Many of our isolated lives fit the normal criteria for depression, but of course these aren’t normal times. So when the world is this depressing, how do you tell when you’re actually depressed?
On this episode of Social Distance, the clinical psychologist Jennifer Rapke joins James Hamblin and Katherine Wells to explain how to think through mental-health questions in the time of COVID-19.
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What follows is an edited and condensed transcript of their conversation.
Katherine Wells: Can you introduce yourself for our listeners?
Jennifer Rapke: Sure. This is Dr. Jennifer Rapke. I’m a clinical psychologist and I am currently the chief of child-psychiatry consultation services at Upstate Golisano Hospital in Syracuse, New York.
Wells: So what do your days consist of right now?
Rapke: Right now, we’re still trying as a hospital to keep as few bodies on site as possible. So my days are sometimes at home doing virtual work and sometimes on site. But our role in the hospital is to work with any kids under the age of 18 that are coming in with a mental-health chief complaint. So they’re here for depression, anxiety, suicide, all kinds of things.
Wells: And is your work essentially the same as it was in pre-corona world? Or are you kind of doing or experiencing something different now?
Rapke: That’s a hard question. My answer is always: It depends, as a psychologist. The content is technically the same, our role in the hospital is still the same, but our method of doing that is very different right now. Normally, I’m physically in the hospital five days a week, so virtual is all new for us. And we’re also really only seeing people when they absolutely have to be here, so the cases we’re seeing are a little bit more severe.
James Hamblin: When we talk about depression, often the medical system has the job of distinguishing: Is this a context-dependent situation where it’s going to go away? And at what point it becomes a pathology.
I understand it is a spectrum, but you as a clinician, you have to decide whether or not someone gets that diagnosis in their chart or doesn’t. There’s kind of a black line that has to be drawn because of the way the system is arranged, at least. And I’m wondering if that line has changed for you at all in the current situation.
Rapke: I see it on a continuum. All of us have varying levels of depression at different points in our life. All of us have varying levels of mood swings at points in our lives. When does it get to the point where, as a profession, we draw this line? The DSM is the main way we do that, where you have to meet certain numbers of criteria, but I never want a family to feel like that discounts their experience. So I don’t in any way want people to misunderstand that just because we don’t say that it gets this code doesn’t mean that that discounts their experience.
Just to go back, it has changed a little bit. At what point would we just talk to a friend? It’s very similar to medical triage, but it’s sort of developing what those levels are. Can I call a friend and feel better, and that sort of changes things? Or have I called all the friends, baked all the cookies, and I still can’t seem to get out of this funk? That’s sort of the first level. If getting up and going for a walk, doing things that would normally help me feel better, talking to somebody that always helps me—if that doesn’t do anything, now we’re to the next point of: How long have I been feeling this way? Has it been just today? Or has it been lasting several days, where I really can’t seem to get myself out of this state?
At that point, you really need to reach out to somebody, whether you have a pastor or a good friend that has a little bit of experience or knowledge. It’s at that point that maybe you need to reach out and do a little bit of screening, maybe even go online to some of the screeners online, some of the reliable ones through your local hospital.
And then I think at that point, if that screener comes up, if your friend who normally can snap you out of it thinks this is more than your normal funk, then it’s time. You definitely have to reach out to somebody, whether it’s a hotline, your pediatrician, a counselor you’ve talked to in the past.
Wells: Those three levels you were describing for kind of self-assessment of how severe things are—do those change, given the fact that so many people are going through traumatic experiences right now, like job loss and death in the family up to housing and food insecurity? Like, does it change how you think about those levels or—
Rapke: I think those levels maybe are the same all the time. I think the pace of those levels probably changes right now. Because normally you can leave the house, you can go somewhere, you can do fun things. And if you can’t do that right now, that probably speeds up the timeline a little bit because the resources that you would have to try to snap yourself out of it are more limited.
Wells: Something Jim and I have been talking about a lot, and I’ve been joking about it, is, like, we’re all so depressed. It’s a depressing time. Everything’s horrible. Of course we’re depressed. But I feel like this is a good reminder that of course this is a depressing and sad situation and there’s so many things happening that are worthy of mourning, but clinical depression is not necessarily feeling sad because something bad has happened. It sounds like you diagnose less on the initial feeling and more on the ability to cope with the feeling?
Rapke: There are specific content criteria for depression or anxiety. But the big thing that really distinguishes that continuum where we all have some level of sadness and depression is: Is it impairing our functioning? Are we able to still take care of our children, to take care of our pets, to do whatever job or tasks we’re needing to do?
Maslow’s hierarchy of needs is a thing I go back to all the time. One of the weekends that I worked on the crisis line, I spoke to this woman who is in a lot of distress and I said: “You are trying to care for all of these people around you and do all of these really concerned things, but you’re also concerned that you guys don’t have enough food and that you guys don’t have clothes or diapers for the baby or formula.”
Let’s take care of these things first, because in Maslow’s hierarchy of needs, the base of the pyramid—and you can’t function without a good base—is food, water, shelter. So if I can’t feed myself, if I can’t feed my family, if I can’t have a roof over my head, if I can’t have basic clothing to keep myself warm and survive, I can’t do other things.
So anytime I have someone that’s in crisis, that’s how I organize their concerns: Let’s focus on the basic, core things and make sure that you feel secure in that. And then maybe you’ll feel more capable of doing these other things.
So the takeaways are functioning, distress, and then: Am I about where everybody else is? I think that’s where the COVID question comes in. Are we all clinically depressed, or are we all just adjusting to a really stressful situation?
Hamblin: It sounds similar to how an internal-medicine doctor doesn’t want to see someone coming into the hospital already in multi-organ failure and delirious. It would have been much easier to know that person at their baseline and see them a bit earlier. And in psychiatry it’s never ideal to hear from someone for the first time when they can’t go to the food pantry or can’t get off their couch and can’t do the things they know they normally would be able to just because they’re in the depths of depression.
At the same time, we have a lot of people feeling these symptoms, and it sounds like if we put the entire burden on the mental-health system and had everyone who was in the early stages of these symptoms reach out, there would be an overwhelming wave. And so things like food and housing insecurity—these things that might be at the root of some of the hopelessness and despair people are feeling—are systemic issues that we can’t put all on mental-health care later, because people can’t deal with these circumstances. It’s the circumstances that we can fix. Otherwise, we’ll just see this flood as it builds up in people who meet these criteria, but we could have prevented it.
Rapke: Yeah, ideally we would be doing more primary prevention. The ratio would be more about doing the food and shelter and water and housing first, and then that would trickle down to other stuff. Secondary prevention is sort of a targeting of risk populations. And then tertiary prevention is you’re just trying to not make it worse. Unfortunately, most of the time we’re doing tertiary. I would love to see, as a society, as a community, more primary efforts. But that’s really complex, especially right now when resources are super tapped.