Chronic Depression with Suicidal Ideation

I was chatting with a friend today about chronic depression with suicidal ideation. They were seeking some advice for how to support a friend of theirs who was living with this situation. The immediate answer of course is to make sure to be receiving appropriate medical assessment and treatment. But I realized, as I chatted with them, that I have a fairly standard approach to helping high functioning people with chronic depression move through their symptoms and experience a greater sense of wellbeing.

Your Brain is an Organ

The first thing I tell people is that their brain is just an organ. Because we are big brained monkeys, we kind of romanticize the brain, but honestly, we should feel about as much emotional attachment to the malfunction of a brain as we do to the malfunction of a knee, an eye or a pancreas. Brains come with all kinds of hardware (genetic predispositions, cumulative damage from concussions, damage from toxins such as alcohol) and software (individual beliefs, family beliefs, community beliefs and cultural beliefs). In this framework, a belief is just a thought that our brain has experienced enough times that it thinks it is true. Brains have different responses to work stress, relationship stress, parenting, sleep deprivation, exercise deprivation etc. There is definitely a mind-body connection, or perhaps a mind-brain connection, but just as we do not usually expect to believe cancer or diabetes or kidney failure away, we should not expect to be able to believe away low mood.

This is a pragmatic approach aimed at de-romanticizing the brain and the way we think about it. What the mind-body connection does do is create robust neural pathways for beliefs. It becomes difficult to distinguish between facts and thoughts. In fact, the mainstay of therapy and coaching is distinguishing between the “facts” of a situation and our thoughts about the situation.

You Can Trust Your Brain…Usually

Our culture is filled with knowledge workers. Compared to a century ago, most people in the developed world do not work in primary or secondary industry, extracting raw materials or engaging in assembly line manufacturing with limited scope for judgement. Even entry-level jobs involve a fair amount of personal interactions, judgement, discernment and analysis. We are used to relying on our brain to give us good information and making decisions based on the evidence of our “senses” by which we mean our brain’s interpretation of verbal, non-verbal and written information and interactions. This tension is felt everywhere, as technology explodes and people attempt to replace human workers with AI chat bots, self-check out and other ways to attempt to replace this human brain work. As anyone who has been in a frustrating infinite loop with an AI chat bot can attest, this work is still in the early stages.

The corollary of most people engaging in knowledge work is that we are used to trusting our brains when they make decisions, offer us thoughts, and generally run much of our lives on autopilot. We are not used to questioning our brain when it gives us a thought. We are not used to seeing thoughts as just one potential interpretation of situation but rather as an objective fact.

Suicidal Thoughts are Common

Then I move onto an interesting fact. Suicidal thoughts are common in adolescents. Passive morbid ideation (I wish I wasn’t here, had never existed, or was dead) is common in the general population. Brains that are burned out and running on empty often generate suicidal thoughts or morbid ideation.

So, often, suicidal thoughts are not a useful source of information.  They seem to be an easily triggered brain  module, responding to stressors in an automatic way and perhaps having some protective function in promoting pro-social behaviours and keeping our vulnerable bodies in line with social norms. Suicidal thoughts are a risk factor for suicide attempts but there are many people who experience passive morbid ideation and suicidal ideation without any corresponding intent to act on them.

If you are having suicidal thoughts or passive morbid ideation, it is important to acknowledge them. Talk to your therapist and physician about them. Share them with a trusted loved one. Don’t be frightened by them and recognize that they are a common response to stress and low serotonin levels. They are a warning to act to take care of yourself, but not necessarily an emergency.

Thank You Brain

Brains are good at executing programs. Brains like to conserve energy and use as little glucose as possible. In other words, brains like to think the same thoughts over and over again. Brains do not like to think new thoughts. So if we have a brain which is used to generating suicidal or morbid thoughts, it will take time and effort to reduce the frequency of such thoughts. This may be especially challenging if we received overt verbal messaging as a young child which was nihilistic or hypercritical.

With practice, we get better at recognizing thoughts as simply one way of interpreting a situation, rather than truth. In such cases, we can practice thanking our brain for offering us a thought, even if we choose not to engage with it.

In my family, the phrase we use when panicking over something anxiety provoking or beating ourselves up over something stressful is – “Thank you, brain.” This usually provokes a watery chuckle and an appreciation for the fact that our thoughts are just thoughts and not facts. We do not have to act in accordance with our thoughts. We do not have to believe our thoughts. We have the choice to act in accordance with our values, rather than in response to our thoughts and beliefs. This idea is summed up in one of the most famous quotes from Victor Frankl’s account of his time in a concentration camp.

Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.

– Victor Frankl, Man’s Search For Meaning

Good Mood is Just One Pillar of Wellbeing

Finally, I offer some hope. Even if a person’s mood remains persistently low and these types of thoughts continue to pop up regularly, mood is just one of the pillars of wellbeing. Martin Seligman, a leader in the positive psychology movement, introduced the PERMA model of wellbeing, encompassing positive emotions, engagement, relationships, meaning and achievement. If positive emotions are not coming our way, even with medication and therapy, we can still work on the other pillars of wellbeing. I encourage you to think about the relationships in your life, what meaning you find in your work and volunteer activities, how you recognize achievement in yourself and others and how engaged you are with your life and the people in it.