Pessimistic, grouchy, bored, blue? Chronic low-grade depression can feel so familiar you don't even know you've got it. But it's rampant among women and underdiagnosed. The good news is that with treatment, you can be better than ever.
At some point, they were happy; they had moments of joy. And then, one molecule at a time, the happiness went away. Sometimes the loss began in childhood, and their well-being disappeared so gradually they hardly noticed. For others, sadness came on like a sudden fog after months of stress. After a while, negotiating daily life was like driving a car with a dirty windshield. It was tolerable. They coped. Pleasure? That consisted of not feeling really bad, interspersed with a few moments of genuine laughter and fun—which, over the years, grew increasingly rare or became possible only with the aid of alcohol, drugs or the temporary high of sex. If someone had asked them, "Are you happy?" they wouldn't have known what to say.
They are four women who have never met: a nurse in Chicago, a literary agent in New York City, a restaurant owner in Montgomery, Alabama, and a writer in Los Angeles. But for each of them, there came a moment when they realized: This can't be normal.
"I walked into a psychiatrist's office, and he said, 'You suffer from depression.' Nobody had ever told me that before. I thought, Oh, my God, I'm seeing the world through a different lens," says Beth Vesel, 43, a literary agent and happily married mother of a 5-year-old boy. Up until that point, Vesel had felt there was simply something wrong with her personality, some character flaw.
"It's like you're walking around with a leg that's half an inch shorter than the other, and everybody tells you, 'The problem is your back,' or 'It's your neck.' And then somebody says, 'Your leg is half an inch shorter, but we can construct a special shoe,'" she says.
Low-grade depression (dysthymia) is one of the most common ailments on the planet and one of the least likely to be diagnosed. Like its cousin, clinical depression, low-grade depression hits women roughly twice as often as men (though some researchers believe mood disorders in men are underreported because of social stigmas). Clinical depression is a kind of mental hurricane: Symptoms include debilitating insomnia, weight loss, anxiety or a mental fog so dense that people forget what they've read as soon as they've read it. The pain is so awful that suicide can seem an acceptable solution.
Low-grade depression is more like a year of drizzly weather. It is, by definition, chronic. A diagnosis requires the presence of symptoms on more days than not for a period of at least two years, which is what makes it so hard to pin down. Any given day might be okay, even happy. Yet in the general run of days, there are more gray ones than not, more unhappiness than joy. Most people afflicted with this kind of chronic malaise instinctively blame themselves: They would rather believe they can solve the problem—if they could just find the right job or the right man or lose weight—than admit they have a psychiatric disorder.
That's not to say that the problems a depressed person fixates on don't exist. But a healthy person might take action, or simply look around for a fun distraction. A person with low-grade depression broods and gets stuck. Caught in that drizzly mental weather, she doesn't seek shelter or buy an umbrella; she goes on slogging through puddles.
Someone You Know Has It
Approximately one adult in six will be affected by some form of depression in his or her lifetime—a rate that varies only slightly among various ethnic groups and cultures. Low-grade depression is less common, affecting 3 to 6 percent of the adult population. Even so, the two-to-one gender disparity means that between four million and eight million American women will suffer from an insidious, low-grade mental illness, most of them receiving no help.
Fewer than half the people with clinical depression ever seek medical advice, fewer than that get appropriate help, and people with low-grade depression fare worst of all. They think, "Hey, nobody said life is a party. If I'm still showing up at work, I must be okay."
Yet the damage chronic low-grade depression inflicts can be even more devastating than a single episode of severe clinical depression. "Being 80 percent of yourself for two years is worse than being 20 percent of yourself for two months," says Frederick K. Goodwin, M.D., former director of the National Institute of Mental Health and now a professor of psychiatry at George Washington University.
Susan G. Kornstein, M.D., associate professor of psychiatry at Virginia Commonwealth University, notes, "Someone with an acute major depressive episode is much more likely to get help because there's an obvious change. But low-grade depression causes greater impairment to patients' overall functioning in their work and social lives because it goes on for so long. These people go unrecognized, even by health care professionals."
That is, they do unless somehow something gives them a glimmer that life can be much better—or unless they sink into clinical depression, says Jane Ferber, M.D., an assistant clinical professor of psychiatry at Columbia University. In that sense, a major life crisis can turn out to be a blessing: It forces people to acknowledge that they have been existing in a gray zone of subhealth.
A Hole In Her Heart
Veronica Aguirre's hard-drinking father left the family home in Chicago when she was 5. "That was a crushing blow for me," she says. "I used to make up stories about how my dad was going to come back and get me. They were lies and everybody knew it, but they let me lie."
Over the years—as a student at an all-girls' Catholic high school, as a young woman partying and working on a Caribbean cargo ship and later as a single mother in Chicago trying to support her daughter while going to nursing school—Aguirre harbored that suppressed grief from her childhood.
Today the 43-year-old home health care nurse looks back and sees in that grief the seeds of the low-grade depression that had dogged her for years. "When I looked at a blue sky, there was an underlying black," she says. "Literally."
Martha Hawkins, a 53-year-old Montgomery, Alabama, restaurant owner, grew up in a poor black family in 1950s Alabama. "Life was just never really right," she says. "I never felt good about myself." The message she absorbed was the one delivered to most southern girls of that era: Be sweet. Try to please. When a boyfriend asked her for sex, she said yes. When she got pregnant at the age of 16, she married the boy because both sets of parents thought it was the proper thing to do. And she dropped out of high school. "After we got married, I always did what his mother said to do," she recalls. "I never made any decisions. It's hard when you have so much to say and nobody to say it to."
The common wisdom about depression—that it's anger turned inward—is a cliché that contains some truth. But depression is a complicated illness that is usually caused by a combination of external stressors and biological triggers.
A family history of depression is a strong indicator of risk. Beth Vesel's early memories are of a mother who suffered from periodic bouts of severe depression and who spent much of Vesel's childhood in a haze of medications. Hormonal fluctuations, which disproportionately affect women in their childbearing years, are also a factor. The two-to-one ratio of depressed women to men holds true only between puberty and menopause; there is little or no disparity between the genders in children and the elderly.
Escapes That Lead Nowhere
Not everyone who suffers from low-grade depression looks back on an unhappy childhood; for some, the problem begins in adolescence or early adulthood—the result, perhaps, of the inevitable stresses that accompany such rites of passage as moving into a first apartment, graduating from college or losing a first love. Someone who is vulnerable might slip into low-grade illness without even realizing it.
That's the way it was for Meri Nana-Ama Danquah, 33, a Los Angeles writer who has written a memoir, Willow Weep for Me (Ballantine). "The depression was just part of who I was," she says of herself in her early twenties. At that time, Danquah had just moved to L.A.; she was writing and working temporary jobs, rarely taking time to enjoy the charms of the city. "I wouldn't go to the park and roller-skate," she says. "It was like, Why bother? I was functional. I'd get up and go to work. You have moments of pleasure. But the basis of your life is not contentment. It's not pleasure. It's almost like having a film over your life."
Some people cope in couch-potato fashion: When having fun seems too much trouble, it's easy to camp out every night in front of the television, raiding the refrigerator during commercials. Low-grade depression and poor eating habits frequently go hand in hand. Scientists aren't sure of the exact biological mechanism, but there is evidence that eating carbohydrates temporarily boosts a person's mood by altering the brain's level and use of serotonin. People with low-grade depression quite often binge on high-carbohydrate foods—pasta, crackers, popcorn—in what some doctors see as an unconscious effort to self-medicate. Ferber frequently sees patients with low-grade depression who are significantly overweight—a fact that, for women living in a culture obsessed with thinness, quickly becomes a vicious cycle: Depression leads to overeating, to a dispiriting look in the mirror and, from there, to deeper depression.
For others, keeping the demons at bay involves sex or drugs. "I was okay until I was about 14, and then I started experimenting with drugs and drinking," Aguirre says. She and her best friend were kicked out of school. "I was high most of the time," she says—which she now realizes was an effort to mask her feelings. Sex was another emotional narcotic. "I was very promiscuous, starving for the wrong kind of attention. I'm lucky I don't have HIV," she says.
Feeling Good Again
Unfortunately, many women get worse before they get better. Danquah had an episode of major depression when she was 22. "I couldn't bathe. I couldn't wash dishes. I barely ate," she says. "I knew something had gone wrong but didn't know why. It's like you're walking down the street, and something falls on you, and you think, If I ignore that, maybe it won't happen again." But when her daughter was born two years later and postpartum depression set in, she could ignore it no longer. "That's what motivated me to really investigate what was going on," she says. "I had made a choice to have a child. It was something I wanted to be present for."
Looking for a good therapist requires perseverance. Both Danquah and Hawkins faced obstacles in the rarified world of psychiatry because they were women of color. Hawkins saw three psychiatrists, all of them white men, without getting much help because she simply didn't feel comfortable speaking openly. And since she was poor at the time, she didn't have much choice about who her doctor was.
Danquah recalls going to an emergency room because she was unable to get a quick appointment with a private psychiatrist. The doctor who examined her was from the Middle East. "He said, 'What do you do?' and I said, 'I'm a writer,' and he said, 'What kinds of things do you write?' And I said, 'I write for The Washington Post and the Los Angeles Times.' He said, 'How long do you believe The Washington Post has been giving you writing assignments?'" She had to put him on the phone with her literary agent to prove she was not delusional.
Doctors are not immune to cultural stereotyping, says Michelle O. Clark, M.D., associate clinical professor of psychiatry at the University of California in San Francisco and an expert in cross-cultural psychiatry. Clark says discussions of psychiatric conditions in African-Americans are influenced by the historical myth of the "happy darky"—the idea that black people are somehow incapable of experiencing depression. Added to that, she says, is the fact that for a member of a minority group to seek help, she or he must violate a basic rule of survival: Don't put your business in the street. "In the black community, anything and everything you say can be used against you," Clark says. "Three-year-olds know the Miranda warning."
Latinas and Asians often face language barriers, says Doris Ayala, executive director of the Latino Family Institute in Chicago. Ingrained cultural views, such as the idea that suffering is God's will, may make it hard to seek help. Because the belief in psychotherapy is relatively new for many immigrants, Ayala frequently combines traditional psychotherapy with referrals to folk healers—curanderos for Central Americans, espiritistas for Puerto Ricans, santeros for Cubans. "I say, 'Let's work together.'"
Many minorities are especially wary of antidepressant drugs, fearing addiction. These medications can provide dramatic results for people with major depression and can also help those with a low-grade disorder. They're not addictive. But the confusion is understandable: Certain anti-anxiety medications, such as Valium and Xanax, can be addictive, and general practitioners frequently prescribe these drugs to depressed patients, rather than antidepressants such as Prozac and Zoloft.
Some people are leery of taking anything that alters their brain chemistry, whether it's addictive or not—as if that were cheating. "I had done so many drugs in my life, and I didn't want to numb myself," says Aguirre. "I thought I had to feel the pain. I cried pretty much every night for two years. I look back now and realize that was foolish."
Even though Aguirre thinks she put off trying medication for too long, she's not sorry she put serious effort into therapy first. At the time Aguirre began seeing a therapist, she had just broken up with her daughter's father and was working full-time as a waitress while going to nursing school at night. Her therapist challenged her most basic assumptions about herself. "I supported my daughter's father for six years—he could never hold a job—but all that time I didn't think I could take care of myself," she says. "My therapist asked me, 'What do you need? What do you want?' I was blown out of the water. I had no clue what she was talking about. It took me about six months to find out what I needed."
Once diagnosed, low-grade depression can be a wake-up call to take a hard look at your life, Goodwin says. It can force a woman to acknowledge, say, that there's deep discord in her marriage or that she needs to drastically revise her self-image.
Danquah's soul-searching altered some of her closest relationships. "I had to say to people in my life and my family, 'I invite you into a healthy relationship, but this toxic relationship ends right now.' "
Without the prod of low-grade depression, Goodwin says, "people aren't as likely to take on the job of figuring out what's going on in their lives. That's one of the problems of moving into medications too easily."
Depression is a whole-self illness. Although certain types of depression have a strong hereditary or hormonal component, it's hard to separate the biological from the situational factors. Regaining health often requires attacking the problem on all fronts: spiritual, physical, social and intellectual. Danquah likes to quote The Salt Eaters, by Toni Cade Bambara: "Are you ready to be well? Because being well is a serious thing."
Danquah, Vesel, Aguirre and Hawkins eventually used medication and therapy; equally important, they all made lifestyle changes. "I support medication, and I would go on it again if I needed to," says Danquah. But she was able to stop taking antidepressants two years ago and credits her continued health to the support of friends, regular exercise, a good diet and maintaining her spiritual health.
"I would take an hour before therapy and think about what I was going to say," she recalls. "After therapy, I would walk in the park or go to a museum—someplace where I could just be in my thoughts. I always went on Thursdays. That became my tranquil day. And then gradually that tranquility spilled over into Wednesday and then into my whole life—until my whole life became a search for tranquility."
Hawkins's discovery of a renewed religious faith was a major factor in her recovery. Her belief gave her a sense of her own power. That, combined with finding a doctor she could trust and the right medications, gave her insight into a lifelong pattern of negative thinking. "I realized that I was going to have problems all my life, and what mattered was how I dealt with them." Over the years, she has painstakingly worked at training herself to think more positively. "Medicine can help," she says, "but if my way of thinking doesn't change, I'm still going to be in the same situation."
Vesel still sees the same psychiatrist who first diagnosed her. Exercise also plays a role in her well-being—in her case, it's modern dance. "No matter how bad I feel, I go in there and know that for an hour and a half my mind is off myself."
As these women describe their lives, it's clear that change was hard work. But all four have opened their lives to joy. Danquah, who once couldn't be bothered to strap on her Rollerblades and go to the park, is in the middle of relocating herself and her daughter to Africa, where she has taken a teaching post at the University of Ghana. "I started by painting my living room yellow so it would get more light," Danquah says, "and I have plants all around me. My plants are a reflection of me." She laughs. "I don't reside here. I live here. There is life going on here."
Signs of low-grade depression
You feel sad, dissatisfied or pessimistic most of the time, although you still have days when you feel normal.
Your appetite changes.
You're tired most of the time.
You have insomnia or you're sleeping too much.
You're harder on yourself than you should be.
You're not working at your peak, and you're having trouble concentrating.
Simple decisions somehow take forever.
You feel that every day is more or less a struggle.
If you have at least two symptoms—especially the first one—see your doctor for a checkup, and if you're physically healthy, ask for a referral to a mental-health professional. If you have five or more symptoms and are also experiencing anxiety, feelings of helplessness and loss of interest in sex, your depression may be more serious. Seek medical help immediately.