Why Aren't You Depressed?
Tess Timmes ~
"Please walk slowly," cautioned Sunita, my interpreter, as I crept down the stony switchback trail towards the rural Nepali village of Dhulikhel. Sunita, in her petite navy ballet flats, hopped down the rocks as easily as the speckled goats grazing nearby.
Emboldened by her speed, I stepped along eagerly, only to catch my size-ten neon running sneaker on a root and splat face-first into the dust. Looking up, I saw four women standing outside their clay-walled homes, their hands pressed to their mouths, their eyes sparkling with stifled laughter. Talk about making an entrance....
After finishing my third year of medical school, I was taking a year off to pursue my masters degree in public health. Through my research that year, I'd learned of an opportunity to spend a month in Dhulikhel, located in the Kathmandu Valley, south of the Himalayas, interviewing the region's women about their use of primary-care and mental-health services. Passionate about women's health, and eager to escape another Boston winter, I signed on.
In Dhulikhel I met Sunita, a local nursing student who'd come to know the area through her prior school projects. Sweet, capable and familiar with the local roads, she was the perfect interpreter and travel companion.
After I'd regained my footing, we started our first day of interviews with the women of Dhulikhel. Sitting on mini-stools or woven bamboo mats outside of each woman's home, Sunita and I worked through our list of questions about prenatal care, Pap smears and mood and sleep patterns while the woman methodically chopped radishes, scrubbed tiny socks and shirts or rinsed rice from pots.
Over the next couple of weeks, we would interview 120 women. After repeating the same string of questions over and over, Sunita and I were soon asking about prior Pap smears in our sleep. Walking ten miles a day together, we quickly turned from complete strangers to good friends, discussing culture, family, politics and our love lives.
As our research went on, I felt particularly intrigued by the depression data. We screened for depression with a standard nine-question test, which asked about mood, appetite and energy levels. Seeing the women's corrugated-metal-roofed houses--some still in disrepair after Nepal's 2015 earthquake--and their lack of indoor plumbing and seemingly endless physical labor, I wondered, somewhat presumptuously, why their answers didn't reveal higher rates of depression.
Having first encountered these very questions during my third year in medical school, I vividly remembered answering them--and my sinking feeling as I'd tallied my own concerning score.
When the December 2016 issue of JAMA reported that 27.2 percent of medical students experience depression or depressive symptoms, my initial reaction was disbelief: That's all?
My third-year routine had included predawn alarms that enabled me to crawl out of bed in time to preround; there were also twelve-hour days in the hospital and regular dinner/study dates with my computer, which ended only when my drooping eyelids forced sleep.
I had always cherished my extracurricular passions, rushing to weekend team bike races or hiking trips. My relationships, outdoor activities and exercise time had sustained me. But during medical school--when those things, by default, fell low on my priority list--I lost time with family, with friends, with nature and, finally, with myself. It was easy to downplay this early in the year, when the occasional low-stress week could convince me that everything was fine. But by the year's end, I couldn't ignore my lack of patience and enthusiasm for the people closest to me, or my lack of energy for my favorite activities.
Here in Dhulikhel, amid so much deprivation, the women reported depression much more rarely than I had anticipated. How could that be? I wondered.
Sitting among them day after day, I began to notice an undeniable and pervasive sense of community. Elderly women chatted with their daughters, neighbors visited to help each other husk corn, and young women gathered together at washing stations. Many Nepali men travel abroad for work, and in the absence of husbands, sons and fathers, these women seemed to deepen their own community ties at home and at work. Some invited me, a complete stranger, into their homes for tea during our interviews. So few of them seemed alone.
Reflecting, I realized that this feeling of community was what I'd lost in my third year, when my own mental health had faltered. Once that year was over, I spent weekends visiting my brother, backpacking with my fiancé and reconnecting with my running group, and my sense of dark isolation slowly melted away.
Now, at the precipice of residency, I feel all too aware that my schedule, priorities and availability are about to flip upside-down again. This time, though, I feel more aware of the importance of relationships and communities in my life, and I believe that I will stay more grounded amid the stress. These pieces of my life do not just bring me joy; they enable me to bring my best, most motivated and empathetic self to the people and patients I encounter.
On our final day of interviews, Sunita and I huddled on a stone ledge beside grazing buffalo and goats, talking with a young mother who was breastfeeding. For the one hundred and twentieth time, we began our inquiry, recorded answers and finally arrived at the depression screening test.
Listening to Sunita ask the questions, and feeling the winter sun warming my face, I mentally tallied my own answers and results, comparing them to my responses of a year ago. Now I felt hopeful, found it easy to concentrate and sensed a renewed passion for the people and activities I love.
After thanking the woman for her time, we climbed the mountainside path on our final trek back to the hospital base. I followed closely behind Sunita, easily matching her steps and speed.
"Your balance is much better now!" she teased.
I smiled to myself.
"Yes, it certainly is."
About the author:
Tess Timmes is a fourth-year medical student at Boston University School of Medicine. She completed her MPH at the Harvard TH Chan School of Public Health between her third and fourth year. Her interests include healthcare disparities, women's health and cancer care, and she is currently applying for residency in internal medicine.