Rosalind Kaplan has been published in several literary and medical journals, including Across the Margin, El Portal, Green Hills Literary Lantern, Signal Mountain Review, The Smart Set, Stonecoast Review, Sweet Tree, and Vagabond City. Her memoir Still Healing: A Doctor’s Notes on the Magic and Misery of a Life in Medicine was selected as the winner of the Minerva Rising 2022 memoir contest and is forthcoming in fall 2023. She is a physician and also teaches narrative medicine at Thomas Jefferson University/Sidney Kimmel Medical College. Dr. Kaplan is a 2020 graduate of Lesley University’s MFA in creative nonfiction.
LIKE REALLY CRAZY HAIR
By Rosalind Kaplan
Three a.m. I want desperately to be sleeping, in blissful oblivion, muscles lax, my body taking long, slow breaths that I will not recall. Instead, I’m wide awake, shoulders tensed, trying to convince myself that “rest” is as good as “sleep,” and that I’ll be fine in the morning if I just relax and allow myself to lie still.
Earlier in the evening, my husband and I talked about my last few sleepless nights, about the irrational thoughts I have when I’m lying awake next to him as he slumbers. We both know that I’m in one of my transient mood dips and that insomnia is a typical symptom. Unlike years ago, we also know this will remit in a few days; it’s my pattern over the last decade. No reason to panic, but still, it’s uncomfortable while it lasts.
“I know it makes no sense,” I told him. “All that circular thinking, useless rumination about everything that’s gone wrong in my entire life, all the stuff that might still go wrong. I hate that my brain still does this. It’s like my neurotransmitters have a life of their own.”
“I know. It sucks to be unable to sleep. But it’s the brain that’s made you who you are, that’s made you smart and funny and a great doctor and teacher and writer and mother. It’s the brain that makes you compassionate, and that makes you the person I love.”
Later, I’ll lie awake, certain he was just saying those things to make me feel better, that I’m really kind of a failure at every facet of my existence. I’ll curse my brain chemistry and wish to be “normal,” like he is. He’s successful, and he also gets to sleep.
And yet, awake, and thinking more rationally, I know he’s right—my moods are part of the whole of who I am.
***
Philadelphia, 2010. I sat on the cool white tile floor of our master bathroom, considering my options. I had crashed into an episode of depression several weeks earlier, and the treatment prescribed by my psychiatrist wasn’t working. I was overcome by a feeling of dread, so anxious that I felt my heart pounding and my hands shaking most of the time. I felt tearful, but if I let myself shed a single tear, I sobbed and sobbed and couldn’t stop. My husband tried desperately to comfort me, but I was inconsolable. Though nothing had changed in my life, it felt like everything was unraveling. On this night, Larry thought I was sleeping, but once I heard his characteristic light snore, I left the bed and crept into the bathroom.
I didn’t want to live another minute feeling this way. I opened the medicine cabinet and retrieved sharp nail scissors. Maybe cutting my wrists could be an option; the scissors were right there. I didn’t have enough pills for a successful suicide. Besides, pills were so cliché. I didn’t have the motivation to go to the kitchen for a knife. But in truth, I didn’t have the nerve to cut myself.
I also didn’t really want to die. Great. Don’t want to live, don’t want to die. But it’s a binary equation. You’re either dead or alive. There is no in-between.
***
Saskatchewan, Canada, 1950s and 1960s. My paternal grandmother was hospitalized repeatedly for depression in her hometown, Regina, and in the province’s more illustrious asylum, Weyburn Mental Hospital, in Weyburn, Saskatchewan. She was treated with shock therapy, which sounds barbaric but is known to be effective. At that time, there were no effective medications for depression.
My grandmother had two brothers and two sisters. Both brothers had depression, and one of her sisters died by suicide in the 1930s, at just thirty-two years old. She drowned herself in a salt lake in Saskatchewan, leaving a young child motherless.
***
Verona, NJ, 1974. It was as if a switch flipped in my brain.
I was fourteen, living an ordinary ninth-grader’s life. I liked school well enough. I wasn’t popular, but I had friends. I played flute in the school orchestra. I met my first real boyfriend, a sweet, easygoing boy named Patrick, at a school dance.
The day the switch flipped, I got up early for a music program trip to Pennsylvania Dutch country. We were going to play a combined orchestra concert with the local school’s orchestra in the afternoon and be back by dinnertime. I woke up with a feeling of doom—not as though something bad was about to happen, but as though it already had. In fact, nothing at all had changed. I got dressed and my mother drove me to school to get on the bus for the trip; I assumed I’d had a bad dream and that the cloud hanging over me would soon break.
That whole day, I felt flattened. I didn’t want to talk to my friends on the bus. The bright, sunny day seemed like some sort of trick. When we arrived at the school in Lancaster, its yellow brick exterior made me think of a prison. Every option at lunch was unappealing. I dragged myself through the hallways, invisible lead weights on my ankles.
As we tuned up our instruments in the auditorium, my silver flute felt foreign in my hands. I usually loved to play, but not that day. I moved woodenly through the concert and was relieved to get back on the bus to return home.
I sat on the steps in front of my house after dinner, wondering what this strange experience represented and if it would go away. I didn’t tell my parents; I was afraid of what this might mean, and sure that my mother, a psychologist who cared for people with real problems, would dismiss me.
Instead, I called Patrick and confided in him. He, in his wisdom of fifteen years, said, “It sounds like you might be depressed. My mom has depression sometimes.” I wasn’t sure if he was right, as I’d thought “depression” just meant being sad. That didn’t explain the whole of how I felt, but it was comforting to talk and have someone listen.
It only lasted a few days, a week at most. Then slowly, colors started looking normal, and food started tasting good again. My mother never noticed anything strange about me, and I soon forgot all about it.
***
Boston, MA, 1979. Five years passed before it happened again. It was the summer after my freshman year in college, during which I’d been happy and seemingly well-adjusted. I’d decided to take Organic Chemistry, a notoriously difficult course, over the summer. I wanted to get a jump on my chosen major, biochemistry, maybe land a part-time job in one of the university’s labs the next semester. I wasn’t afraid of Organic Chem; I’d excelled in basic chemistry and felt confident I could do the work.
But with many of my friends away from Boston for the summer and a much-changed routine because of the long hours in lectures and labs, I quickly began to feel unmoored. A week into the course, I found myself irritable, anxious, and unable to sleep at night. I lost my appetite and started to avoid the cafeteria. I had no energy for social interaction and isolated myself from my classmates.
Though I felt awful, I continued to go to class and to study for the twice-weekly exams, grimly determined to finish the eight-week course. I might have gone on like that indefinitely, but I couldn’t focus on my work. It took twice as long as usual to assimilate information. I became worried that I’d fail Organic Chem.
I convinced myself that the crux of the issue was insomnia. If only I could sleep, I’d be able to study and learn.
At Student Health, the receptionist sent me to the Mental Health waiting room. A youngish, red-haired, red-bearded doctor ushered me into his office.
“So, what’s going on?” he asked. “You’re one of our Summer Organic Chem students? I hear that course is a bear! A whole semester’s work in eight weeks.”
“Yeah, I guess. But it’s not the coursework so much as that I just have insomnia. I can’t sleep at all.”
“Are you feeling depressed? Anxious?”
“Not…really. Just tired. I really need to sleep.”
“Has this happened before?”
“Not this bad. I’ve never slept well.”
“Do you think about hurting or killing yourself?”
“Oh, no!”
“Do you think you should drop this course?”
“No. I’m not dropping the course. I can finish.”
“Do you want to see a therapist?”
“No. I don’t have anything to talk to a therapist about. Honestly, I just need to sleep.”
“Okay, I’ll give you something for sleep, but I think something else might be going on— you would probably benefit from seeing a therapist. I think this is only going to be a temporary Band-Aid on a bigger problem.”
He was right. I knew it. But ripping off the Band-Aid seemed like a bad idea at that moment. If I let my guard down, I might not finish my course.
Somehow, sleeping and finishing the course were enough, at least in the short term. When fall semester began, my friends back in town and the daily routine familiar, the switch flipped back. Now I knew that there really was an “on” and an “off.” That first time, when I was fourteen, hadn’t been a fluke. And if it flipped that summer without warning, it could happen again, at any time.
I bounced back quickly from the depressive episodes of my adolescence. But as I got older, the lows became more frequent, lasted longer, and were more disruptive. Occurring at times when the stakes were high and I needed to perform—in school, as a parent, as a doctor—I learned to compensate, to keep moving and working and being productive. I was good at hiding my despair from others, but my private world went to hell during these weeks or months of depression. Each time, it felt as though my mind had been hijacked, and I desperately wanted it back.
***
Chicago, Illinois, 1950s. My father, a doctoral student in biochemistry, was hospitalized and treated for depression with insulin shock therapy, a form of shock therapy that caused seizures by drastically lowering blood sugar. Ironically, he returned to his lab after he recovered and, while researching anti-tuberculosis drugs, accidentally helped discover one of the first effective antidepressant medications.
While trying to increase the potency of isoniazid, a common drug for tuberculosis, my father and his colleagues noted an interesting effect of a drug variant called iproniazid. The patients taking this new preparation didn’t have faster improvement of their tuberculosis, but they experienced mood elevation. More research by my father’s lab determined that the drug inhibited an enzyme called monoamine oxidase, involved in the metabolism of serotonin, a “feel good” neurotransmitter. Iproniazid became the first antidepressant, an MAO inhibitor.
My father was the middle child in his family. Neither of his brothers suffered with depression. But who knows how far back on that side of my family I might have found depressive symptoms if I’d asked the right questions? My grandparents were Jewish immigrants from Moldova, then part of Romania, during times of political unrest and religious persecution. Survival, not contentment, was the measure of success. Mood—happiness and sadness and elation and grief—was not discussed. In my grandparents’ time, it was taboo to discuss psychiatric issues, which is, I imagine, why nobody wanted to speak up about my family history.
My father was twenty-eight when he and my mother married. His psychiatric hospitalization was behind him, just where he wanted it. He didn’t tell his new wife about it. If he was depressed at all during the following three decades, he hid it very well.
The father I knew was quiet and serious, a researcher who eventually became the CEO of a major scientific publisher. He was an even-tempered parent, kind and loving. He called me “Mousela,” Yiddish for little mouse, helped with math homework, made a mean salami omelet. He could be quirky, sometimes worrying excessively about our health or warning us not to talk about the family’s liberal politics or our almost-Russian heritage, lest someone believe we were Communists. Perhaps these were signs of anxiety, but to me, he was just my father, and I loved him. There were no overt clues to the deep despair that came before his life with us, nor to the depression to come in his later years. And with his family of origin far to the northwest, further isolated by a language barrier, it was not difficult to push his family history to the far corners of his mind, out of the reach of his wife and children.
***
Philadelphia, PA, 1983. During an episode of depressive symptoms in medical school, I became convinced that I was incapable of learning medical biochemistry, even though I’d excelled in biochem in college. The anxiety and loss of control I felt this time sent me to psychotherapy for the first time.
Therapy in the 1980s in Philadelphia was still dominated by psychoanalytic thinking. My therapist referred to her methods as “psychodynamic”—I wasn’t in analysis, lying on a couch and free-associating, but we focused on my relationships with my parents, on my early life and the conflicts I’d been presented with—a distracted and unpredictable mother, a brother with social and emotional handicaps that rivaled his intellectual brilliance and musical talents, so that most of our parents’ energy was expended meeting his needs. I adapted by playing the part of good girl and people-pleaser. As a teen, I avoided getting caught in any rebellious behavior, intuitively aware that changing my family role might topple the whole system.
The idea of psychotherapy, then, was to help me resolve conflicted feelings I might have toward my family. After a few weeks of therapy, I felt understood, and I understood myself a bit better. The kindness and steadiness of my therapist was a salve to my frazzled nerve endings. Did this mean that my childhood conflicts were at the root of my depression? Could I be “cured” through talk therapy and never have another depressive episode?
According to studies, a form of therapy called cognitive behavioral therapy, which reframes the negative thinking patterns associated with depression, is as effective as medication for achieving remission of depression. Yet that does not mean it can prevent future periods of depression, nor does that mean the other myriad types of psychotherapy work. My own sense is that most types of psychotherapy with a supportive, competent therapist might move a depressed person toward a remission, but many depressions remit on their own too.
I only wish that therapy had been a “cure” for me. The biggest relationship struggle I had was only with myself. I stayed in psychodynamic therapy for a long time, and it helped me navigate lots of decisions and concerns in my life, but it didn’t stop me from falling into future depressive episodes.
***
San Diego, CA, 1985. My parents moved to San Diego right around the time I started medical school, because of corporate restructuring at my father’s publishing company. Shortly thereafter, Dad started having chest pain. A cardiology evaluation found that he had likely sustained one heart attack and was at high risk for another. He underwent triple cardiac bypass surgery.
I flew in from Philadelphia, where I was a third-year medical student, to be with my mother during the surgery. It all went smoothly, at least on the surface. My father was released from the hospital, and I returned to school within a few days.
It was in the weeks after his surgery that Dad learned that he, too, had an on-off switch for his depressive disorder. After all the years of remission from his early depression, he had come to believe that it was a one-off. But the stresses of illness and surgery caused the switch to flip, and he fell into another deep depression.
He was stabilized with medication, specifically tricyclic antidepressants, which were easier to manage than the MAO inhibitors my father worked on at Northwestern.
In the course of helping my father get care for his depression, my mother learned about his previous episode, as well as his extended family history. As she shared this story with me and my brother, she was clearly outraged that her husband had kept such important facts of his life from her.
I was concerned with how my parents were adjusting to this new reality. I phoned them frequently, unsure what else I could do from the East Coast. At some point a couple of months later, my mother stopped being angry and my father started to sound more like himself when I spoke to him. I stored the new pieces of family history away, not yet realizing their relevance to my own life.
***
Philadelphia, 1980s. After the first year of med school, I enjoyed a long stretch of mood stability. While the stresses of residency—sleep deprivation, stress, and long work hours—might have pushed me over the edge, I was surprisingly resilient. Maybe the sense of purpose or the camaraderie were protective, or maybe it was the effects of psychotherapy.
I let myself believe I was “fixed,” until it became clear that I wasn’t. At thirty, just finished with my medical training, I gave birth to my first child and experienced a crippling postpartum depression. In retrospect, I can say that I should have expected this to happen; up to 85 percent of women have some emotional dysregulation in the first several months after giving birth. The risk of true postpartum depression is higher in women who have previously had depressive symptoms. Yet for some reason, my therapist, my obstetrician, and I all ignored the risk, leaving me unprepared for the havoc wreaked by the abrupt drop in hormones.
This depression was more painful than the previous ones and was harder to hide. It was especially disturbing to feel so miserable when I had a new baby—I was “supposed” to be overjoyed, and I had this tiny new life dependent on me. Therapy wasn’t enough this time, but I resisted starting medication for months because I was nursing and didn’t want to expose my baby to drugs.
Data on the effects of antidepressants on infants was spotty back then. Ironically, looking back and knowing what I know now, I think my depression was a bigger risk to my son than traces of antidepressant in breast milk would have been, but knowledge of postpartum depression was still in its infancy.
I finally gave in to medications after four months, when a series of personal tragedies, including my mother’s sudden death, added to my pain. Because my psychiatrist was most comfortable with a tricyclic antidepressant, amitriptyline was the first drug I tried. It seemed to work. Within a few weeks of starting the medication, I felt less anxious, more able to focus on work, less tearful. Over the next few months, I returned to my baseline. Eventually, I stopped taking the amitriptyline.
Many patients on antidepressants don’t stay on them long term. There’s only about a 50 percent chance that any given antidepressant medication will be effective. Even if it is, some people will have side effects that make the medication intolerable, and others are wary of psychiatric medications. This isn’t surprising, given that we still don’t fully understand how most of these medications work.
For someone on medication for a first depressive episode, it makes sense to discontinue medication once a prolonged remission occurs. However, data shows that people who have had multiple episodes of depression are destined to relapse if they go off medication, and that continuation of a successful antidepressant medication may prevent further mood disturbance.
Amitriptyline was my first medication but not my last. In the ensuing years, my moods bumped up and down, and I was on and off medication. Once it became clear that the SSRIs had fewer side effects than older medications, I tried fluoxetine (Prozac), but it gave me severe headaches. Other SSRIs did the same. A slight variation on the theme, drugs called SNRIs, soon became available. The first SNRI, venlafaxine, worked as well as anything for me, and without the headaches. I continued it, functioning well and without severe depression, for many years, until a little bit before the Nail Scissors Crisis.
***
A framed black-and-white photo of my extended paternal family sits on a shelf that flanks the main staircase in my house. It dates back to 1964, the first time my parents and brother and I visited Saskatchewan. My grandparents sit in the center, my parents and an uncle and aunt standing behind them. All the kids sit primly in the front or on the edges—my four cousins and my brother, all dressed in white shirts and ties, and me, about age four, in a miniature skirt suit. Do I imagine it, or can I see the depression there? My grandfather’s expression is both flat and very stern. My grandmother, in a baggy black dress and with dour facies, appears ancient and broken, though she would only have been in her mid-sixties. Both my father and his brother look grim. My mother and aunt sport smiles that might have been plastered on.
There it was, right in front of me. Depression personified. Does being in Saskatchewan make you want to die? Or is it just being part of this family?
***
By the time I hit my late forties, my mother had been dead for close to two decades, and my father had succumbed to heart disease and dementia, after struggling with another late-life depression. My brother had also suffered depressive episodes, but also a single episode of mania, during which he had grandiose thoughts and didn’t sleep for an extended period, and so was diagnosed with bipolar disorder. He was doing well on mood stabilizers.
I’d been feeling well on venlafaxine until my early fifties, when I often found myself tired and irritable. Maybe it was perimenopause, or parenting older teens, or the practice of medicine in the age of productivity metrics that did it, but who knows? My psychiatrist had moved away, and my primary care doctor wasn’t equipped to tweak my antidepressant regimen. I consulted a new psychiatrist with an expertise in psychopharmacology.
What followed was a lesson in diagnostic bias. I described my concerns as specifically as possible. But my off-and-on depression, accompanied by my ability to hide it and remain highly productive, swirled suspiciously in front of my doctor, who began asking about manic symptoms. The answers (I don’t sleep well, I don’t gamble or take sexual risks, but I do have a proclivity for risky sports activities) didn’t demonstrate typical mania but didn’t reassure him either.
The psychiatrist decided to treat me for a “mixed state,” a situation in which he believed I was both depressed and also a bit manic. He eliminated my antidepressant medicine for fear that it would precipitate worsening mania, which could be dangerous. Instead, he prescribed mood stabilizers and antianxiety medications. These drugs contributed to my fatigue but had no positive effect on my mood or anxiety.
I understand how my doctor came to his conclusions. Psychiatric diagnosis can be very tricky, even subjective. Diagnosis is based on a set of criteria outlined in a book called the DSM V, the Diagnostic and Statistical Manual of the American Psychiatric Association, fifth edition, a publication which exists to enable psychiatrists to classify a set of symptoms into a diagnosis. Unfortunately, not every patient’s symptoms fit neatly into a box, and the DSM V’s diagnosis codes are more useful for billing purposes than for tailoring treatment.
Psychiatrists also depend on family history to solidify a diagnosis, as there is known to be a genetic component to many psychiatric disorders, including depression, bipolar disorder, and anxiety. My brother’s bipolar diagnosis was especially confounding, as the sibling of a patient with bipolar disorder has a one in four chance of also having the disease.
His reasoning was, however, fundamentally flawed. While I may have been “hyperproductive,” none of my behavior ever came close to meeting criteria for mania. I’d also been on antidepressants for almost twenty years without any obvious ill effects, and much of that time, they’d been helpful. And my father and his family had what appeared to be unipolar depression, not bipolar disease. Children of parents with depression are about twice as likely to become depressed as those with parents without depression, and children who have both parents and grandparents with depression are at even higher risk.
Still, the most significant indictment of my treatment was that the longer I was off antidepressants, the more anxious and hopeless I felt, no matter what other drugs were thrown at me. A month or so into my new drug regimen, there I was on the bathroom floor, holding nail scissors and wishing I had the nerve to hurt myself.
Instead, I just sat there for a long time. Maybe the calm of the white tile cooled my feverish thinking, because I suddenly had a rational, useful thought: I went to the psychopharmacologist feeling irritable but not truly depressed. Now, following his guidance, I’m in a state of full-blown mental illness. He keeps telling me I need to give it more time. But maybe the real problem is that he’s just wrong, in which case I ought to get another opinion. With that thought, I returned to bed and fell asleep.
***
Sometimes I wonder whether I would have handled things differently had I known my familial risk. I always felt like my depression was very biologic, rooted in my neurochemistry. But neurochemistry may not be mediated by genetics alone. Family members raised by or with each other have shared environments. Depressed or manic or anxious parents and siblings influence children from the moment they are born, or even before. More recent theories suggest that the effects of trauma can be passed down from generation to generation. It’s possible that environmental factors can change one’s neurotransmitters, or even one’s neuronal wiring, so that behavior itself may shape lives, turning gene expression on or off.
What if my father hadn’t grown up with a depressed mother? Would he have suffered as he did? What if he’d told us about his shock therapy much sooner? Would that have changed the course of his life, or mine?
***
After the Nail Scissors Crisis, I researched psychiatrists and chose one who had a strong background in depression research and treatment. My first visit with him was different than any I’d had with other psychiatrists. He used evidence-based questionnaires, along with his clinical judgment, as diagnostic tools and concluded that I did not have bipolar illness and that an antidepressant was the right choice of treatment.
He chose a different SNRI than I’d last been on and prescribed it in a higher dose, believing that I’d never been treated with an adequate dose to give me a robust remission. Within a couple of weeks, my mood and concentration were the best I’d ever remembered them being, and I felt essentially no anxiety. I remember thinking, This is what it feels like to be normal.
Six years later, I’m on the same medication at the same dose. If you asked me how I feel, I’d say “Fine,” and this time I’d mean it.
This isn’t the end of the story. My depression is in remission but not gone. In the binary equation, I’m happy to be alive. But mood isn’t binary. It’s a continuum, and I’m in a good place on the continuum. “Not depressed” is not the same as “happy.” I can be happy or sad or somewhere in between now, where before I often had no choice.
I think the causes, for me, are multiple and very entangled. The predilection to depression was woven into my DNA. The way I was “wired” in childhood, living in a complicated family that didn’t always meet my needs, probably set me up for activation of those genes. The untreated episodes of depression as an adolescent may have made things worse. My medication now seems to work well, but God only knows what medication errors along the way have done to my neurochemistry.
My husband is right when he says that depression is part of what makes me who I am. Unlike a medical condition such as hypertension or asthma, depression is tightly wound into personality. Much of the way I think and function has been informed throughout my life by my moods. Perhaps I am a more pessimistic person than I would have been if I didn’t have depression, but I think it has also given me my sense of humor. My particular sense of humor is a bit macabre at times, a little twisted. But I can laugh in the face of some pretty grim stuff, and that’s not a bad thing.
Living with depression has given me more compassion than I might have otherwise had, a good quality in a doctor, though I’m not sure it makes life easier. When someone tries my patience, I stop to wonder what they might be struggling with, and try to be kind.
For much of my life, I fought against my depression as though it was a dreaded enemy.
These days, I don’t so much struggle against it as try to accept it as a part of myself that needs to be tamed and managed, sort of like really crazy hair. Medication takes out the snarl. Psychotherapy keeps it out of my eyes. But pretending that a head of thick, wavy hair is straight and smooth is futile. The waves are sometimes wild, but they’re also beautiful, and it’s a shame to hide them.
The Galway Review 