Student depression

University terms are starting all over the country. When I was an undergraduate, the Cambridge term started late, in early October, and our terms were only eight weeks long. That first one was seven weeks six days too long for me.

I have had several responses from students to my blog on dysthymia – low-level persistent depression, or what is now called persistent depressive disorder. The people who contacted me are just the tip of the iceberg. In your class of a hundred fellow students it could be that as many as nearly twenty of them are mentally ill, to some degree, right now. That’s a lot of sick people; imagine a class where twenty people were sneezing and coughing non-stop. Who are these people? Can you tell? Are you perhaps one of them? And a couple of lecturers are probably depressed right now, too.

What’s the leading cause of death for young people aged 20-35 in the UK? Those risky boys speeding round blind bends in their sporty cars? Drugs? Falling under a bus blind drunk? Being mugged and murdered? No, by some way, it’s suicide. Suicide is also the leading cause of death for men under 50. And most people kill themselves because they can’t take the hopelessness and pain of depression any longer. And if suicide doesn’t kill you, depression is associated with a host of disorders, such as heart disease, cancer,  and dementia, which might get you later.

Depression and anxiety are closely related, and usually go together. Epidemiological studies show that anxiety and mood disorders are remarkably common: it’s estimated that one in three people will suffer in their lifetime, and between one in six and one in ten are ill now. The reporting of mental illness has increased, but whether that’s because of better understanding of the disease, better diagnosis, reduced stigmatisation of the ill, increased pressure of contemporary life, or, most likely, all of these, is unclear.

When I was young (under twenty, say), I didn’t know what depression, anxiety, and obsessive-compulsive disorder were, although in retrospect I suffered from all of them. I was aware of something my relatives talked about in rather hushed tones called “a nervous breakdown”. I’m still not entirely sure what one of these was, but I think it was a sudden mental illness requiring some kind of treatment, and even incarceration in an “asylum”. Treatments were very limited back in the 70s; remember that chlorpromazine wasn’t released to the market until 1953, the first benzodiazepine, Librium, in 1960; and the first antidepressants in 1957 (iproniazid, a MAO inhibitor) and 1958 (imipramine, a tricyclic), although these drugs have many serious side-effects. The relatively more benign Prozac (fluoxetine) wasn’t available until 1987. I don’t think I knew about these drugs until I switched as a student from Natural Sciences Physical to Psychology. Indeed when I was a teenager, I thought of treatment as shock treatment; that’s about all there was.

Attitudes started to change when Prozac became widely available; perhaps that’s generally true – diseases only begin to lose their stigma when there is some hope. When I was young “cancer” was another dirty word, sometimes just called the “c word”. Don’t ask my younger self about swearing though; when I was ten, I thought the filthiest word in English was “pub” (where my father went Sunday lunchtime).

I was the first person in my family to go to university, and I had no idea what was involved, no idea really what a degree was (although I knew students “read” for it on University Challenge), no idea how to manage money (fortunately credit cards weren’t available then), no idea how to manage my time, no idea how to study independently, no idea how to live, no idea how to make use of what was available, no idea what a girl was, and no idea of how to cope when I was a raving loony without realising it. I was extraordinarily shy, which didn’t help. I wasn’t lazy; I tried my best, but I had no idea how to organise my time. I expected university to be like school, which of course it isn’t.

I stuck out the first year, mostly because I drift through things and staying was the easiest thing to do, and I was just clever enough to get by in spite of my deficits. The turning point was joining a society where I met other people. I still can’t say that I felt at home, and at the end of the first year I got a summer job where I did. I was earning good money, I had friends of sorts, I seemed to have some purpose, I felt like I was part of a community, and I wondered why go back to Cambridge. At that point I nearly gave up.

I don’t really know why I didn’t; it was easier to stay than not. And when I went back to Cambridge I discovered psychology, and things started to look up.

If I knew then what I know now I would have got professional help. I would have started with meta learning rather than learning. I would have been bolder about asking questions. Mostly I would have realised that I was ill, I wasn’t alone, and that I should talk to people.

Obsession

Depression alone is bad enough, but unfortunately it is rarely a pure affliction: people with mental health issues are usually doomed to suffer many versions of misery. Depression and anxiety go together, so much so that many researchers believe that there is a deep relationship between the two. Unsurprisingly then, both benefit from the same sorts of pharmaceutical treatment (SSRIs).

Anxiety comes in many forms, and many of us suffer from more than one. At different times I’ve had my share of social anxiety, generalised anxiety, panic attacks, agoraphobia, and other phobias. I have found that one of the most striking – I want to avoid the word distressing because all forms of anxiety are distressing to those who suffer from them – is obsessive compulsive disorder (OCD). When I was a young teenager my life was blighted by OCD, often in florid forms. In the night I would go down the stairs dozens of times to check that the front door was shut; I would get up multiple times throughout the night to check that my bus pass was still in my school jacket pocket; I would repeat things in multiples of three. I was afraid of contamination, the idea that germs and disease could spread by touching something that touched something that touched something, or even by having seen someone with a disease. I would then wash my hands several times (in multiples of three of course). I was afraid other people could read my thoughts, or would misinterpret an innocent gesture as an offensive one, so would apologise inwardly to them (in powers of three; twenty seven sorries is bad enough, but just try eighty one).

All classic stuff. I didn’t know what OCD was then, and I just suffered, alone, in misery. OCD is, to use a cliché, living hell, and it’s even worse if you think you are alone and have no idea what’s going on. In retrospect something should have been done about it, but I just grew out of it. Mostly – I still have a tendency to overcheck things, usually three times, but no more, and only occasionally, so it doesn’t bother me. We can live with some pathology. Being obsessive even has its advantages as an academic; there’s nothing wrong with checking your data a few times, or being careful about proof reading and checking your facts are right. Being a writer is sometimes obsessive; we often feel a pressure to write. I think you need to be a bit obsessive just to overcome all the negative feedback writers get. The boundary between OCD and having an obsessive personality isn’t always clear – as ever the problems start when what we do makes us unhappy, or interferes with our lives. We also have a problem if our behaviour doesn’t make us unhappy, but affects those around us.

As with all mental illness, the precise causes are unknown, but as with depression there is almost certainly there’s both a genetic and environmental component. The brains of people with OCD look different, but again whether that’s a result or cause of the illness, or whether both result from something else, is not know.

But not all obsessions involve an obvious compulsion other than one to keep the obsession going.  We all have things we worry about from time to time. Most of us are familiar with “ear worms”, tunes that get stuck in your head. I suffer very badly from these (I speculate it’s to do with my psychopathology). It can drive me mad – or more precisely even madder than I already am. They’re the strangest tunes too – I once endured a week of John Denver singing “Annie’s song” non-stop. Worst of all though are obsessive thoughts, the rumination on particular events, ideas, or people that takes over our minds. It is horrible. The compulsion, in as much as there is one, is to continue the obsession. The thoughts – bad thoughts – involve regret, guilt, and fear. When I was in my OCD phase as a teenager at the end of every school term I would struck by the idea that I had done something wrong, and the school holiday would then be ruined by the fear of punishment that would await me on my return at the start of the next term. Of course I never had done anything, and was never punished; it was all in my head. It’s impossible to reason yourself out of OCD.

I think obsessive thinking is verging on psychosis, because things really are out of control. We might refuse to accept that the obsession is irrational, and some people might even act upon their obsessions – I assume that is how people become stalkers. I just suffer though.

Obsessions without compulsion is called “primarily obsessional OCD”. I was encouraged to see that the Wikipedia entry on OCD says that “Primarily obsessional OCD has been called one of the most distressing and challenging forms of OCD”; it’s more than distressing, it’s mental agony. I almost envy people with OCD because at least enacting the compulsion provides a little relief, no matter how short.

However illogical and crazy the behaviour might seem to someone who has never experience OCD, it is impossible to reason your way out of the illness. You can’t tell yourself that it’s irrational to wash your hands so many times. First, the compulsion is stronger than our belief system. And second, there is always a grain of truth we can cling to – it is just possible that a disease might be passed on by touching something that was touched by someone who touched someone with a disease, for example. There is though a clear treatment plan for OCD that involves breaking the link between obsession and compulsion. One of the best books I have read on OCD is Brain Lock: Free Yourself from Obsessive-Compulsive Behavior, by Jeffrey M. Schwartz. He identifies four stages in treatment: relabel (you must recognise what is obsessive and clearly label it as such); reattribute (this thought is not me – it’s my OCD); refocus (the really hard bit, where you have to shift attention, at least for a while); and revalue (to take the whole cycle as something not to be taken as face value, and to adapt the view of a more impartial observer – being mindful). He suggests gradually building up a delay between having the compulsion and having to do it – you might only be able to manage a few seconds at first, but you increase it, perhaps very slowly.

Such treatments, while effective for dealing with the compulsive actions, don’t immediately help us in being able to stop the bad thoughts coming in the first place. In a recent bout, ruminating on a mistake I had made, I tried saying internal loudly and firmly, “It was my choice”, which I eventually simplified to a loud “STOP!” in my inner speech. This approach eventually worked – or the bout blew itself out. A friend told me that a common technique is to visualise a STOP road sign, and I have since tried combining visualising the sign with thinking STOP! It is exhausting work though; bloody exhausting. At least my obsessions appear to have a natural life span, and eventually, after much pain, they eventually peter out.

The intrusiveness of thoughts is one reason why I find meditation so difficult. My thoughts just won’t go away. Even when counting breaths the thoughts overwhelm my inner voice counting. There is a paradox here because if I could just be mindful and live in the present, I wouldn’t be so obsessed by Bad Thoughts, but the Bad Thoughts stop me being able to attend to the present. Coming back to the now and trying to be present does help me when I’m being obsessive, and I think it’s a skill at which one can get better with practice.

I am grateful to and encouraged by everyone who has written to me about my blog. So many people suffer alone; it is time to stop the stigma of mental illness. For a long time I thought I was alone in suffering from obsessional thinking; if we all shared more we would be less isolated, less frightened, and maybe just a little better off. Please feel free to share this blog with whoever you might think would benefit from it.