back into an electrical impulse which races along the dendrite (that dirt path), into the cell body, and then to the axon -- which changes the electric impulse back into a chemical -- and the whole process starts all over again. We have anywhere from 10-100 billion neurons in our brains, and they can communicate with each other in less than 1/5000 of a second. It's amazing stuff; our brains are processing incredible amounts of information at astonishing speeds, converting electricity to chemicals and back again.

So what happens to the message once it's been received by a neuron? Well, it's released from the neuron that started it and floats in the synapse -- the space between neurons in our brain. It's then either taken back by the neuron that started it (that's called reuptake) or broken down into another chemical called monoamine oxidase (MAO).

There are three neurotransmitters that have typically been focused on when it comes to depression -- serotonin, dopamine and norepinephrine. Any one (or more) of the three have been shown to have unbalanced levels in people who are depressed. Basically, the chemicals that tell our brains to regulate our mood, sleep, appetite, stress and sexuality are in short supply or the brain has trouble actually knowing what to do with them.

While at first we believed that it was the level of these chemicals that were the main cause of the problem, there has been research that indicates it might be the connection between neurons in certain parts of the brain -- like the amygdala, thalamus and hippocampus, all of which have been shown to be physically different in people who deal with depression. Anti-depressants target certain processes in our brains to elevate the level of these neurotransmitters and to improve the number and quality of connections in the areas of the brain associated with them. SSRIs, or selective serotonin reuptake inhibitors, basically prevent one of these neurotransmitters from being called back to its parent neuron. So there are more of them floating in the synapse, waiting to be picked up by other ones and pass along the appropriate messages. MAOIs, or monoamine oxidase inhibitors, are drugs that prevent these neurotransmitters from being broken down if they're not doing the reuptake thing.

So, to sum up, depression can be caused by an imbalance of three neurotransmitters -- serotonin, dopamine or norepinephrine. This imbalance could be caused by an overly efficient reuptake process that calls back these chemicals before the job is done; it could be caused by bad connections between synapses in certain parts of the brain; it could be caused by the brain's inability to form these chemicals properly to begin with. Each possible medication treatment targets one aspect of this problem, and possibly only one neurotransmitter. That is why it can take some time for medication to work in the first place (because physical and chemical changes to the brain don't happen overnight) and some time for your psychiatrist to find the right medication (because the problem might not be that your serotonin is too low, it's that your dopamine can't attach properly to synapse receptors).

Even though our brains have a "post office" that passes along literally billions and billions of messages between neurons every single minute, sometimes something goes wrong with the system and we lose the ability to send and receive postcards that say "Having a great time, I hope you're doing well!" Sometimes, it's not even something in the brain -- it could be hormones that are causing different physiological responses in the body that ultimately end up affecting the brain. There are no quick or inexpensive tests to pinpoint exactly what's going on with the chemicals in the brains and bodies of us depressive people, so medication is often our most educated guess.

There are, of course, different kinds of depression. Major Depressive Disorder is what most of us think of when we talk about depression, but there is also Persistent Depressive Disorder (where depression lasts more than two years), Bipolar Disorder, Seasonal Affective Disorder, Postpartum Depression, Psychotic Depression (which is accompanied by hallucinations, delusions and paranoia) and others. A proper diagnosis can lead a psychiatrist towards one or more medications, but most often treatment will happen on multiple fronts; while looking for a chemical solution, cognitive behavioral therapy can help us identify and manage thoughts and emotions that come from depression.

What's important to realize is that depression is a distinct physical illness -- as real as diabetes, AIDS or Parkinson's Disease. There is a real chemical and/or physiological disorder in our brains that affect how and what we think, our levels of energy, our ability to manage conflict and stress in our lives.

During depressive episodes, our brains are going through changes that make it much more difficult to manage our moods, sleeping patterns, appetites and other things. When we're depressed, we may literally be physically incapable of being happy, maintaining a balanced perspective, sleeping or eating as we should, or even getting out of bed. The chemicals that allow us to do that are simply not present or active within our brain.

That is what those of us who manage depression have to face. While many of us are lucky enough to have access to mental health care and responsive treatment, many more of us are unable to visit a therapist or psychologist; have no means to seek help; or are in an environment where mental illness is poorly understood, stigmatized or completely ignored. Those of us trapped within those situations often have no recourse but to suffer alone and helpless.

So many of us who have this illness recognize that there's something wrong with us; that we can't feel happy or motivated or interested the way most people can, or that we feel empty and hopeless even though we have no reason to. We know that our inability to do everything that might be expected of us can be a real burden on those around us, and that it can be difficult or impossible to explain just what's happening to us. When we're in a place where getting out of bed and just taking a shower is all that we can do today, it can be extraordinarily alienating for even the most well-meaning advice to miss the mark of our experience, to offer ideas or solutions that the depressed person is simply incapable of imagining.

It's an awful thing to be in that place. We can often be unable to think of times when we didn't feel this way, or imagine a future in which we won't feel this way. This is going to sound lame, but U2's song "Stuck in a Moment That You Can't Get Out Of" was a revelation for me; it really captured the major problem of depression for me, that idea that this is something ugly and permanent that I will have to bear for the rest of my life.

For those of us with this illness, there are a number of things that make our manifest symptoms and internal experience unique. Specific brain chemistry, personality traits, environmental and social factors, hormonal imbalances, life experience and so many other factors contribute to how we express, cope and view depression. And I know how difficult that is to help with, but trust me -- it's not any easier for those of us trapped inside of our own heads.

On Wednesday, I'll talk more about my personal experience with depression. But for now, here are a few links that offer further information.

All About Depression -- A website that offers information and resources about what depression is, how it works and manifests, and treatment options.

What Causes Depression? -- A page from the Harvard Medical School that talks about what we know (and still need to learn) about the physical and chemical roots of depression.

Antidepressants (Wikipedia) -- Wikipedia, of course, has an extensive article on antidepressants and how they work chemically. What's interesting is we still don't know exactly WHY they work; but the data gathered over the decades prove that they do.

National Alliance on Mental Illness -- NAMI is the leading organization in the United States dedicated to mental illness and improving the conversation about it within our country. They also have tremendous resources, information, and outreach.

See you folks on Wednesday. If there are any questions about depression or comments about information I've presented here, please let me know!