I grew up in a culture of relative stoicism. We’re the people who always reply to, “How’re you?” with, “Fine, thanks.” Fine was code for, “There is no immediate emergency.” You only ommitted fine if there was something your questioner needed to leap up and do right away: “The house is on fire.” “I’m wet and freezing cold and need a towel and a lukewarm bath.” “An axe-murderer is chasing me up the walk, shut the door.” Otherwise you don’t make a fuss—you’re okay. You’re doing well. You’re hanging in. We’re all fine here. How are you?
My family’s trying to break this trend, but oh, it’s hard. We have the hideous urge to downplay and gloss over, to appear strong and keep from alarming other people. It can be hard to leave each other the spaces to elaborate: I’m fine, but. It takes courage to squeeze more words out.
The other week my father called me, prompted by a get-well card I mailed him on the occasion of his being hospitalized twice for being suicidal and joining outpatient treatment for severe depression. I was on a day off, since I’d just completed a 48-hour shift at the foster home, and was about to begin an emergency 48-hour shift with a special client being housed in a motel.
Him: How’re you?
Me: Oh, I’m fine. But, y’know, a little stressed. It’s pretty tiring. I was just working with the client who’s kind of aggressive, and also needs adult diapers changed, which is out of my comfort zone. But, y’know… I’m coping.
Him: [Sympathetic words etc.]
Me: What about you?
Him: Oh, well. Hanging in there. I’m going to the outpatient group a couple nights a week at the hospital, and then this Friday night group in preparation for a more serious program they’re waiting for an opening to show up in. It’s, I don’t know, pretty interesting. You hear some people and think, ‘Jeez, I don’t have it so bad.’ But it’s also pretty hard, to be trying to deal with all this stuff and not know how to talk about it. They ask me, ‘What’s the feeling word?’ and I don’t know. I don’t know what I’m feeling.”
Me: So… everything sucks right now?
Him: …Yeah. Just about.
Me: I’m sorry.
So this is a post for my family and everyone else who is fine, thanks, how are you? while bleeding to death internally. It’s for people with mood disorders who wonder, “Am I just weak, maybe? Doesn’t everyone feel like this, and just cope with it better than I do?” It’s for the people who don’t even remember what “happy” feels like. Because what I want to point out is: It’s not fine. We’re not okay. This isn’t normal. We need help.
For this post I’ll use the Beck Depression Inventory (2nd edition), which is a highly reputable measure of depression used for all kinds of different people. It’s not my favourite (I like the PHQ-9 a lot, f’rinstance) but it has the special advantage of providing descriptive sentences to choose between, which serves my purpose here. The BDI-II can easily be administered and scored with a pencil and paper, although it should properly be interpreted by a clinician with graduate-level training before deciding its results mean “depression” and not “finals week” or “thyroid issue”. That’s the bit that isn’t simple math, but involves a more contextual understanding of people and their circumstances (and possible tendency to under-report and say they’re fine, and how are you?).
Anyway. The BDI-II has 21 questions, and each question has four possible items scored from 0-3, with a higher score indicating more overall depression. This means that the highest possible score is a 63. Very few people tend to score all the way up to 63, because being that depressed is often—how shall we say—fatal.
I’ll divide the BDI up into three sections by severity. The first chunk is the twenty points or so before the ceiling. If you score above 30 or 40 on the BDI-II, you have my sincere congratulations on just being fucking alive, because oh my god, that is unspeakably depressed. I really hope you have a good support system. Someone who scores 40 or above is expected to have severe difficulty with basic lifeskills; this level of depression means problems with getting out of bed, doing basic hygiene self-care, and reliably making and eating food. This kind of person really benefits from inpatient psychiatric care just because other people make sure that their depression does not seriously damage their own health and safety.
These are the kind of answers Super Depressed people often endorse:
- I blame myself for everything bad that happens
- I feel like crying, but I can’t
- I feel my future is hopeless and will only get worse
- I would kill myself if I had a chance.
Moving from my dad to me, a score of 17-30ishis, how shall we say, “Depressed”. It’s not hellaciously depressed, but nor is it just, y’know, normal. This is depression that may not incapacitate, but creates a disturbance in some part of your ability to feel happy and healthy, hold down a job, care for dependent children, go to school, do creative work, or pursue meaningful social relationships. I know a lot of people in this range who find they have to prioritize: they can parent but not exercise, or be creative but not have a social life. Expressly targeting mental health for treatment (whether talk therapy, psychopharmacology, or positive lifestyle changes) is likely to bring benefits, even if they aren’t as dramatic as those super depressed people can experience.
There is a huge amount of diversity in how people who are just plain depressed, but not hellaciously depressed, look, act, and feel. Some people are pretty chipper but casually suicidal, or conscientiously productive and emotionally dead inside; others cannot get off the couch or self-isolate from friends, but manage to retain a bearable inner mental landscape. But here’s a sampling of responses in this range:
- I feel guilty over many things I have done or should have done.
- I am so restless or agitated that it’s hard to stay still.
- It’s hard to keep my mind on anything for very long
- I get more tired or fatigued more easily than usual
Now that we’ve looked at people who are depressed, I want to point us all to the elephant in the room:
People who aren’t depressed at all.
(I find myself wanting to add, “Lucky motherfuckers”)
I pull this one out for clients who can’t imagine not being depressed. “What would it be?” they ask cynically. “Happy Pollyanna with flowers and sunshine and little woodland animals?” So I pull out the BDI they’ve probably recently completed and read off the answers they didn’t check.
You know how people answer if they’re going to score a 0 on this test?
- I do not feel sad.
- I am not discouraged about my future.
- I do not feel like a failure.
- I don’t have any thoughts of killing myself.
- I don’t feel particularly guilty.
“Not depressed” does not mean you are unspeakably joyous at every moment. After all, it’s defined by the absence of an experience. If you’re not depressed, you can be happy or sad or angry or lonely; you can admit you’ve made a mistake or have a bad day or feel guilty about something you’ve done.
But the thing is, those moods end. They change. What’s more, people without depression have what can seem from the outside like an amazing amount of control over their moods: they can just decide to be happy, and then they are. They don’t like being sad, so they do something nice, and they stop being sad. Stress dissipates with a relaxing exercise; guilt is eased by making amends; loneliness is salved by connection. Literally the only feeling that’s off the table to meet this definition is a pervasive, omnipresent cloud of sorrow, agitation, shame, and worry following their every step.
You know another thing about a score of zero on the BDI?
IT’S THE MOST COMMON FUCKING SCORE.
Here’s a map of how BDI scores and depression diagnoses are distributed in the population:
This is actually for a population with a relatively high rate of depression. (It apparently sucks to be an urban woman in the UK?) As you can see, the most common scores are low ones, the vast majority of which fall below the BDI’s first cutoff at 17. By the time you reach what the study considered a score indicating reliably diagnosable depression, 40, the number of respondents has nearly collided with the X axis. The vast majority of people (72-99%) actually experience very few symptoms of depression on a regular basis.
- Most people feel neutral or optimistic about the future.
- Very few people hate themselves.
- It isn’t normal to feel like a complete failure or the cause of every problem in your life.
- Everyone you meet may have a story that can break your heart, but very few of them are living them right now.
I’ve been depressed since I was a child so I’m no longer truly surprised by the depths of suffering and self-hatred people can live in, but I am continually surprised by health. I remember when I went on my first antidepressant at 21 and thought, “Oh my god, if everyone feels this good, no wonder going to school is easy for them!” and now I know that what I felt then wasn’t even health—it was just a lighter shade of depression. Even just going from a score of 30 to 20 felt like someone had loosened my manacles; I was lighter and freer and more in control.
In short, everyone who’s ever said that diagnosing depression is just “pathologizing ordinary sadness” can fucking bite me.
Veerman, J. L., Dowrick, C., Ayuso-Mateos, J. L., Dunn, G., and Barendregt, J. J. (2009). Population prevalence of depression and mean Beck Depression Inventory score. The British Journal of Psychiatry, 195, 516-519.
The populations with the most depression in this study were from Dublin and Liverpool; I have paternal ancestors from within 50 miles of either.