I don’t quite feel like myself. I haven’t in a while. I know why that is. Still, I can’t escape.

The edges and contours of episodes of depression are never the same. Depression can be apathetic, listless, only emerging from bed in the morning because the impact of the consequences just slightly outweigh the weight of hopelessness; depression can be filled with sorrow, tears pouring out of our faces at the first inconvenience or reminder of pain; depression can even sometimes remind us of the beauty of the world.

Chronic disease too does not look the same for everybody.

This time, I have grown listless and terrified, incapacitated by anxiety and fear unlike any time in my life since I was a young child obsessing over tornadoes. This episode has been unlike most of my previous episodes. I think I’ve written those words before, but can’t recall where I wrote them. This has been what this episode has been like. I’ve briefly written about what I’m going through, maybe in an Instagram caption or story, or maybe it was over text or in my journal. I have written in my journal most days over the last six months. Those journal entries have been lengthy, yet few have felt therapeutic. My short-term memory and physical health have also been affected, first dealing with severe gastroparesis followed by an unexpectedly challenging bout with RSV. In the past, my anxiety wracked my brain and impeded my ability to sleep, but still motivation was accessible, enabling me to at least exercise or socialize. Now, I fall asleep relatively easily, less so because I’m physically exhausted since I’m not exercising much right now, and definitely not because I feel fulfilled; I fall asleep easily because I can literally feel a lack of dopamine and serotonin in my brain, preventing me from even feeling the highs that at least still existed in previous mental fogs. The constraints and circumstances of my life have usually existed in such a manner that the lowest lows of depression were avoided, providing me with enough of a foundation that getting out of bed — while of course still difficult — felt reasonable. And now, getting out of bed feels incredibly difficult and nearly pointless.

As I write these words, fully knowing that people I love and care about will read them, I feel the familiar tingle of anxiety creeping up my spine. That feeling, that sense of vulnerability, is one I know well. I have felt it every time I’ve written about my mental health. Sometimes it’s uncomfortable enough that I decide not to publish what I’m writing. Other times, what I was writing felt necessary, a way for me to move forward with genuine acceptance. Those pieces turned out to tether me to a sense of mental stability at the surface while I bobbed below. In this episode, I’m not tethered to the surface; my tether has been replaced by an anchor.

Not only do I feel like I have forgotten the lessons I’ve learned throughout my life during difficult times, I feel like I have forgotten who I am. I feel like I don’t possess agency. I am burnt out and depressed.

In a psychology class over ten years ago, I learned of an interesting study that has ricocheted in my mind for several years. It was about what happens to motivation and fulfillment once we earned financial compensation for activities. This study has popped into my mind every time I think about writing, the greatest passion in my life outside of my love for others and nature, and what would happen to my passion for writing as I became a professional writer. I wondered if I’d fall out of love with writing if I only ever wrote pieces that led to compensation. I love writing regardless of if I get money, but I’d be lying to you if I tried to claim that I felt equally as fulfilled when I wrote a piece for money compared as to when I write non-compensated blogs or essays. The study’s conclusions, though, shouldn’t really be applied without first thinking about the conclusions a bit differently. Instead, the study itself tells us about the concept of intrinsic motivation, or the motivation that compels us to do things for the sake of doing them instead of doing them for the outcome or reward. Of course rewards motivate us, but extrinsic motivation feels more hollow than its intrinsic counterpart. It is obvious that we feel more fulfilled when we do things that we do because we want to do them. It’s also obvious that feeling like we’re doing things that we have to do can take a very serious toll on us.

This toll is due to what else this study reveals: The importance of agency to us in our lives. Agency describes our ability to feel like we are in control of our decisions and actions.

Physicists and philosophers can debate whether we truly have free will or not; in living, though, the reality is less influential than what we perceive. If we feel like we chose to do something, we feel better about it. If somebody monetizes their hobby, it probably doesn’t actually diminish their love for the hobby, but their motivation becomes convoluted when the act of doing the hobby is no longer the goal; the money is. And in a world where money is so incredibly important, the offer of money leads us to associate the hobby and its resulting money as our livelihood. In that way, our jobs are much more than our jobs; they are our tickets, our dues, for the right to live life.

As we get older, we accrue traumas and responsibilities. We encounter burnout. And we lose our sense of agency. Once we lose that, our identities become hijacked. We become shells of ourselves. We become depressed and anxious. It is hard to escape an episode of depression when it feels like you’re trapped in the middle of the ocean during a never-ending hurricane and have no idea who you are or how you’ve accomplished anything before. This is how I’ve felt lately.

In the past, I had a battery of coping mechanisms that helped me overcome. In a strange, paradoxical way, cystic fibrosis actually proved to be a boon, preventing me from reaching the depths of depression. CF, as a friend put it while we commiserated together a few hours ago, was the grim reaper, silently watching over our shoulders. This very real, very present threat anchored me in the present, and it anchored my days. I feared what could happen if I didn’t take my pills, do my treatments, or exercise. CF and respiratory flora are indiscriminate and random. They are painful and deadly. They cause suffering. They triggered fear and an awareness of death. I don’t miss those days. Yet maybe those days showed me something that I have since forgotten in the years where I have found physical stability.

I did not choose to have CF, none of us do. If given the choice, I’d surmise most of us would’ve chosen not to have this condition. But I’ve never known an alternative reality. I have been privileged enough to witness a total reversion in my current health status and future prognosis, which has been a major shock for me and probably many others. This has led me to a place of stability and complacency that has eroded my sense of self and agency, which were fundamental and crucial assets whenever I encountered a health challenge. This is a privilege, I recognize, and I do not take that lightly. But privileges can carry burdens, some seen, some invisible.

I first experienced suicidal ideation when I was a kid. Suicidal ideation, both the experience of it and also talking about it, have provided me a sense of agency when I’ve felt powerless, a sense of control over the very thing that stokes the deepest, most instinctual fear within us: The fear of death. I never wanted to die because I hated life; I ideated because I was sick of suffering and agonizing. The thought of controlling my death instead of the dying from an indiscriminate, random disease gave me relief and a much-needed sense of agency. Agency is the very foundation for fulfillment. I don’t believe we can feel fulfilled if we don’t feel like we have any control. Envisioning my own death significantly reduced the fear of death within me.

CF also gave me the license to contemplate death from a very young age, something I actually consider to be a great privilege. I attribute my writing, my drive to understand and pursue science, and most of my spiritual and personal growth to the heaviness of growing up with CF. Had I not been thinking about death from a very young age, I may not have been driven to pursue life without taking it for granted. Hard to know, but, once again, in the spirit of agency, allowing myself to find something meaningful in having CF is a way for me to exert agency.

About six weeks ago, I spoke at a workshop on mental health in cystic fibrosis for CF social workers. During this talk, I spoke on the unseen, sometimes confusing emotions that can come with having a chronic disease. Obviously I am but one person, incapable of depicting the whole gamut of how humans process their chronic diseases. People respond in strange ways, sometimes predictably, sometimes not. As I’m writing this now, I’m realizing that the point I made at the beginning of this essay, about how I’ve talked about the geometry of this episode of depression before, that was how I described this episode at the workshop I participated in not too long ago. In the past, writing about my grief, anxiety, or depression served as a therapeutic for my depression. The volumes produced in the midst of the episodes were rarely intentional; those writings were often written after weeks of protracted fixation on a particular anxiety. In therapy, it’s hard for us to advance through traumas if we don’t process them, a nebulous, convoluted process that happens as we reframe and hopefully transform our past experiences into meaningful lessons that allow us to move forward, the process of accepting something that has previously been impossible for us to accept. I don’t mean this cynically; the experience of grappling, accepting, and progressing through aspects of life that cause us great suffering is one of the most beautiful testaments to human resiliency. We as humans experience grief and yet retain the ability to love others and work through things. I’m not suggesting that we must romanticize trauma; but to move forward, we do have to process things as best as we possibly can.

Another part of mental health discourse that has grown irritating and disconcerting to me is that while there is more conversation about mental health than ever, our solutions and ideas still seem to lack imagination or the essence of true, legitimate solutions. We likely can’t cure depression, nor is that probably the right goal for us to aim at. We should seek to reduce preventable human suffering, that is the bare minimum. And mental health is a legitimate crisis. Positively, one of the root causes of depression, loneliness, was declared an epidemic by the United States Surgeon General, a step in the right direction in how we address the nuances and varying etiologies of depression.

The reason a pharmacological-centric approach to treating mental health is insufficient and misguided is because the root causes of mental health issue are not solely genetic, but “a complex interplay between genetic and environmental factors”; this is the importance in understanding scientific research and how questions get framed. A genetic etiology for one’s depression can be an example of correlation and not causation. Everybody who has a genetic predisposition for depression does not necessarily develop depression; conversely, everybody who has depression does not necessarily have a genetic predisposition for depression. In other words, external conditions play a fundamental, sometimes causative, role in depression, even in those who are notgenetically predisposed to depression. This is important, and as the mental health discourse expands, it’s something we need to center in the conversation.

Back to the idea of curing depression: We most certainly will not do so through drugs alone. Antidepressants are about 30-35% effective in resolving depression in most cases (and one study even suggests they may have no more beneficial effect than a placebo), and the evidence supporting a single mechanism of depression appears to be nonexistent; to think we will suddenly understand the breadth and depth of depression so discretely (and this would also require a much, much better understanding of the brain) that we could develop therapeutics to treat depression entirely is unfounded in reality, nor is it a reasonable goal. A more realistic goal is for us to accept that honing in on every specific mechanism involved in depression is useful so long as we recognize that we can’t expect cognitive behavioral therapy to ameliorate depression in an underemployed parent living paycheck to paycheck. If we ignore the material conditions that drive people to feel depressed, we will never advance any meaningful care to treat depression in a majority of the population. The depression that arises directly due to material conditions, especially when we are intensely stressed and overwhelmed, usually hits hard and quickly, revoking our ability to process things in a way that allows us to adjust and develop coping mechanisms.

This is what I have learned over the last six months. Agency, the sense of control we have in our lives; self-confidence in how we can handle challenges that unexpectedly impede our progress; and hope that we will overcome the obstacles we encounter, these three concepts are what come together within us to overcome depression. These three concepts are hard to maintain when our material conditions do not cultivate them within us. If we are in an environment where we are constantly stressed and overwhelmed, where we don’t feel like we can do things correctly, or where we don’t feel like we ultimately have any control over the outcome of things, we lose our agency, self-confidence, and hope.

This is why depression can become so pernicious and chronic. It is hard to repair those aspects of life within us, and even harder when our agency, self-confidence, and hope have been decimated.

This is why a pharmacological-centric approach is insufficient. A medication alone can’t resolve things if other changes aren’t made to reinforce the traits of agency, self-confidence, and hope.

This is why I have struggled so much recently. In the past, writing was rooted in both pain and hope. I haven’t felt hopeful for a long time.

I also don’t think all of this is unidirectional. I think most of this has a bidirectional or cyclic relationship. As our agency improves, so does our hope, which in turn improves our agency, and so on and so forth. The same happens in the reverse direction; as we lose hope, our self-confidence and agency erode, this cycle reinforcing itself downward. As I’ve lost my agency and my sense of hope, my self-confidence has been crushed too.

Probably the most promising thing of all of this is that I feel like I have finally put my thumb on what has been driving my depression. Throughout all of this, I have been reminded, as I’ve been reminded so many times before, that people are intrinsically compelled to love, support, and be there for one another. I have seen this time and time again, this time no exception. I feel incredibly grateful that for as much as I’ve felt loneliness, I’ve rarely felt truly alone. The people in my life have been my anchor, and I feel deeply grateful that through all of this, I’ve been shown grace, love, patience, support, and understanding.

I haven’t published a personal piece of writing in a while. In that time, I’ve written a lot about pulmonary diseases and I’m proud of that writing; I’ve journaled tens of thousands of words and I’m proud of those entries, which have most certainly served as the framework for this piece that is finally coming together; but I’ve not written anything personal in much longer than I’d like. I’ve wanted to. But nothing felt right or genuine. Tonight, I’m grateful that I finally sat down to write and pull the pieces together. This has been very important to me.

In the past, publishing a piece like this would serve as the conclusion of an episode, the climbing out of the metaphorical hole. I’m hopeful that what I’m feeling tonight is exactly that.

tré