Characters on the Couch: Depression
by AJ Grant"This is my depressed stance. When you're depressed, it makes a lot of difference how you stand. The worst thing you can do is straighten up and hold your head high because then you'll start to feel better. If you're going to get any joy out of being depressed, you've got to stand like this." - Charlie Brown
As the writers of Buffy the Vampire Slayer's season six can attest, working with a character who suffers from depression is not an easy task.
How can you generate interest in a character who finds it impossible to do anything besides lay in bed all day? Who cries without any apparent reason? Who doesn't seem to enjoy anything anymore and would rather be left alone? There can be an all too fine line between accurately portraying the illness and leaving your audience wondering why the protagonist hasn't changed facial expressions since the Carter administration.
Despite the difficulty, authors continue to write depressed characters - just as they continue to write married characters, skinny characters, fat characters, gay characters, and cat-owning characters. Depression is simply too common to ignore. Recent studies have estimated that about 16% of the population have or will have suffered clinical depression in their lives. Clinical depression is the leading cause of disability in the United States, and the World Health Organization estimates that it will be the second leading cause of disability in the world by the year 2020, exceeding even heart disease.
Depression's prevalence doesn't mean that you have to write about it in every story - or in any story. However, many of your readers may have, or may know someone who has, clinical depression, and they will expect you to be accurate and understanding.
And interesting to read. Let's not forget interesting.
Let's Get Clinical
Over the years there has come to be a difference between "depression" and "clinical depression." The reason for this is that "depression" on its own has become a catch-all phrase for anyone who feels down in the dumps.Get yelled at by your boss, spill chocolate ice cream on your shirt, and come home to find that your power is out and most people will nod with understanding if you say that those events made you feel depressed.
But there is a difference between a run-of-the-mill bad mood and clinical depression. Bad moods are temporary. They may involve the same crying, lack of appetite, and generally subdued manner of clinical depression, but these things go away after a good meal with friends, a vacation, or a good night's sleep.
Clinical depression, on the other hand, does not go away once the power comes back on or the shirt gets cleaned. Clinical depression is not merely sadness; it is sadness when nothing is wrong, sadness to a disabling degree, or sadness over an inappropriate length of time. This is why, unlike "had a bad day" depression, clinical depression is a medical diagnosis. The person who has it has an illness, the same as someone with pneumonia or cancer. And, like pneumonia and cancer, someone with clinical depression has much better odds of recovering if they get treatment.
Bad Enough I'm Depressed, Now I Have To Prove It?
For a diagnosis of depression, patients must show five or more symptoms from the DSM-IV-TR's criteria for Major Depressive Disorder. (Assuming they are American. If they are not, then they need to fulfill the requirements of the ICD-10. Don't know what the DSM-IV and ICD-10 are? Go read Characters on the Couch: Introduction to find out.)Of those five symptoms, at least one must be feelings of depression and/or anhedonia (the inability to enjoy the pleasures of life, like eating, sex, or getting a big tax refund) for at least two weeks. On top of those, the patient needs to round out the required five or more with:
As far as that last symptom goes, while not all those who have clinical depression have suicidal ideation (thoughts of committing suicide) or actually try to kill themselves, it is common. Studies have shown that in the United States over 30,000 people per year successfully commit suicide and over 730,000 make the attempt.
Make It Go Away!
Treatment for depression varies depending upon the patient. One of the frustrating aspects of depression is that there is no quick cure. Even medication doesn't provide an instant fix. Instead it can take weeks for any effect to be felt, and that assumes the patient is on the right medication to begin with.Types of treatment include:
Medications typically take 2-3 weeks before they start to work, and it can take up to three months to determinef whether they are truly effective or beneficial to the patient. Not all antidepressants are created equal, and medicine designed for someone who can't summon the energy to get out of bed is not going to be the best treatment for someone whose depression manifests itself as agitation and a near-constant inner monologue about how worthless she is. In addition, anti-depressants can have side effects as difficult to deal with as the depression itself.
As a result, the search for the right medicine often takes a year or more as different medicines are tried, each needing a three-month trial period before patient and doctor can decide whether to continue with it. This often frustrates patients, particularly as the depression itself can make it difficult for them to try new things. Moreover, when anti-depressants fail to help immediately, patients can become convinced that they are incurable, or that treatment isn't worth persuing.
That's All Well And Good, But What About My Character?
Authors who choose to write about depression have many options for how to express it. Fiction and genre fiction in particular offer the tools of metaphor and symbolism. Anne Rice worked depression into her novels by having her vampires bury themselves underground as a physical manifestation of their mental inability to cope with the world around them. J.K. Rowling turned her experience with clinical depression into the Dementors, who suck all the joy and hope out of those they attack.Writing realistically about depression can be harder. After all, if a character who sits and stares mindlessly at a stream of water runs the risk of making boring TV, it runs an even higher risk of being boring in a novel that has no pretty pictures to help set the tone.
However, written narrative has the ability to present information in ways that television cannot. To begin with, we can crawl inside the character's mind. What onscreen is moments of a blank expression can, in a written story, be highly detailed paragraphs recounting the character's thoughts of misery and worthlessness. Perhaps your protagonist is desperately trying not to cry. Perhaps she's telling herself what a horrible job she's doing at cleaning the dishes, and that nothing she ever does will be right. Maybe she's even looking at the water coming down from the faucet and finding herself amazed by how tempting it is to fill a glass with it and then use it to swallow a bottle of aspirin.
Depression also manifests itself in ways unlike catatonia. Your other characters may notice that their friend is increasingly irritable lately. Maybe she's showing a newfound sensitivity to noise, particularly as it affects her ability to concentrate. She might be self-medicating with food or alcohol. Attempts to get her to join in on previously regular activities may result in fights, or she may appear flakey as she offers up lame excuses for why she can't go.
If she's suicidal, they may notice her tidying up loose ends. Things like birthday cards might get mailed out weeks or even months in advance. She may start giving away possessions, and stop making plans for the future.
The symptoms or symbols that you show all depend upon the form of depression that you want to represent. Once you understand depression for the illness that it is and are familiar with the scope of the effect it has on the patient's life, you are better equipped to channel that knowledge to the written page. Doing so can make the difference between who's actually depressed: your character, or the readers who paid good money for a story they couldn't relate to.
Useful Links
National Institute of Mental Health Depresison HandbookDepression screening test from NYU
Dealing with depression and suicide
National Mental Health Association Suicide fact sheet
EMedicine - Depression and Suicide
Dedicated to the memory of Olwen Ellen Baker.
© AJ Grant
AJ Grant has a BA in psychology from Columbia University, which may go to prove the argument that a little knowledge is a dangerous thing. A full listing of AJ's articles and stories can be found on AJ's website. AJ is a staff writer for Reflection's Edge.