Getting Help with Mental Illness
“We flat-out don’t talk about mental illness,” psychiatrist Catherine Birndorf says. “ILLNESS is the key word here. Just like physical illness. When we use words like distress or emotional problems or some other euphemism that’s more palatable, we are obscuring the fact that anxiety and depression are real illnesses. They can be deadly when untreated. They can cause huge emotional losses. And huge economic losses—depression is one of the leading causes of missed work.”
Depression and suicide rates are staggering: According to a recent CDC report, suicide rates have risen 30 percent in the US since 1999. In 2016, close to 45,000 people died by suicide. Globally, the World Health Organization has reported that about 800,000 people die by suicide each year.
“We’re all so afraid to have the conversation,” Birndorf says. Which she sees as a huge barrier to destigmatizing mental illness. It’s an illness that bears a disproportionate amount of shame compared to nearly every other disease or condition that we think of as physical in nature.
Mental illness is complex and yes, terrifying. But not talking about it doesn’t make it less so. “We can’t not talk about depression or suicide in society as a means to protect people.” Birndorf likens this to never talking about safe sex—it doesn’t make sense, it doesn’t serve us.
While there is no guarantee that we can keep ourselves or our loved ones safe through therapy or medication or any other means, so many of us have been asking: How can we help? In response, Birndorf outlines tools to recognize depression in others and yourself, ways to open up the conversation, and advice for getting into treatment. Her most poignant piece of advice might be this simple one: Don’t be afraid to ask questions because you don’t have the answers yourself.
A Q&A with Catherine Birndorf, M.D.
First, it’s never too early to seek help or help someone else get help.
A little bit of anxiety is normal and can be adaptive—to a certain extent. A mental illness or disorder is when things go too far. It’s okay to be sad sometimes but it’s concerning if you’re sad all the time. Or if you’re not interested in anything you used love to do. Or if you feel isolated or hopeless. When these feelings or conditions are more intense, last longer, or impair your life—then you’re in a different category. We have to respect that and get help.
There’s an acronym, a short cut that medical students use to identify depression and that I still use. It’s called SIG-E-CAPS. Depression is defined by having five or more of the following symptoms, including low mood or anhedonia, which is a loss of pleasure in things that used to bring you pleasure. Part of this definition is that patients have the symptoms for more days than not over a two-week period. Some people take issue with these diagnostic criteria but it’s still the way major depressive episodes are defined so that we share a common language and description when we use the word.
Here are the eight SIG-E-CAPS symptoms—you want to be aware of changes in the areas of:
Psychomotor agitation or retardation, which means being really amped up or slowed down physically
Hopelessness, helplessness, not seeing a way out, negativity. Also, shifts in energy—which could be anything out of the norm. Is someone not acting like themselves? Are they isolating and withdrawing from friends and family? These are all potential signs of unipolar or major depressive disorder. When we screen for bipolar illness, we’re also looking at symptoms of mania, like lack of sleep or behaving recklessly: Do they have a lot of energy and feel like they don’t need to sleep? Are they suddenly spending thousands of dollars on clothes when you know they’re normally a very frugal person?
Can you say, hey, what’s going on?
Don’t ignore whatever the change is for you. Notice if you’re drinking more. If you’re going out nonstop or not at all to avoid feeling something. Pay attention to yourself. If you’re not feeling good, don’t tell yourself that you’re fine. Notice if you’re acting differently. Take stock. Stop and ask yourself: Why am I passing up these social opportunities? Or, why do I feel so grumpy? People are saying I’m acting weird and that I’ve been defensive, or that I’ve been irritable and angry. What’s going on with me?
Don’t blow yourself off. If you’re behaving in ways that are foreign to you—that’s real. Know who you are and what’s normal-ish for you. And when something is up, let’s deal with it.
Medication has saved far more lives than it is has taken. Therapy of all kinds—short-term, long-term, talking—is wonderful. And for some people with mild to moderate depression, therapy might be enough. But medication should not be discounted. Combining medication and therapy is often one of the fastest and most effective ways to get well. We treat medical illness with medication whether it is physical or mental. And there is nothing to be ashamed of.
“It’s really important that we change the discourse around medication and stop making people feel ashamed for taking it or for considering taking it.”
Patients often ask me: If I start taking medication, does that mean I’ll be on it for life? No, not necessarily. You might be on medication for nine months to a year until the brain recovers and then you could try to taper off with your doctor’s support. Some people will say, Oh, I don’t want to mess with my brain chemistry. But the brain is already not well.
It’s really important that we change the discourse around medication and stop making people feel ashamed for taking it or for considering taking it.
That said, there’s thought to be some correlation between when people initially start taking medication and when people die by suicide. This doesn’t mean that medication causes people to have suicidal thoughts. What’s more likely is that before some people start taking medication they are amotivated, can’t function, very down in the hole, and don’t have any energy. They might get an initial uptick when they get on medication—before they start feeling better—that gives them just enough energy to hurt themselves.
We have to talk about depression and suicide. People are so scared to say anything. We’re afraid of making others feel worse or being suggestive. Even many doctors are afraid to bring it up. A lot of people think that they shouldn’t ask questions they don’t know the answer to. Like, don’t ask someone if they’re struggling, because if they are, you might not know what to do. But you can ask questions if you don’t know the answers yourself. Don’t be scared to ask someone how they’re doing if you’re worried. It doesn’t mean you’re going to be able to help them. It means you’re willing to look for help.
I was a head resident at Smith, where I oversaw a big house of students. That was really my first experience of helping people “on site.” At my recent college reunion, some of the women asked me how I knew what to do at the time. But I didn’t have to know. I just had to keep my door open, not be judgmental, and know who to call. I was the liaison. Of course, there were so many things I couldn’t fix. But I could get a student to health services, where they could connect with a knowledgeable professional. I could hold their hand, let them cry, and help them think. I could stay with them.
Have the self-confidence to ask questions when you don’t have the answer ready. Be secure enough to ask. Don’t be embarrassed. You don’t have to know everything.
“Don’t be scared to ask someone how they’re doing if you’re worried. It doesn’t mean you’re going to be able to help them. It means you’re willing to look for help.”
Slow down and look them in the eye. Ask them, for real, how are you? If they brush it off immediately, with, I’m fine—say, no really, how are you? Wait, pause. Don’t talk. Give them space to think. If they don’t open up, say something like, I’m worried about you. I’ve been thinking a lot about you.
You’re looking for a way to open the conversation. They might say, “What, you’ve been thinking about me?” And you can let them know that they don’t seem like themselves lately. Maybe they just seem down to you or they haven’t been socializing. Ask them if everything is okay.
These are simple but not easy things to say. It helps to have a couple of phrases that you’re comfortable saying in advance.
A friend’s wife who has depression is trying a new medication. He told me that he worried about her. I asked, do you tell her? He’s a doctor. He told me that his biggest fear was that she would kill herself. And he was too scared to tell her this. He didn’t want to upset her or have her know that he could be thinking that. But you must imagine she is, I said.
“We’re all such mysteries, even to ourselves. Asking scary questions is a part of intimacy.”
It feels suggestive or taboo to bring up suicide. But I think it’s a generous, intimate thing to be able to say, have you ever thought about hurting yourself? That’s one of the most profound things you can share. To feel seen and heard and known and loved by another—that is intimacy. We’re all such mysteries, even to ourselves. Asking scary questions is a part of intimacy. Tell someone what’s on your mind and say, I just wonder if that’s on yours.
Of course, sometimes people will get offended. And again, these are not easy conversations. And I’m not suggesting that having them means that no one will be depressed or no one will die by suicide. We can’t always know when someone is struggling. And even when we do, and people are in treatment, they sometimes still hurt themselves. But these are all steps in removing some of the secrecy and stigma from mental illness so that more people can get the help they need.
You can say something like, I know you’re saying that you’re okay but I just want you to know that I’m here for you. I’m always open. Ask them to look at you. Tell them that they can call you any time of day. And that they can think about it.
Talk to someone else who knows your friend. This isn’t a betrayal if you are genuinely concerned for their wellness and safety. It’s important to check in with others in their circle if they won’t talk to you. Call their sister or a friend or their mom. Think of another version of an intervention or someone who can get to them.
My kids will sometimes tell me that a friend of theirs seems off and ask me to call their mom—I’m like, yes, I’ll do it! I often lead by saying to that other mom, I hope that someone would do the same for me if they were worried about my kid.
If someone tells you that they haven’t been feeling well, that they’ve been feeling depressed—thank them for opening up to you. Tell them that you’re glad they’re willing to tell you that. It’s a privilege.
And then what? You, who is in a reasonable state of mind, can help them get treatment. That could be helping them get to their primary care doctor for a recommendation of a mental health practitioner. Maybe you know a psychiatrist they could talk to. Maybe you look up local services, community centers, general practitioners. You could consult the National Alliance on Mental Illness, which offers resources for getting support.
Your job is to be with the person.
Treatment is everything. It doesn’t turn you into someone you’re not—it helps you get better so that you can be the best version of yourself.
People will say they don’t have the time or the money—and I respect that. (To a point, since some people will use it as an excuse not to engage). Honestly, it can be hard to find good, affordable treatment. And yet it’s crucial. One option I recommend is going to a teaching hospital where there is a residency program. Often, you’ll find good, affordable treatment at university hospitals. Or start with your local mental health clinic. Call your insurance company and ask them about your mental health coverage.
A lot of people are scared to go talk to a psychiatrist. I ask people to drop their pre-conceived notions about therapy. Also, it’s okay to be unfamiliar with how therapy works—and to say that you are. Talk to the doctor on the phone first so you can get a sense of how they work. I think it is scary to go to a psychiatrist for the first time when you have no idea what to expect. When I see someone who is therapy naïve, I say, let me orient you, and give them an overview of how it works. We all have to be good consumers and advocates for ourselves. Ask to know about the doctor and their process.
“Treatment is everything. It doesn’t turn you into someone you’re not—it helps you get better so that you can be the best version of yourself.”
And know that it might take meeting more than one doctor to find the right fit for you. It’s a relationship—both parties have to agree that the doctor can provide what you’re looking for and need.
Also, for some people, it makes them more comfortable to bring a friend the first time, who can sit out in the waiting room.
There’s very little conversation about mental illness. We know if someone has any number of physical illnesses but we often have no idea that someone has been struggling for years with mental illness. Let’s not sweep it under the rug. Let’s talk about mental illness like the real illness it is. Depression and bipolar disorder can be deadly when untreated. Morbidity and mortality are higher than with many other chronic illnesses.
It’s helpful when people say, I struggled or I struggle with mental illness. And it’s encouraging to see people with platforms, or people who might look like they have it all, say, I struggle, too.
We have to all take a part in destigmatizing mental illness.
Dr. Catherine Birndorf is a clinical associate professor of psychiatry and obstetrics/gynecology and the founding director of the Payne Whitney Women’s Program at the New York-Presbyterian Hospital/Weill Cornell Medical Center in Manhattan. She specializes in reproductive mental health and cofounded the Motherhood Center in NYC, for pregnant and postpartum women who need extra support. She’s also at work on a new book about the emotional side of pregnancy and postpartum.
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