If you’ve never experienced Bruce Springsteen performing live, I highly recommend it. Seeing this fabulous, famous and wealthy rock star performing in front of thousands of adoring fans, many of whom know every word to every song, one would never guess that he has struggled with episodes of debilitating depression and profound self-doubt. I recently read Springsteen’s memoir, Born To Run, and was impressed by his courage in revealing the painful details of his depressions and also his treatment.
Everywhere you look these days, news stories talk about rising rates of depression, suicide, anxiety, loneliness and stress in the United States. In addition to an increase in the incidence of these disorders, another important factor is the decreasing stigma around mental illness. As people feel more comfortable talking openly about their mental health struggles, these issues get more attention. This effect is magnified when respected celebrities and “influencers” disclose the facts of their struggles. Other recent examples include Michael Phelps (depression, suicidal thinking and substance abuse), Lena Dunham (anxiety, obsessive compulsive disorder and depression), and Lady Gaga (past eating disorder and depression). We should also give credit to those who were brave enough to come out of the closet decades ago, when it was even less safe, including Brooke Shields (postpartum depression), Jane Fonda (bulimia nervosa), and Catherine Zeta-Jones (bipolar disorder).
The hope is that this openness will decrease the shame associated with these illnesses, encourage people to get support from their families and friends, and to seek professional help when needed.
How do we differentiate between “clinical” levels of depression, anxiety, mood swings, disordered eating, and difficulty concentrating from the “normal” anxiety, mood changes and insecurities that we all experience as reactions to the challenges of daily life? In fact, fluctuations in mood and anxiety are mostly beneficial and adaptive, allowing us to experience pleasure, warning us of dangers, motivating us to study for the upcoming big exam, and challenging us to grow and change. Most people find a flat, unreactive mood to be quite uncomfortable and disagreeable.
There seems to be a sweet spot for anxiety. Too little anxiety and we won’t be motivated to study for that organic chemistry exam. Too much anxiety, and we’re unable to sleep the night before, and then have a panic attack during the test; our brain freezes and we don’t remember anything we studied.
Psychological experiences and syndromes occur along a spectrum, with no true “normal.” So, for example, it’s common to have mood swings in response to the weather or life stresses. We feel sad when grieving, and anxious when interviewing for jobs. Most of us experience anxiety in new social situations or when performing. How do we differentiate shyness from social anxiety disorder? Grief from clinical depression? Mood swings from bipolar disorder? Drinking too much in college, or smoking marijuana, from a substance use disorder? The aftermath of trauma from PTSD?
It is generally when a constellation of symptoms is numerous and severe enough to cause significant distress and/or impairment of functioning, over a sufficient duration of time, that a clinical “disorder” may be diagnosed. We make these clinical diagnoses according to criteria delineated in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). Some of us are more susceptible to developing these disorders due to genetic factors as well as childhood environment and experiences.
Emotional pain doesn’t track with the DSM-5. A person’s level of psychological distress can be just as acute without meeting formal criteria for any disorders. “Normal” grief and loss can cause profound suffering. So can loneliness and social isolation, dissatisfaction with an important relationship, lack of a sense of purpose, and feeling unfulfilled in one’s life path. It’s not unusual for people to feel some shame in seeking psychological help for issues that may seem less serious. Psychotherapy (talk therapy), sometimes even over a few sessions, has the capacity to open things up in a way that can be profoundly transformational. Sometimes it’s a matter of learning, or re-learning, how to better care for ourselves, and giving ourselves the permission to do so.
My son jokes that every time someone tells me they have been feeling sad, unmotivated or tired, I recommend a morning walk or run outside. While, clearly, this is not the proper or full remedy for all ills, it does include many of the non-clinical strategies that have been shown to help with depression and anxiety: structure to the day, exercise, behavioral activation, morning sunlight, and getting a dose of the outdoors and nature. Better yet, run/walk with a friend and get the social contact that has been found to be crucial for mental wellness. Research also supports engaging in mindfulness practices, including meditation and yoga, minimizing alcohol consumption (and other substances,) and prioritizing sleep. Getting a sufficient amount of sleep each night and maintaining a regular sleep-wake schedule is one of the most basic and powerful strategies for a healthy mind and body.
Psychiatric medications may be considered when symptoms are numerous and severe enough to meet criteria for a specified mental health disorder or syndrome. For example, mild to moderate depression can respond just as well to psychotherapy as it does to medication, but more severe depression tends to respond better when psychotherapy is combined with antidepressant medication. Personal preference is important, as people may feel more comfortable with one treatment modality over another. Medication often plays a central role in more severe disorders such as bipolar disorder and schizophrenia.
There are other treatment modalities, old and new, more and less invasive. These are too numerous and varied to cover here, but include: acupuncture, electroconvulsive therapy (ECT), ketamine, transcranial magnetic stimulation (TMS), and even recent research on the use of psychedelics for PTSD.
Springsteen’s memoir describes his state of agitated depression: “…everything brought waves of an agitated anxiety that I’d spend every waking minute trying to dispel. Demise and foreboding were all that awaited and sleep was the only respite.” With help from family and friends, along with psychotherapy and medication, “…things became a little more normal as time passed. I’ve long ago stopped struggling to get out of bed and I’ve got my work energy back. That feels good. Two years have passed and it can feel like it never really happened.”