Winter is coming

The autumn equinox this year was 22 September. From then on the sun peaks at midday overhead somewhere in the southern hemisphere until the spring equinox late next March. In practice, day and night are of equal length on the equinox, or would be if our earth fortunately didn’t have an atmosphere. In London, on 21 June the sun rises at 4.43 and sets at 21.21; on 21 December the corresponding times are 8.03 and 15.53. That’s nearly nine hours more light in the summer. With such a dramatic difference at this latitude, no wonder so many react to the difference.

Light plays a central role in regulating our biological clock. …

Winter is here – almost.

The autumn equinox this year was 22 September. From then on the sun peaks at midday overhead somewhere in the southern hemisphere until the spring equinox late next March. In practice, day and night are of equal length on the equinox, or would be if our earth fortunately didn’t have an atmosphere. In London, on 21 June the sun rises at 4.43 and sets at 21.21; on 21 December the corresponding times are 8.03 and 15.53. That’s nearly nine hours more light in the summer. With such a dramatic difference at this latitude, no wonder so many react to the difference.

Light plays a central role in regulating our biological clock. We live on a natural rhythm called the circadian rhythm, and our internal clock is set by the action of light on the retina of the eye, transmitted by special tracts of nerve cells to the pineal gland. The pineal gland, situated near the centre of the brain, manufactures a hormone called melatonin. Melatonin helps send us to sleep, so much so that in some counties it is available without prescription as a sleep aid, and melatonin is also used in overcoming jet lag.

Light then is essential for keeping us awake, and sleep plays an important role in maintaining our mood. Most people have heard of seasonal affect disorder (SAD). The definitive mental illness diagnostic system, the American Psychiatric association Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth edition) officially classifies seasonal effects on mood as “recurrent major depressive disorder with a seasonal pattern”. In winter people with SAD are – well, sad. Some people become depressed only in the winter months, and maybe autumn and spring too, and for some people their pre-existing depression becomes worse. Unsurprisingly, given that in winter days are shorter the further north (and south in the southern hemisphere) you go, there are substantial geographical variations in the incidence of SAD, In the USA, in Florida the figure is very low, just over 1%, and in Alaska nearly 10% of the population is affected. Pity the three hundred thousand inhabitants of Murmansk, situated north of the Arctic Circle, which does not see the sun at all between 2 December and 10 January.

I should point out that not ever researcher accepts the existence of SAD. Some studies have failed to find any correlation between mood and time of the year. As with all studies on this sort of subject, much depends on the detail of exactly how mood is measured, how many people are studied, and whether or not they are receiving any treatment.

If people’s moods are affected by the amount of sunlight available then you would expect the suicide rate to vary with the seasons. It does, but not in the simple way you might expect. In the northern hemisphere the suicide rate increases dramatically in May and to a lesser extent June, and in the southern hemisphere in November. This pattern is strange and there is no accepted account of why it happens. One explanation is that when people are very depressed they are too ill to kill themselves, and need the upsurge in energy when they are starting to feel better. I don’t find this explanation wholly satisfactory because I have always felt most suicidal when I feel most depressed; it’s then that I want the pain to end. Most people when they start to recover feel relief. Another possibility is that when people are improving there is a surge in the chemical, or neurotransmitter, serotonin in the brain, and serotonin is associated with aggression as well as mood. In depressed people aggression can be directed towards themselves, leading to self-harm and suicide.

Suicide rates also vary across regions. If you look at a map of Europe there is an increase as you go from the south and west to the north and east, and again it is not simply the case that suicide is always more common in cold, dark regions; socio-economic and cultural factors play a large role too,

I graph my own mood, as I suggest everyone with a depressive disorder does, and have noticed a slight seasonality effect, but it is much less pronounced now I that I am on fairly effective medication.

We are not completely helpless when the nights start drawing in. Those fortunate to be able to overwinter in southern California should now start thinking about packing their bags. Those a bit less fortunate should book their winter holidays, going somewhere likely to have as much sunshine as possible. For the rest of us, there are still things we can do. SAD lights, which emit very bright light (look for at least 10,000 lux) and which produce light in the shorter, bluer frequency range, are now cheaper and much more widely available than they were just a few years ago. But one of the best therapies is free: being outside in natural light as much as possible, particularly in the morning, especially if it’s sunny. Wrap up and get outside.

(The above is an expanded version of my new column in What’s hot London!)

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.

What is “normal” for a depressed person?

“Dysthymia, now known as persistent depressive disorder (PDD), is a mood disorder consisting of the same cognitive and physical problems as depression, with less severe but longer-lasting symptoms … dysthymia is a serious state of chronic depression”. Wikipedia.

As part of my mental maintenance, I keep a mood diary. I’ve experimented with several kinds, including apps, but now just use the very simple system of noting one number at the end of each day, on a scale of 1 (extremely, suicidally depressed) to 7 (ecstatically happy), with 4 being “average”. Here is my chart for the last 18 months or so.

moodgraph

The first point to note is that this graph is by no means representative of my life. It begins in April 2016, when I had already been in weekly therapy for well over a year and had at last found the medication that worked (to some extent) for me. I’ve shown the trend line (a guess at the average) which shows a continuing slight improvement over time, although I think this is line is affected by a prolonged and severe relapse I had in the summer of last year. To complete the statistical background, my scores do seem to follow an approximate Gaussian (“normal”) distribution, with my mean score in the middle of the range, at about 4. (Actually it’s very slightly beneath, at 3.8.)

It’s the word “normal” that causes me trouble. What is normal? How can I gauge my mood and experience against what other people feel? And is it reasonable to expect mood scores to follow a Gaussian distribution, and if so what will the mean be?

To give a concrete example, consider someone with PDD (persistent depressive disorder). Their daily mood ratings will presumably be low every day, for long periods of time. Hence compared with people without PDD you would expect their mood rating, if they were comparing themselves with the rest of the population, to be low (as they’re not severely depressed, probably in the 2 to 3 range).

But how do people give ratings of their behaviour? Maybe, completely reasonably, people compare their mood with what they think other people experience – so the moods are relative to the population rather than the individual. But how do we know what others feel?

I use a strategy between the two. And I’m not happy about treating a rating in this inconsistent if not incoherent way. I think a 7 should be “extremely, unusually happy”, although no one should expect to be ecstatic all day long. A 4 should be average for me but not too bad. When I rate a day as “average” I mean I’ve been a bit depressed that today, but no more so than average for me

If you have PDD, your normal is low. I don’t know how other people feel most of the time, but I suspect it must be better than I do. Do you wake up looking forward to the day? Does a day pass without you thinking about suicide and death? Does your day bounce along when you’d say you feel happy? Does your life have meaning? Can you sleep naturally? Do you feel like you have the energy to do everything you want to do? Does the thought of emptying the dishwasher or taking a shower fill you with despair? If so I envy you. Your 4 is not my 4.

The opposite is also presumably true: someone who isn’t depressed has no idea how those of us who are feel. So please keep your comments about “when I’m down I always find going for a good run sorts me out” to yourself.

As I have said before, being depressed steals your life.

Giving up

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Surely everyone who has ever been seriously depressed has felt at some time like just giving up. I don’t just mean committing suicide, although that is often not far from the backs of our minds; I merely mean throwing our hands up in despair and sitting on the ground, like rebellious toddlers, and refusing to take part in life anymore. Sometimes this feeling comes from some silly event. The other day I knocked over a glass of white wine. It wasn’t simply that I couldn’t face clearing it up, but the event was imbued with some great significance. I am reminded of the scene at the end of the movie 2001, when the ageing Bowman eats his solitary dinner and then knocks over the glass on his table with his cuff; that clearly means something (although I have never been quite sure what). My broken glass signified for me that everything is pointless; all things come to an end, usually rather quickly. I just wanted to sit down and cry. I had had enough.
Sometimes I do some mundane repetitive task and think there must be more to life than this. I know I’m thinking a cliché, and that in fact my life is relatively comfortable, interesting, and good, but that knowledge doesn’t help. Doing the rubbish, collecting the trash, can often bring me to total despair. Looking at the toilet thinking I should clean it again. It’s the again bit that gets me most. Emptying the dishwasher. Washing the bedding. I feel despair wash over myself as I think, not again. This daily routine is killing me. On a good day I will wonder how many more times I will have to empty the dishwasher or clean the toilet before I die; on a bad day I think I can’t face doing it one more time. It is all ultimately so pointless.
The final words in the great Kenneth Williams’ diaries were “Oh, what is the bloody point?”. It is still debated whether his death was suicide or an accidental overdose, but for me that last entry can have only one meaning.
When the world ends I will have a cold, so I won’t be able to treat even Armageddon with the concentration and focus it deserves. Big Things always happen when I feel unwell. The rest of the time it’s the accumulation of little things, the endless repetition of life, that gets me down. Doesn’t everyone worry that at the very best, when they brush their teeth they’re just going to have to do it again a few hours later, and at worst, this time might be the last that we ever do it? Or does everyday life just pass most people by?
When you’re depressed, every day seems the same. There’s no colour. There’s nothing to look forward to. What is the bloody point?