This special episode is co-presented by SMI Adviser, a Clinical Support System for Serious Mental Illness; and by NAMI, the National Alliance on Mental Illness. SMI Adviser is funded by the Substance Abuse and Mental Health Services Administration and administered by the American Psychiatric Association.

These podcasts include the real-life experiences of people with mental illness and family members. Some of the content includes discussions of topics such as suicide attempts and may be triggering. If you are in need of support at any time during the podcast please contact the NAMI HelpLine at 800-950-6264, available from 10:00 a.m. – 6:00 p.m. ET, Monday through Friday. To receive 24/7 crisis support, please text NAMI to 741741 or call the National Suicide Prevention Lifeline at 800-273-8255.

This episode is the first of a two-part discussion about major depressive disorder led by Dr. Ken Duckworth. He leads a deep discussion that offers insights for individuals, family members and mental health professionals: living with it, loving someone who has it, treating it, the impact of cultural identity, and more.

Music: "Sidecar" by Podington Bear

Transcript for Audio

This is The Medical Mind, a podcast about innovations in mental health care from the American Psychiatric Association. This special episode is co-presented by SMI Adviser, a Clinical Support System for Serious Mental Illness; and by NAMI, the National Alliance on Mental Illness. SMI Adviser is funded by the Substance Abuse and Mental Health Services Administration and administered by the American Psychiatric Association.

These podcasts include the real-life experiences of people with mental illness and family members. Some of the content includes discussions of topics such as suicide attempts and may be triggering. If you are in need of support at any time during the podcast, please contact the NAMI Helpline at 800-950-6264, available from 10:00 a.m. – 6:00 p.m. ET, Monday through Friday. To receive 24/7 crisis support, please text NAMI to 741741 or call the National Suicide Prevention Lifeline at 800-273-8255.

The topic for this episode is major depressive disorder. It is the first of a two-part discussion led by Dr. Ken Duckworth. He leads a deep discussion that offers insights for individuals, family members and mental health professionals. Living with it, loving someone who has it, treating it, the impact of cultural identity, and so much more. Let's dive right in.

Ken Duckworth: Hi, it's Dr. Ken Duckworth, I'm the Chief Medical Officer for the National Alliance on Mental Illness or NAMI. Welcome to our podcast, where we're interested in learning from people's experience and cross-matching that with the research literature. Today, we're discussing major depressive disorder and we're very fortunate to have, a married couple, one who has lived with major depressive disorder and his spouse and, we also have a researcher, who has spent his career working on this.

Our guests are Marty Parish, from Iowa. His wife, Peggy Huppert, also from Iowa, who's the executive director of NAMI, Iowa and Dr. Andy Nierenberg, from the Harvard Medical School and the Mass General Hospital, who is a longtime friend of the NAMI family and has done a tremendous amount of work in mood disorders. I'd like to start with Marty.

Marty, tell us a little bit about, what your experience is now with depression and how long this has been in your life?

Marty Parrish: Sure. My experience now is that, I'm maintaining, would be the best word. I am in recovery. I have not had a major depressive episode now in about three years, which is just an astronomical amount of time for me.

My first episode that I draw back to occurred when I was 17 years old. So, that's 40 years ago that I have had reoccurring episodes of depression. And this is both under treatment with therapy and with medications, but to go three years without a major depressive episode is just, seems almost miraculous.

Ken Duckworth: Is this your longest run, Marty? Is three years your longest?

Marty Parrish: Is my longest run, yeah, and that's even with medication and we can talk about that because once many depressives--and I'm included--once a medication starts working after about six months or so, you're thinking, “I might not need this anymore.” You slack off and, in my case, I found all through the hard way that I had about an eight-month window before I slipped back into the deep, dark depths of depression.

Ken Duckworth: Meaning once you stopped the medication, you still had a runway, [Marty Parrish: Yeah] but then after eight months or so, is that accurate?

I think that’s a pretty common experience.

Marty Parrish: That's my understanding too, from other people I've talked with. First four weeks after you stopped the medication is just fine. You feel really good. So again, that reinforces the notion you don't need the medication and what many don't realize until much later is you begin that slip and slide into depression, in a way that you don't recognize, and other people start to notice it, but you don't. And by the time you recognize you've slipped into it, you're stuck, buddy. You are there.

Ken Duckworth: So, one of the things my patients have told me over the years is taking medicines every day, when you feel well, is just an unfortunate or negative reminder of the fact that you live with a particular vulnerability. Is that what the thinking was for you? Or is it more really, “I'm obviously good to go this time?”

Marty Parrish: Combination of both. In many cases, you want to believe that you have been cured. You want to believe that your brain has fixed itself, that you no longer need it, and you don't want to be reminded that you have to take it. The second thing is, yeah, you've had six months now, feeling good. You're good to go. Should not be a problem. And I think, in the early days there was thought that maybe, six months of treatment would be enough to last a lifetime. For some people, maybe it is, but for someone suffering with chronic episodes, that's not the case. You will go back down.

Ken Duckworth: Can you tell us a little bit about your spouse, Peggy, and how you shared this with her when you were dating and what you have learned together from your experience. I'm also going to be asking Peggy about this, but I just, I wanted to start with your introduction of your wife.

Marty Parrish: I don't know how much I hid at the beginning because, I self-medicated and stayed in a pretty good mood. I mean that I drank a lot of alcohol. And so, she couldn't see the depression. In fact, I don't think she saw it until several months after we had been dating. A little background here: I'm originally from Arkansas, but I did go University of Michigan. I got out of the South for a while.

I spent some time on Capitol Hill, worked as a volunteer legislative assistant. I came to Iowa in 2007 to work as a volunteer initially with Joe Biden's campaign. I got picked up as IT Coordinator and I worked on staff, for the campaign through the caucuses. It was during that time that I met Peggy and what she didn't know is that I was actually running from my loss of pretty much home, life, everything in the South as a result of depression and drinking. After the campaign was over, I crashed. She saw me become very isolated, very uncommunicative for three or four days at a time.

And I think that's when she thought, oof, she made a big mistake.

Ken Duckworth: Well, let's ask Peggy a little bit about that.

Peggy, can you talk a little bit about your life with Marty and how depression fits into it? Obviously not the whole story, but today we're trying to understand how spouses and individuals can do best with major depression.

Peggy Huppert: Sure. I had suffered from episodic depression, so I was somewhat familiar with it. I recognized it when I saw it, and Marty's right. When I met him, he was in the thick of a caucus campaign. He was working a lot and he was very excited and motivated to help elect Joe Biden. And then the caucuses happened, and it was not a very good result for Joe Biden and he really did crash. Then he went back to Arkansas. So, I didn't see the crash for too long before he left. He ended up coming back, but it was very much a rocky, on again, off again, relationship for a while before we finally got things resolved to the point where we decided to make a go of it. But Marty's right, too. He was drinking heavily. He was also using tobacco, so that was masking a lot of what was really going on. I knew he was drinking too much. But I didn't know the depths of his both anxiety and depression. And it would come out in different ways at different times. For a long time, I had no idea of really how much he was suffering and how much he had suffered. Even though I had dealt with it with my daughters, this was just a completely different thing. So, I was in the dark, really.

When I finally took Family to Family five years ago, I had the reaction that a lot of people have, which is, “Oh, man. If I had only known.” I felt like I did so much wrong because I didn't know. And, then you have guilt about that, but what I've learned from NAMI is, you can only do with what you know at the time and when you know better, you do better.

I worked for the Cancer Society at the time. I was the Director of Government Relations and I consider myself to be a fairly informed, knowledgeable, enlightened person. But I was very naive.

Ken Duckworth: Hmm. I wanted to key on one thing that Marty said, and I want to ask you about this, Peggy.

Marty said, sometimes other people notice that you're starting to slip into a depressive episode, but that you, the individual with the condition, may not. Is this something you can talk about in your marriage? Can you say, “I wonder if,” or “I'm noticing that.” How was your communication about identification of a recurrence?

Peggy Huppert: Yes, that's definitely true. They also said when Marty went through TMS, the spouse will probably notice improvements before the patient will. And I think that was true. But I can also almost immediately tell when I see him, whether we've been apart for the day or whatever it's been, just from the expression on his face, if he's having a good day or a bad day. And sometimes he'll say, “Yeah, you know what? You're right. This has not been a good day. What told you that?”

Just from his expression or the way he responds to something I say or something I asked. So, I think it's definitely true, but I think a lot of times, as people close to others who are suffering, we have to become aware of what those things are.

We have to learn the best way to raise it with the patient. So, one of the things I've learned is-- I don't ask why, because that is triggering for Marty. Don’t ask me why. I'm not perfect at it, but I'm trying to find different ways of raising it with him that is not going to make him defensive.

Ken Duckworth: And Marty, have you been able to communicate with Peggy? “Here's the kind of feedback that works best.” Cause, it sounds like she's really figured out that “why?” is not a winning pathway with you.

Marty Parrish: Absolutely. That was one of the things that I can't explain why it's triggering. I did take her with me to a therapy session, so the therapist could explain it. It turns out that “why” can be considered a judgmental word, I guess, is the way he put it. It's a word of judgment and can be taken that way. And that seemed to be the way I was taking it.

What I did say to Peggy, I said, “I don't know, but when you ask me ‘why,’ you trigger me.” I said, “So let's use a Southern phrase-- how come?” I said, “That doesn't bother me as much.” If you ask me how come I didn't shut the door to refrigerator after I got the milk out, that's not nearly as bad as asking me why I didn't shut the door when I got the milk out of the refrigerator.

Ken Duckworth: Your Arkansas background, you can hear it. This is the art of communication with all marriages, of course. But, when you're talking about something vulnerable, it's the potential to activate defensiveness, it's crucial to develop these communication patterns where you cannot be defensive because of course your spouse is likely to be your best early warning signal, if you can't see it yourself. You did mention TMS, that’s transcranial magnetic stimulation. We'll talk about that later. You did mention NAMI's Family to Family, which is our free course that, supports families and given to more than half a million people, and has been shown in randomized controlled trials to help families feel more empowered and hopeful. And it provides a lot of information.

I want to turn to our academic colleague, Andy Nierenberg. Dr. Nierenberg, Peggy and Marty have figured a lot out about communication, but I also wanted to just say, in your travels, as a researcher, I was taught that depression was an acute condition. Marty is describing it more as a recurrent condition, which I now see from the literature is more how people think about it. So, I want to start there. I was taught, you had an episode, then you were fine, then you had an episode. But then later of course, I've come to learn, there's different ways to conceptualize.

Can you comment on that piece?

Andy Nierenberg: Sure, so part of it is that about 50% of people who experience an acute episode may have that episode and no others. Whereas the other 50% can have it come back. There are all sorts of risk factors for that. Part of it has to do with how old you had your first episode, the older that you’ve had it, the more likely it is to come back. There's a sense that people can be sensitized to stress and that it can take less and less of a stress over time that can provoke the episode of depression, where the flavor of the stress is usually loss. As we all know, life can be full of all sorts of losses. Some of which are easier to deal with and some of which are more challenging.

Ken Duckworth: Andy, do you find that couples who can talk about anticipating and early identification of depression promote a healthier way of approaching the condition? Andy Nierenberg: Yes. And I think Marty put it very well in, in the questioning of the question “why.” That, if Marty experienced that as judgmental, like "why did you do that?" As opposed to, "how come you did that?"

The “why” sounds a lot more accusatory. I think if couples can be supportive of one another, where the person who has the depression can be open to observation as opposed to accusation. I think that can help. Whereas “I didn't realize I'm doing this,” or “I didn't realize that perhaps these are the early signs that it's coming back. So, thanks for observing that.”

Ken Duckworth: Thank you, Andy. I want to go back to Marty. Marty, can you talk a little bit about when you first thought you might have a depression, how you interpreted it and how the people around you thought about it with you?

Marty Parrish: Interestingly, a lot of people still look at… the way I looked at depression, they still look at it in the same way. It has to do with my religious upbringing and my religious upbringing was one that any issue you have, particularly an emotional or a mood issue, is somehow spiritual related. God's trying to tell you something or you're not doing something right. The first time I had depression, that first episode, I sort of knew that it was depression, but I wasn't completely aware that it was depression.

I thought, maybe I was having a spiritual breakdown of some sort. The answer to that issue is to go out and pray more, get involved in church. And admittedly, social engagement helps alleviate someone's mood. But in my case, I had gotten to the point, that I literally, for a couple of weeks there, couldn't interact with anyone.

So, that religious background, that attitude actually hindered my recovery, hindered me seeking help for many years. I went through college, and I went and worked on my masters, and I completed a masters, in ‘86, but it wasn't until 1987, that, having four shots of rum before I went to church one morning made me realize that maybe I've got a problem. I needed the four shots of rum because I was really too depressed and didn't have the energy to go to church. When church was over, I'd had enough, for whatever reason. And I went to an urgent care clinic and that was the first time I sought treatment.

Ken Duckworth: So, you recognized that, the drinking that you were doing in order to function to get to church was over a line and then you went to urgent care.

How old were you then?

Marty Parrish: I would've been 24 at that time.

Ken Duckworth: And your first episode began at what age?

Marty Parrish: At 17, so this was seven years.

Ken Duckworth: You had many years when you were not getting help, and how did the church view alcohol? Was that considered a problem? Or was that just ordinary life?

Marty Parrish: I'm Southern Baptist, you don't drink. That's not an option. The option is you need to read the Bible and you need to pray more. I have an interesting story of that period. A couple of years before I went to urgent care on that Sunday, I was having coffee with a friend of mine, we went to high school together. And, we were having a conversation about depression because he was depressed. I had just read a book called The Mask of Melancholy by John White, who of all things was a Christian psychiatrist. So, if a Christian psychiatrist can write around depression, maybe it's something real, maybe it's medical and not spiritual. And that's what i learned from that book. Explaining that to my friend, he didn't accept that. Two years later, I'm on my way to recovery.

Ken Duckworth: Well, my. Let's talk a little bit about alcohol. It's common for people to use substances to try to change their state. And, that can be challenging to find treatment that addresses both substance use and psychiatric vulnerability like major depression.

Can you talk a little bit about how alcohol weaves into this narrative of depression?

Marty Parrish: My experience with alcohol was not lifelong. In fact, the first time I began to use alcohol was to alleviate the depression. So to me, it was a legal method of dealing with something that was causing me pain, but I didn't have to go to the doctor and be considered “crazy.” I'm using that term with quotations, "crazy," because, that's the environment I was coming out of-- that if you've got depression, you're crazy.

Ken Duckworth: People didn't always use the most helpful terms, particularly back in the day.

Marty Parrish: Right, exactly. Which is one of the reasons I'm trying to help now tell the story, is to break that stigma a little bit. Now, as you grow older and you become more tolerant of alcohol, you use more and more and more of it. And of course, your depression, the longer it lasts, the worse it can be. I could have periods where I wouldn't drink, but many times those periods occurred after I'd gotten on medication and become stable.

My first medication was Elavil. That has such a sedating side effect, there was no way I was mixing alcohol with that. That may have been the thing to help break that alcohol dependency, to some degree. Because, once the Elavil kicked in about six weeks later, the light came on, like in a dark room and I was no longer depressed. And, I saw for the first time in my life that I can live a life without depression. So, that helped break that cycle of depression and drunkenness.

Ken Duckworth: When you felt better, were you no longer looking for alcohol to change how you felt? Or did you do recovery groups or psychotherapy? How did the treatment for the depression contribute to your sobriety?

Marty Parrish: For the most part, if I were not depressed, if I was healthy, I didn't actively seek alcohol. Now, that's not to say that I wouldn't maybe have a drink, but it was rare. You could tell when I was getting depressed, because if I were going to have a drink or a glass of wine, it was never just one.

Ken Duckworth: I see, when you're gonna go for it, your thinking was, let's do this bigger.

Marty Parrish: Right. Over time, that became the issue. That began to interfere with everything, not just from the consequences of drinking, but also it made it impossible to deal with the alcohol. And that's one of the things I was going to say, that some of the newer medications don't have a noticeable impact. A person doesn't realize that medication is working on them and if they continue to drink that medication is not going to work for them, because it's basically going to be knocked out by the alcohol.

I had to learn that the hard way by going through it many times. Luckily for me, I had a therapist. And my wife Peggy sat down, nine years ago and said, “If you don't give up the alcohol, tough luck, you're not going to make it and we can't help you. You're going to make a decision, either the alcohol or us.”

It took that equation away from the depression because you can't deal with the depression until we deal with the alcohol, at that point. It had gotten so bad.

Ken Duckworth: Peggy. What was that like for you? It sounds like you really gave Marty very clear feedback.

Peggy Huppert: I did [chuckles]. The drinking had gotten really bad. And, I know Marty says that, for a lot of his life, that he was a happy drunk and was fun to be around. That actually was the case when I first met him. As we went along, when he would drink, he would get very angry. It was really scary and it culminated in, on the 4th of July we were at a party and he drank too much. And then, he disappeared and came back later and was violent. I had to call the police. He was in therapy. He was taking medication at the time. But he was not being honest with his therapist about his drinking.

His therapist had no idea. And so, we all got together, and I relayed some of the things that have been happening and it was an ultimatum. He said, AA is not going to do it, Marty. You're going to have to check yourself into Powell, which is a local hospital-based treatment.

That’s all for this episode of The Medical Mind. Look for the second part of this discussion, led by Dr. Duckworth, in the Medical Mind episode list.

The mission of SMI Adviser is to advance the use of a person-centered approach to care that ensures people who have serious mental illness find the treatment and support they need. Learn more at SMIAdviser.org.