When depression is a message

smoke signals from within end stage capitalism, and psychiatry's empty promises

What if sometimes depression is a message, and not a disease:

I’m going to use some examples here. I agree that what we call major depressive disorder in the DSM is most likely many different things crushed together into one name. This is about one specific instance of those things and does not apply to you, or even me, a fellow sufferer of one of those other things. But maybe this is someone you know, or maybe it is you. I want these folks to feel a little bit less alone today, and a little more seen and valid.

A mid 30s male logs onto Zoom. Alvin was born to a pair of mixed parents, his father an immigrant from China who came to the US and started a corner grocery store in Queens. And his mother is American born Puerto Rican who grew up in Queens and fell in love with the hard working and charitable man behind the counter who not only studied English but Spanish as well to better serve his community. You’ve likely met him before if you’ve ever stopped at the neighborhood store to grab a drink. Alvin is, by all accounts, the product of a working class generally supportive but not always understanding of inter generational issues, multicultural typical American home. Alvin finds himself, after graduating, the first in his family to get a college education, in Silicon Valley working for a tech startup. His family is proud, beaming even. Alvin graces my virtual psychiatry office today feeling a bit off lately. He doesn’t even have time for a visit to the actual office, instead he’s holed up in some kind of soundproof cubicle teleconference office in a sterile hyper modern startup office. Typical. Alvin isn’t sure what’s wrong. Maybe adhd? He feels hopeless. Ready to “throw in the towel” but remains vague on what that means (and so begins the bullet dodging we all know so well about SI aka “don’t 5150 me, bro”). Alvin isn’t broken, and his mood and currently ego dystonic (read: he doesn’t wanna do it) thoughts of veering his car off the Bay bridge on the way into work are kind of a shock, compounded by the fact that both his parents endured way more, he thinks, than this. He must just be soft, he thinks his dad would say (He might, but IRL probably not, depression kind of does that to you, making you come up with worse things to say to yourself than anyone else would IRL).

Alvin is working increasingly long hours for a startup that demands more and more churn as the funding starts to run dry and that fancy SoMa office bill begins to bleed their VC and startup capital dry. He sees home less. He wants a dog, but can’t imagine leaving them at home while he is at work all day and sometime night. He sleeps poorly, and has nightmares where he is back at work, in a meeting, about to give a report when he opens his slides and they’re all blank. The stares of his coworkers wear through him like a particle beam. And then… he wakes up, drenched in sweat and shaking, an hour before his alarm. He gets up. Goes into the office early. Dragging himself like a reanimated corpse filled with blue bottle espresso (now presented by Nestle!) His boss, the startup ceo, is pleased at his initiative. He may be getting a promotion.

Alvin isn’t depressed? Or is he? He has low mood, suicidal thoughts, sleep problems, low energy, difficulty concentrating (on account of the existential dread of the ever looming reports about financial insolvency, and hearing his dads admonitions from childhood in his head) and at the end of the day yeah he’s a little bit irritable too, withdrawing socially. He feels like he’s moving in slow motion. Alvin must be depressed. He meets good old DSM criteria, and his PHQ9 pharma corporation advertisement checklist for depression also looks like…well…shit. That’s how he got an appointment with me, the highly masking neuroqueer shrink that’s locked into a corpomed contract because I have med school loans to pay and our family stories ain’t that different. I try and play it up like I’m locked in some kind of dystopian cyberpunk sci fi by jazzing up my wardrobe to make me feel better, but make no mistake I’m counting the days, and I’m glad there’s no bridge on MY commute. More importantly, Alvin is crumping. Crumpling? Idk why we started using that word in the ICU but it stuck. In the ICU it meant that the body’s own innate healing and homeostatic regulatory mechanisms are failing, ya boy needs pressors to maintain organ perfusion and maybe help breathing and shut is hitting the fan…FAST. The next steps if it gets any worse is cardiopulmonary arrest and cpr, chest compressions, and likely some broken ribs underneath your aching hands trying to get perfusion and return of spontaneous circulation (ROSC). Alvin is just as sick as that icu patient with a gunshot wound from a stray bullet while grocery shopping in West Oakland, but WE BLAME Alvin. The other guy gets to blame the bullet.

Alvin didn’t do this to himself, and his body’s homeostatic mechanism to regulate him is failing. Something in his body knows there is something wrong with him going to this job, perhaps something wrong with the job itself. His body is revolting against the situation he is placing himself in in the most existential way possible. His body’s response is to project an image of driving off a bridge. Just like the icu patient who is losing blood and not vasoconstricting in all the right ways to maintain perfusion of vital organs, and has run out of strength to fight against flooded lungs to get oxygen into the blood. I can manually ventilate the ICU patient. I can also “manually ventilate” Alvin. It won’t heal the underlying problem though. The socioeconomic trap he finds himself in trying to singlehandedly hold up a failing business is the bullet in his chest cavity. As your doc-in-the-box/HMO shrink, I can’t take the bullet out even if I know it’s there. I can, through a series of convoluted referrals, send you to “job stress program” where I can give you time off work to “attend treatment” (as if it’s your fault you can’t cope with a failing economy and employer) but the reality is most people use that time to ready their resume, quit, and find another job. The therapist’s best role is in helping people like Alvin stand up and quit instead of sinking with the ship. As for me? I can numb the pain with a bit of Prozac, Lexapro, Zoloft, maybe some Trazodone to help the sleep. Whichever one keeps you just numb enough to keep driving over that bridge, eyes fixed forwards, and into that office where you perform absurdist ballet all day and evening long on a mechanical keyboard you bought as #selfcare.

So, instead of the time off for therapy, we choose meds, and Alvin does get better on paper. He’s less irritable, he’s sleeping, and he’s productive at work without doom and snark in meetings, and when he dreams of empty presentations now he laughs and goes “oh well. Fuck it!” Alvin’s doing so well on paper, his boss promotes him. More work! A pittance more money too, though.

Now Alvin is starting to think about the bridge again a year later, and the medical system calls this a recurrent episode of MDD. Personally? When I look at the bigger picture im complicit. The problem with psychiatric meds is the opposite of what conspiracy theories tell you. The problem is that they DO work. I numbed down the pain of a sprained ankle and sent my best player, injured, back into the game. He played even harder and now he’s way worse off than before. So I do what any good employee of corpo health would do. I raise his Prozac dose even higher. And maybe if I have a heart, I start to hint at setting boundaries with work. It won’t be easy. On paper, he gets better again. Ever better as his own life and dreams slowly wither away in sacrifice of the triviality of the app developer he works for, making something that outwardly seems cool but inwardly seems soul sucking and banal, like mobile gacha games. He is wealthier, but not proud.

He thinks often of his dad’s bodega. He wonders if his dad ever felt anything like this existential feeling of pointlessness and realizes that this is a new entirely alien experience of his generation. Some part of him cries when he thinks of another life he could have lived “in another life, I’d have enjoyed just doing laundry and taxes with you” sets the tone so many of us know all too well. I see this pattern played out again and again on the stage of my ever increasingly large patient panel, easily over a thousand now. I am complicit in simply managing by text message and useless rating scales, helping to keep a grimdark dystopian servitor class of tech priests, good people at their core, sufficiently comfortably numb to continue punching a clock and clicking their keyboards into oblivion.

Our metric for improvement is return to productivity, and target symptom burden removal, and on paper I look great. In person this doesn’t feel great. Both Alvin and I know the truth and on a good day we can both be honest about it with one another. Sometimes depression is a message. Sometimes depression is a warning sign that something in your universe is wrong. Quite often we are stuck. One of the first lessons of working in inpatient psychiatry is that what you really need to be able to prescribe someone is a house, and some stable source of food. But in other situations, even the working poor can be trapped in a horrible cycle of needing to keep an abusive job in order to stay on health insurance so they don’t die. The market just doesn’t work when healthcare is tied to your employment. You can never effectively risk it and go on your own to start your own venture if you’re unlucky enough to have even a single (even stable!) health problem. Depression is often a message, a ghost in the machine, and it is telling us that something is deeply wrong with our life. Instead of blaming the system, depression has us blaming ourselves. We are sad, depressed, and really we should be quite angry. Perhaps this is where Freud found his ideas on depression as anger turned inward. What I can say is that CBT doesn’t work in these cases nearly as well as we wish it did. The stressors, the despair and the feeling of being Sisyphus is real. The best I can do is recognize it, and spend some of that sacred half hour to hour we have together to validate that it’s not you, it really is everything and everyone else that sucks.

Best captured by Godspeed You Black Emperor:

“We are all trapped in the belly of this horrible machine, and the machine is bleeding to death. I open up my wallet, and it is full of blood”