it’s been nine years and i still want out

content warning: depression, self-harm, suicide.

i have read the dsm-5’s symptoms for major depressive disorder enough times that i can recite them from memory. it’s five or more of the following symptoms during the same two week period:

1. depressed mood
2. loss of interest in activities
3. significant changes to weight or appetite
4. insomnia or hypersomnia
5. psychomotor agitation or retardation (observable by others)
6. reduced energy
7. low self-worth or excessive guilt
8. reduced ability to concentrate
9. thoughts of death or suicidal ideation

and append “most of the day, nearly every day” for symptoms 1 to 8. i remember these by remembering that they’re divided into three clusters:

• 1 and 2 are affective, having to do with feelings.
• 3 to 6 are somatic, having to do with bodily sensations.
• 7 to 9 are cognitive, having to do with thoughts.

in addition to five of the symptoms, the dsm-5 also requires that the symptoms cause “clinically significant distress or impairment” in the context of a social life, or school, or work.

the icd-11 adds hopelessness to the cognitive cluster. the dsm-5 considers hopelessness to be part of the depressed mood symptom, but i think it’s orthogonal. the icd-11 also says that symptom assessment must be made “relative to typical functioning of the individual.”

the typical diagnostic instrument for depression is the phq-9, which i’ve filled out twenty or so times now. there’s nine questions, one for each of the dsm-5 symptoms, and each asks the patient how much that symptom has “bothered” them over the past two weeks. the scale goes not at all (0), several days (1), more than half the days (2), and nearly every day (3). then there’s one last question, which is “how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” the standard cut-off score is 10; the last question doesn’t contribute to the score but is still used for assessment.

there’s plenty of caveats with the phq-9. it relies on self-report, and it (maybe?) has a high rate of false positives. the cut-off of 10 is arbitrary, chosen to balance sensitivity and specificity. and it’s not like there’s a ground-truth for whether someone has major depression, because all mental disorders have to be defined relative to cultural norms, and the boundaries between normality and pathology vary across settings, blah blah blah.

i’m not sure i’ve ever conviced myself that i have a depressive disorder, at least with a strict interpretation of the diagnostic criteria. i mean, i’ve seen my office visit records, and they’ve had depression written on them, but it’s not like i’ve ever had a provider flat-out tell me that they’ve diagnosed me with depression. which seems to be the thing people do for, i dunno, adhd at least?

a lot of the time, i’d guess that my phq-9 score hovers around 8. that’s a score of 1 for all the symptoms except changes to weight or appetite. then plus or minus severity for depressed mood, loss of interest in activities, low self-worth, and reduced ability to concentrate.

this range of scores hinges on whether i consider the symptoms to be bothering me, though.

• consider having trouble concentrating. it bothers me in the sense that i wish i had infinite concentration and i don’t, sure. but is that bothersome enough? doesn’t everyone wish, at least several days over every two-week period, that they were better at concentrating?

• or like, doesn’t everyone get fatigued for no reason every once in a while? though that doesn’t quite bother me, because it’s not like i use my body much anyway. it’s enough to be noticeable when i wake up in the morning and feel like i have nothing to look forward to, but everyone goes through that, no?

• and with depressed mood, or suicidal thoughts? if, per icd-11, we should evaluate relative to my “typical functioning”, then i’m doing fine. relative to where i was nine years ago, i’m doing great. i only actively feel sad for around 20% of my waking hours, instead of 50%. these days i only wish that i didn’t wake up. it’s been nine years and i still want out, but that’s better than thinking about how i’m going to kill myself.

symptoms aside—the main reason i’m not sure about a diagnosis of depression is the criterion of impaired functionality. allow me to set aside modesty for a moment. i think, in many respects, i’m quite high-achieving. i graduated from mit with stellar grades. i have a job that thinks of me highly enough they’re paying thousands of dollars to an immigration firm to help get me a visa. i was awarded the karl taylor compton prize, which the awards convocation describes as the “highest awards presented by the institute to students and student organizations”. that visa application consists of four hundred pages of evidence that i’m an “individual with extraordinary ability”. i play a crucial role in events like the philippine mathematical olympiad or the galactic puzzle hunt. i hang out with people enough that i have to play tetris with my social calendar.

how can anyone look at this list of achievements and think i’m having trouble with my life? people should envy me. what claim do i have to difficulty with my work or my hobbies or my relationships? how entitled do i have to be to want my life to get any easier? maybe i should just shut up.

diagnosis is only a tool, though. the goal isn’t to draw the boundaries around labels, the goal isn’t to define which traits compose a disorder. i can’t make map and territory references without thinking of rationalists, so pretend i wrote something about that as well. anyway, from a clinical perspective (and as with all the bullshit i spew, caveat lector), what matters more is whether there is a need for treatment, and if so, what should it be?

the point of treatment is to “get better,” whatever that means. the question i’ve been asked is along the lines of: if i could magically change one thing about myself, what would i change? my answer used to be along the lines of: i wish i wasn’t sad all the time. i am no longer sad all the time, but it’s not like i’m happy the rest of the time. is the goal to be stable, then?

while the dsm-5 is a deeply serious book, it has a small section, tucked toward the end, about an alternative model for personality disorders. it claims that normal personality functioning includes, among other things, a healthy amount of self-direction. its standard for having little or no impairment in this area says:

this part seems so out-there to me. here is a book about psychopathology, claiming that a healthy person is someone on the route to self-actualization. that’s the kind of thing i’d expect from a spiritual book in the self-help section, not a 992-page clinical-reference-doorstopper. and yet! i can’t help but feel attacked by this. when was the last time i’ve aspired to anything? when was the last time i’ve felt fulfillment?

seven months ago, around the time i started my new job, my manager asked in a one-on-one what my career goals were, and i said i didn’t have any. i still stand by that. when i do accomplish things, there isn’t space to pause and celebrate and squeeze whatever hypothetical fulfillment out. there’s always another mountain to set my sights on, another test to pass. maybe it’d be better if i did feel aspiration or fulfillment. but i wonder if i’m only here in the first place, if i’ve done as much as i have, is because i don’t.

the study of suicide is called suicidology, and i know too much about it for someone who’s a non-expert. while the terminology is fraught, it’s generally agreed that there’s a difference between:

• wishing you were dead (what i’ll call passive suicidal ideation),
• thinking about killing yourself (active suicidal ideation),
• having these thoughts and intending to act on them (suicidal intent),
• harming yourself without intent to die (self-harm),
• harming yourself with intent to die (suicide attempt),
• and killing yourself (suicide).

there is a huge difference between these behaviors. from numbers alone, around thrice as many people have suicidal ideation than make a suicide attempt. there’s also a huge difference within these behaviors: it’s one thing to have active suicidal ideation, and another thing to have specific thoughts about how you’d kill yourself (even without an intent to act on them).

so, i think any good theory of suicide should not only explain why people kill themselves, but it should also explain the large difference between ideation and action. such a difference points to separate sets of causes and risk factors that lead to either behavior. so, what are they?

the first (and i think, most famous) such theory is the interpersonal theory of suicide. the two big claims it advances are (1) the necessary causes of suicidal ideation are thwarted belongingness and perceived burdensomeness, and (2) the ability to enact lethal self-injury is acquired, and is what transforms ideation to action.

claim (1) is stronger than it seems at first: not only does it say thwarted belongingness and perceived burdensomeness cause suicidal ideation, it says it’s always a cause. it proposes that people have a need to belong that is unmet when you’re disconnected from others, or when you have no one to turn to, or when you don’t support others. it also proposes that everyone with suicidal ideation hates themselves or views themselves as expendable.

claim (2) directly addresses the issue of why so many more people have suicidal ideation without acting on it. people have strong survival instincts (for, say, evolutionary reasons), but the interpersonal theory also says that it’s possible for people to override these instincts, and then die by suicide. a good model for how this can happen is opponent process theory, which is the most popular explanation for things like afterimages.

a super handwavy explanation: when you look at something cyan, two opponent processes run in your brain. there’s one that perceives cyan. after a while your brain adapts by “perceiving less cyan”, by running a process that perceives some amount of cyan’s opposite, red. once you stop looking at cyan, the latter process goes on for a little while, so you still perceive red. opponent process theory generalizes this to explain why withdrawal symptoms get worse the longer you’re on the drug, why skydivers experience more excitement after skydiving several times, and in this case, how painful experiences increase the risk of suicide.

two other major theories are the integrated motivational-volitional model, which to me reads like the interpersonal theory but with a bigger scope and slightly more vague, and the three-step theory, which claims that the primary role of connectedness is as a protective factor against stronger suicidal ideation.

the three-step theory contrasts with the interpersonal theory by saying that disrupted connectedness isn’t a necessary component for suicidal ideation. the theory predicts that, even if the amount of pain due to e.g. perceived burdensomeness grows, if connectedness grows proportionately, then suicidal ideation doesn’t worsen. this makes explicit the saying “suicide is not chosen; it happens when pain exceeds resources for coping with pain,” which i first read on suicide: read this first. as a consequence, you can go about suicide prevention via either reducing pain or increasing connectedness.

these two ideas—that the capacity for self-harm is acquired, and that the balance of pain and connectedness influences suicidal ideation—have stuck with me ever since i read about them.

it comes down to identity, as it always does. three thoughts:

1. perceived burdensomeness is a cognitive distortion, hence the word perceived. like many distortions, it happens when the way i view myself differs from how others view me, when the externally constructed identity diverges from the internal perception of it. in a loose sense, some forms of thwarted belongingness are also cognitive distortions, like when i perceive “no one cares about me” even though, in fact, people care about me, and profess that care for me.

2. another way it comes down to identity is how much i include the depression or suicidality as part of it. there’s this advice i read from blythe baird’s tumblr, which says to “do everything u can to avoid making sadness ur aesthetic!! if u attach too much of ur identity 2 melancholy, it makes it that much harder to relearn ur worth as something that lies outside the barrier of ur suffering.” also, my friends don’t think of depression as a salient part of my identity, so why should i?

3. from the perspective of existential kink, i’m depressed because part of me wants to depressed, or, is afraid of what would happen if i was not depressed. part of it is, you know, incorporating depression into my identity, which means the prospect of not being depressed is a threat to it, and thus painful. but also, depression is such a convenient excuse for not having to be great. it’s fine if i’m not as cool as i want to be, because i’m depressed!

on this day nine years ago i planned to kill myself. it hasn’t escalated to that point since.

the other day i asked my psych if there was a point to my treatment if i’m already better than i was before, if i’m close enough to normal that i can stop trying to get even better. she said it’s a “personal decision”.

from my writing, four months ago:

(after all, the ability to enact lethal self-injury is acquired.)

i have never been to mclean, which is the psychiatric hospital that nearly all mit students get admitted to if they are hospitalized for mental health reasons. i’ve not heard good stories about it. part of the reason i don’t attempt suicide is that i’m afraid of how bad of an experience inpatient treatment or involuntary hospitalization would be.

exercise is probably the single intervention with the highest chance of making me feel significantly better. and yet, i have not tried it, at least, not seriously.

i tell my psych that i’ve had chronic passive suicidal ideation for years now, but that it hasn’t been bothering me, so whatever. she says that most people do not, in fact, have passive suicidal ideation for years at a time.

relief is a feeling is one of the platitudes i sometimes think about when i contemplate suicide. as a thought experiment, i’ve imagined what it must be like to experience being dead for a hundred years in between every second, where i spend the gap between each moment dead, and i come back and i don’t remember being dead. and it doesn’t feel any better, because i’m still alive the next moment. i don’t want to die, i want the pain to stop, and i want to be around when it does stop.

i tell people that i don’t think of the future in time scales longer than a year from now. i used to say it’s because i don’t know if i’d still be alive in a year. well, the verdict is in: i’m alive. have been alive. it’s been nine years since i’ve first had suicidal thoughts and i’m still here, and signs point to me still being here in a year, two years, another nine years, probably more. i still don’t think of the future in time scales longer than a year from now, but that’s unrelated.

while we’re in the business of extrapolating, we might as well observe that things have been getting better.