In February 2021 I checked into a psychiatric ward. The emergency department doctor admitted me after I answered yes to the following questions: Do you have little interest or pleasure in doing things? Do you feel bad about yourself or that you are a failure or have let yourself or your family down? Do you have trouble concentrating on things such as reading the newspaper or watching television? Do you have thoughts that you would be better off dead or of hurting yourself?
Yes, yes, yes, and yes. After several weeks of crippling anxiety and depression, I was back in a place I dread more than any other, but I know it’s the safest place for me to be when I feel that low. This wasn’t the first time I’d been there, and unfortunately it probably wouldn’t be the last. That’s the bad news. The good news is that I recovered and expect to recover again.
How It Began
I had my first episode of major depressive disorder in 2005 at the age of forty-one. I had been under a tremendous amount of stress, having just gone through a divorce. I was also going to grad school while simultaneously working full time and raising two young daughters. I wasn’t sleeping well and had been feeling increasingly anxious and sad. Then Hurricane Katrina hit. Although I had lived in the Washington, D.C., area for more than twenty years, New Orleans is my hometown—I still have relatives who live there and great affection for the city and its unique culture.
I was devastated to see people suffering in squalid conditions in the Louisiana Superdome. I could not fathom why we could not get water and food to people in an American city when we could airdrop necessities in war-torn countries across the globe. I felt as if my city had been abandoned. I couldn’t think straight. My thoughts went round and round in a spiral. I had less and less energy and was unable to concentrate on my work. Eventually, I couldn’t get out of bed in the morning, and it took a tremendous amount of energy just to take a shower. My distorted mind convinced me that my family would be better off if I were dead, and I came up with detailed plans for how I would end my life. Over the course of six months, I was hospitalized five times.
I tried a variety of antidepressants, gradually increasing the potency of the drugs. I saw a therapist and psychiatrist regularly. I participated in cognitive behavioral group therapy. Still, I sank further into depression. Finally, a physician friend recommended electroconvulsive therapy, or ECT. This therapy had gotten a bad rap over the years, especially in One Flew Over the Cuckoo’s Nest, which portrayed it as a punitive, painful treatment. Mental health professionals told me stories about how, in the past, ECT often had been given to patients in psychiatric wards without their consent, without anesthesia, and with severe adverse effects. But others told me that it was now safe and extremely effective.
I was reluctant. However, as I had been unable to work for more than six months and knew that my family was deeply worried about me, I decided to give it a try. It ended up saving my life.
My ECT was performed as an outpatient procedure, as is generally the case. The actual procedure took about five minutes. I received general anesthesia and muscle relaxers, and electrodes were placed on my scalp. Low-intensity electrical impulses were then emitted to create a brief, controlled seizure that affected the neurons and chemicals in my brain. Treatments are generally given three times a week until the symptoms are in remission, and they may be spaced out over months as maintenance therapy.
It was as if my brain was jump-started. It made me feel better almost immediately, and I felt nearly recovered by the fourth treatment.
ECT is one of the most effective treatments for severe depression. Yet this is the first time I’ve publicly admitted that I’ve received the treatment because of the stigma associated with it. Mental illness is stigmatized in general, and ECT is so stigmatized that many people are afraid to even mention the treatment that helped us get better. Why are those of us who’ve received it so reluctant to talk about it? No one is ashamed of receiving chemotherapy or immunotherapy. Yet in addition to the negative media impressions about ECT, mental health professionals still portray it as a “last resort” for those with “treatment-resistant” depression. I am left feeling as if it’s my fault that I need it—and ashamed for being suicidal—when I should be shouting to the world about the benefits, for me, of this treatment.
Recurrence
After I recovered in 2006, I was healthy for ten years. I thought I had this depression thing whipped. I went on to have a successful and demanding career. First, I was the chief health lobbyist for AARP during the passage of the Affordable Care Act. Then, after a stint at the Department of Health and Human Services, I became the executive director of the White House Conference on Aging under President Obama. When applying for security clearance for the White House job, the questionnaire asked whether I had been hospitalized for a psychiatric condition in the past seven years. Luckily for me, it had been more than seven years since my hospitalization when I applied, but I have friends with mental health conditions who have been denied security clearance. Even worse, I know people who refuse to be treated for their mental health conditions because they fear it will negatively affect their security clearances and, thus, their ability to qualify for high-level positions.
Over my career, I have received recognition for my hard work and dedication to health and long-term care policy. Close friends have told me that they are surprised to learn that I ever suffered from depression. I’m friendly and approachable—I don’t meet the stereotype associated with people living with depression as sad, angry, and withdrawn.
In 2016 I left the White House to join a small nonprofit organization. I loved working in government, but as I was a political appointee, many friends and colleagues counseled me to leave so that I could return to a government position if Hillary Clinton was elected. Similar to 2005, I was burning the candle on both ends: I was writing countless grant proposals, overseeing a large team, and volunteering for many social causes and campaigns. The 2016 election was much more polarizing than any I’ve experienced. Most people did not expect Donald Trump to win—including me. The election results caused me to crash after months of building anxiety.
Once again I spiraled downward. I couldn’t get out of bed. I couldn’t work. I had thoughts of harming myself. This time, my husband urged me to start ECT much sooner in the cycle, and once again, it worked. Within a matter of weeks I was back at work, pretending nothing had happened. I kept pushing myself harder to show everyone that I was “normal.” I thought I had a pattern: I would function at a high level for many years and then my depression would be triggered by a significant event. I thought I’d be healthy for another ten years.
But I started feeling signs of depression again only a year later. From my health services research, I knew that my diagnosis, major depressive disorder, can be triggered by a major event that prompts a person to recall previous traumatic experiences (for instance, my mother’s death when I was very young). During an episode I am unable to function and have so little energy that even small tasks take extra effort. Many others suffer from persistent depressive disorder, which refers to a low mood that lasts for at least two years. Many people with persistent depressive disorder are able to function day to day but feel low most of the time. I also learned that depression is highly recurrent, with at least 50 percent of those who recover from a first episode having one or more additional episodes in their lifetime, and 80 percent of those with a history of at least two episodes having another recurrence, according to the literature. So I know that this illness may be with me for a long time.
Not Alone
In 2018 two celebrities, Kate Spade and Anthony Bourdain, died by suicide in close succession. Several news articles described how selfish they were for taking their own lives. Journalists questioned how someone who was so successful and admired could do this. In reading these articles, I knew that the writers didn’t really understand depression. They didn’t get how it takes over your mind and distorts your thoughts. Depression convinces you that everyone around you would be better off if you were dead. You are a burden, a disappointment, and incapable of functioning. In addition, many people judge those with depression. If they would only exercise more, meditate, see a therapist, take their meds, and so on, they wouldn’t be depressed. But I did everything that was recommended. I exercised nearly every day. I meditated and saw a therapist regularly. I took my antidepressants. Still, I got depressed again. And I’m still struggling to accept the fact that it is not my fault.
I’ve observed that many high-achieving people experience bouts of major depression, but we generally hide it from others. Our expectations for ourselves are high, and when we can no longer perform at such intense levels, depression convinces us that we are failures and worthless. So, in the wake of these deaths, I decided to speak out.
I share my own experience in the hope that I can help people better understand depression and—more important—give those living with depression hope that they can recover. I also aim to raise awareness of stigma and recovery surrounding mental health issues. As part of my efforts, I work as a network leader with the Stability Network, a growing movement of people living and working with mental health conditions. We share our stories to inspire others and change how people think about mental health. Our message is one of hope and recovery.
In disclosing my illness to others, I’ve discovered that most people I know have been touched by mental illness in some way.
In disclosing my illness to others, I’ve discovered that most people I know have been touched by mental illness in some way. Indeed, one in four Americans ages eighteen and older suffers from a diagnosable mental disorder in any given year, according to the National Institute of Mental Health. Mayo Clinic notes that women are nearly twice as likely as men to be diagnosed with depression. The National Institute of Mental Health estimates that 17.3 million adults in the US had at least one major depressive episode in 2017.
Yet people don’t usually tell you about their own experiences until they hear about yours. I’ll never forget when one of my neighbors told me that her mom had died by suicide. On the outside, my neighbor lives the picture-perfect life. She’s a beautiful, successful lawyer with two wonderful daughters and a loving husband. She confided that losing her mom to suicide had utterly changed her life—it had devastated her and her sisters. She has never gotten over it. And she still misses her mother every day. I remember this story whenever I’m in the depths of despair—I remind myself that my daughters and husband will never be better off without me, no matter how bad I feel. This knowledge has helped me pull myself back from the brink and push myself to get better.
Better Treatment Options Needed
People living with depression and the people who love them need to know there is hope for recovery. The Milken Institute has conducted several studies and surveys on mental health. Several themes have emerged that identify a three-pronged approach to better mental health infrastructure. We need to create awareness of early symptoms as well as an environment in which people feel comfortable reaching out for help without stigma. We need accessible, affordable, culturally competent, and effective care. And we need treatments that work quickly and effectively with few adverse effects. Guided by these themes, I share here my own vision for how we can do more for people living with depression.
First, we need to reduce stigma. By speaking out about my own experience, I hope to make it easier for others to get help. One silver lining of the COVID-19 pandemic is that it both raised awareness about how many of us struggle with our mental health daily and identified coping mechanisms to help.
The science of mental health is evolving. Many mental health professionals now talk of mental health being on a spectrum. For example, research has found that there is a continuum in our ability to regulate emotions. Characterizing mental health this way can help reduce stigma and increase hope that better days are ahead.
Second, care needs to be more accessible and equitable. For too long, the US has treated mental health differently than physical health. Despite the passage of the Mental Health Parity and Addiction Equity Act of 2008, good mental health insurance coverage is hard to come by. Numerous studies document the shortage of mental health professionals to meet the demand for services, and the pandemic has exacerbated this discrepancy.
Access to psychiatrists and psychologists has been challenging even for me, although I have good health insurance, am well educated, and have the financial resources to pay for care. I belong to a large, integrated health plan that ostensibly covers therapy. However, because of high demand, patients can generally only see their therapists once a month, which is not enough—especially for patients with severe symptoms. My out-of-network therapist does not take health insurance of any kind, which is typical in the area where I live. Thus, private weekly therapy is often limited to the affluent.
It is well documented that racial and ethnic minority groups have experienced disparities in mental health and substance misuse related to access to care, psychosocial stress, and social determinants of health. And the economic and health impacts of the pandemic have only exacerbated these disparities. New research by the Centers for Disease Control and Prevention found that Hispanic adults reported a higher prevalence of psychosocial stress related to not having enough food or stable housing than did adults in other racial and ethnic groups.
In light of these challenges, policy makers might consider making group therapy or peer-led therapy more available to people with mental health conditions. For many conditions, research has shown that group therapy works as well as individual therapy. Personally, I’ve benefited more from individual therapy, but group therapy might be a second-best alternative, given the shortage of mental health professionals now. Government grants to community-based organizations to provide training for peer counseling could offer much-needed help in areas without access to mental health professionals.
Barriers to care still exist for people like me with a supportive family and workplace and with financial resources. The barriers are much larger for low-income people, for whom care might not be culturally or linguistically appropriate or for whom the stigma might be even greater.
Third, there is need for alternative treatments. Although ECT has worked well for me, it has several drawbacks. Patients must receive general anesthesia, which can have adverse effects and make the recipient unable to work for at least the day of the procedure. The adverse effects, including headaches and memory loss, can also be intolerable for some.
Recently there have been promising findings on alternative treatments for depression such as ketamine, LSD, and psilocybin-containing mushrooms. In his book How To Change Your Mind, bestselling author Michael Pollan argues that psychedelic-aided therapy, properly conducted by trained professionals, can help with overcoming addiction and depression. In a small 2020 study of adults with major depression, researchers from Johns Hopkins Medicine found that two doses of the “magic mushroom” chemical psilocybin relieves symptoms for at least one month. However, more research, investment, and testing are needed before these treatments are considered clinically accessible.
Some researchers predict that effective therapies in the future will look more like ECT and transcranial magnetic stimulation (TMS). TMS is a noninvasive procedure that uses magnetic fields to stimulate individual neural circuits to improve symptoms of depression. Although it has been proven to be effective for 50–60 percent of people with depression who have tried and failed to receive benefit from pharmacological interventions, transcranial magnetic stimulation is an intensive therapy that requires sessions that occur five days a week for several weeks.
In addition, too often US society invests heavily in new pharmaceutical options instead of researching the effectiveness of nonpharmaceutical alternatives such as acupuncture, mindfulness, and building community. The government should invest more in researching these alternative treatment options, and insurance policies should encourage effective nonpharmaceutical treatments to be tried first.
Fourth, social prescribing should be explored. This is a concept practiced in the UK and other parts of Europe that is also starting to gain traction in the US. Social prescribing is a means of enabling health professionals to refer people to a range of nonclinical services to promote prevention and wellness.
In his groundbreaking book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions, author Johann Hari offers social prescribing as a way to make people with depression feel valued and connected. Hari gives an example of a social prescription that has stayed with me for a long time: He tells the story of a nurse who was bullied at work and was depressed—she hadn’t left her house for several months because of her depression. Her doctor prescribed working on a project with a small group of similarly disconnected people. Their task involved turning an abandoned area in London into a vegetable garden. At first the participants barely spoke to each other and focused on growing tomatoes or zucchinis. The gardening helped the participants focus on something other than their own distorted thoughts. Over time they got to know each other and provide peer support for their depression. The nurse bonded with others around her, reconnected with nature, and found meaningful work that improved the neighborhood. All of this markedly improved her mental health.
Social prescribing holds promise, but unfortunately, evidence of its effectiveness is sparse, and there is wide diversity in how social prescribing services are designed and delivered. Further, some are concerned about the prospect of social prescribing being used in lieu of, rather than in addition to, good medical care. Still, greater investment in researching and delivering nonmedical interventions such as those mentioned above is sorely needed in the US.
Learning To Thrive
My journey has been long and hard, but I’ve learned a great deal about depression and ways to treat it. We need some alternative, affordable, accessible treatments and more people trained to provide mental health services. Too many people are struggling and need help. My message to those people is: You are not alone. There are many of us coping with mental health conditions every day.
I’ve also learned a great deal about my resilience and capacity to recover. It is possible to thrive with a mental health condition—I am living proof.
