Signs of depression families miss, and the stigma behind it [PODCAST]

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Someone you love says they are fine. They still eat, they still go to work, and no one asks a second time. Nneka Oluoha is an internal medicine physician and the author of a novel about a Nigerian immigrant living with depression. This episode is based on her article “The signs of depression a husband almost missed,” published on KevinMD. She explains why depression is an illness the entire family carries, and why the people around someone are left with challenges of their own. You will hear why she believes therapy belongs to men and to children, and where the pressure to look strong begins. She found the same stigma in the United States that she grew up around in Nigeria. Her answer is not complicated: more honest conversations, and a willingness to sit and listen when someone cannot say what is wrong. If someone close to you keeps insisting nothing is wrong, this conversation will change what you listen for.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Nneka Oluoha. She’s an internal medicine physician. Today’s KevinMD article is “The signs of depression a husband almost missed.” It’s an excerpt from her book, Live for Me, Nkem. Nneka, welcome to the show.

Nneka Oluoha: Thank you so much, Kevin. I’m very happy to be here.

Kevin Pho: All right, let’s start by briefly sharing your story and then jumping into why you decided to share this particular excerpt on KevinMD.

Nneka Oluoha: I am a physician who grew up in Nigeria. I did my medical school and most of my training in Nigeria, and then I immigrated to the United States, where I did my residency and started working. That’s my background.

Somewhere along the line, I’ve always been someone who loved to write, since I was very young. It’s been one of my passions, but I never quite pursued it. So one day I said, “That’s it. I have to make this goal into something and make this dream tangible.” That was how I started writing Live for Me, Nkem. From a few scribbles and ideas, it became something tangible that I can actually hold and read. That’s my story in a nutshell.

Kevin Pho: All right. Tell us about the novel that you wrote. What’s it about, and why did you decide to write it in the first place?

Nneka Oluoha: Live for Me, Nkem follows the story of Nkem, who is a Nigerian immigrant living in the United States. The reason I wrote it is that I felt the story of Nkem is very universal. She’s Nigerian, but she’s anybody you could meet out there. She could be from almost any ethnicity you could think of.

I had a big misconception before I came to the United States, which was that people here would be much more enlightened, that people here wouldn’t have any misconceptions or fallacies about mental health. I thought, “It’s 2026.” So I thought people would know a lot more, and I realized that wasn’t necessarily true. There’s still a lot of stigma. There’s still a lot of misunderstanding. You have some genders not wanting to speak up because they think it makes them weak, stereotypically.

The more I heard these stories, the more I had the idea for Live for Me, Nkem. I found myself thinking, “What if there was a woman who had a mental health problem and was afraid of speaking up?” After a series of what-ifs, I had a few ideas on paper, and before I knew it, I had a huge manuscript. So that’s how the story of Live for Me, Nkem came about.

When I told this story, I realized that it’s not just for Nigerians. It can be for anybody, because, like I said before, mental health is universal. The stigma is universal too. It might present itself in a different way, but eventually it’s very similar. That’s why I felt this story needed to be told.

Kevin Pho: You mentioned the word stigma in mental health multiple times, and you said that stigma is universal. Talk to us about some of the stigma and some of the misperceptions regarding mental health issues that you want to highlight in this book.

Nneka Oluoha: One of the biggest examples in my novel is my protagonist Nkem’s mother. There are several things she says to her daughter. Sometimes she says, “Don’t be lazy,” or, “You have to be stronger. You’re a parent now. You can’t go hide in a corner and say you’re depressed. You have to take care of your children. You shouldn’t appear this way. You should do this.” Essentially, it’s as if this is something you can battle with strength of will: If you say, “OK, I’m strong, I’m going to do this,” then you can do it.

That’s not necessarily true. It’s an illness, and like every other illness, you need the proper medications or the proper strategy to overcome it. That could be medications, or it could be therapy. But you can’t sit in a corner and say, “OK, I’m strong, so therefore I can overcome my mental health illness.” That’s one of the stigmas that my book explores.

Initially, I used to think that maybe that was something specific to some parts of Nigeria in the particular time that Nkem grew up in. But when I came here, I realized that it’s not, particularly from some of the patients that I saw. I heard similar stories about what they were told growing up, or even what they are being told currently. Maybe you have someone to whom you say, “You need help for this issue,” and they tell you, “No, I’m a mother. I need to go take care of my children.” And I say, “But you can’t even take care of yourself. You need to take care of yourself first before you can care for someone else.” They just have that belief: “No, I have to white-knuckle this and go do it.”

Kevin Pho: Now, did you incorporate a lot of what you saw as a physician into the characters in your story?

Nneka Oluoha: I would say in a way, yes, because being a physician is what helped me understand mental health. Otherwise, I wouldn’t know how to tackle it. Being a physician is what made me able to tell the story of Nkem. But I think most of what I could write about was what I saw, what I experienced, and what I saw around me growing up. That’s where most of the story came from. The knowledge about mental health came from being a physician.

Kevin Pho: Now talk to us about the excerpt you specifically shared on KevinMD. It’s titled “The signs of depression a husband almost missed.” For those who didn’t get a chance to read your excerpt, just set the scene for us. Tell us what this particular excerpt is about.

Nneka Oluoha: That’s one of my favorites in the book. Live for Me, Nkem explains how depression is an illness of the entire family, because when someone is depressed, the people around them can feel it too. They have their own challenges as well. In that excerpt, Chima, Nkem’s husband, is also struggling. He’s trying to understand his wife, because this is no longer who he married. She’s very different from how she used to be. She barely goes to work and comes back, and everything else in between is swallowed up. He’s also being burdened with the household work and the care of the kids. So he’s trying to find out how to help her. How do you help someone who pretends they are fine and who doesn’t ask for help?

So he’s gone to Nkem’s mother to explain that things are getting worse, that this is no longer the daughter she knew, and to ask how they can all come together and help her. That’s where the scene starts. It starts with Chima going to Nkem’s mother to see how he can convince her that her daughter needs help. What he sees there is maybe what he expected, because he’s been dealing with his mother-in-law for a while, but this was a last-ditch effort to try something new.

He gets there, and Nkem’s mother welcomes him in. They sit, she offers him food, and they talk. The more he tries to explain that things are getting worse, the more she tries to redirect the conversation to the things he might have done wrong, or his family might have done wrong. The more he tries to tell her that something is wrong with Nkem, the more she says Nkem is the way she’s always been. “Does she eat most times?” Yes. “Does she still go to work?” Yes. “Then she’s fine. It’s the same.” That’s how she concludes the scene. That’s what the excerpt is about.

Kevin Pho: Take us through a little bit of your writing process. How do you translate some of the experiences that you’ve seen as a physician into the stories that you tell in this novel? Did you have a background as a writer? Take us through how you create some of these scenes drawn from what you’ve seen as a physician.

Nneka Oluoha: I think I’ve always had an overactive imagination, even before I went to medical school. I was the kind of child who would see a blanket and not see a blanket. I’d see a castle. I’d take the blanket, drop it, and make little walkways in it. I’d make a tower. I’d make a garden, all in a blanket. I was that kind of child.

Back then, growing up when I did, I made my own dolls out of paper, because I didn’t have actual dolls. I’d take paper, cut it out, and fashion my own dolls, and somehow I could see all the characters in this tiny piece of paper. I would have a husband, a wife, their kids, and they’d have a dog. My parents even remind me of some stories I’ve forgotten. So that was always me.

When I see people, I think about their stories. Even now, as a physician, I could have a patient to whom I say, “You need to take this medication,” and they say no. I hear the no, but I’m hearing something beyond that. I’m hearing, “Maybe I don’t have someone to help me sort out my medications. Maybe I can’t afford this medication. Maybe this medication has a side effect that I’m too embarrassed to speak up about.” I hear all those stories behind the no. And sometimes I think about it, and that becomes an idea.

Kevin Pho: I know that this is a novel, obviously fiction, but for your readers, after reading this story, tell us some of the key messages that you want them to come home with.

Nneka Oluoha: What I want people to take away from Live for Me, Nkem is that sometimes depression doesn’t look the way people expect it to look, especially from the outside. The biggest message is that depression is a challenge for the entire family, because once someone is depressed, the people around them also carry those burdens, whether they want to or not. It affects them as well.

I also want people to be more open to therapy, especially across genders. Someone told me once that men don’t go to therapy. This was a long time ago, and I asked, “Why not?” The answer I got was that men should be strong. “They’re the ones who manage whatever needs to be managed. Women are the ones who go and talk about their problems. Men deal with the problems.” And I said, “I don’t think so. I think everybody can benefit from therapy.” So I want that to be a message as well. I also want people to learn that children can benefit from therapy too.

I think the biggest one is being there for someone who needs us, because sometimes you really can’t help. The most you can do is listen, because you can’t take medications for someone. You can drive them to therapy, but they have to participate themselves. Sometimes the most you can do is just listen and be what that person needs at that time. If they need you to talk, then you can talk. If they just need you to be quiet and listen, then you are quiet and listen.

Kevin Pho: Now, one of the things that I want to get back to is the stigma that surrounds mental health care and some of the cultural obstacles to it. What are some ways to relieve some of those misperceptions and remove some of the stigma across cultures? I know that there are some cultures where mental health is more stigmatized than in others. What are some ways that you can suggest, or have observed as a physician, to cross those cultural obstacles?

Nneka Oluoha: I think the biggest thing would be more honest conversations, because most conversations in some of those cultures are not as open as they could be. When people have mental health challenges, they may want to hide it or not say what’s going on, and the stereotype keeps getting perpetuated. If we have more honest conversations, say how we really feel, or say what happened to us, or, for instance, if someone in a more influential position talks about their challenges, people can learn to normalize it and say, “Oh, if this very important person went through this, then if I’m going through it too, it means I’m not weak.” It makes people more willing to step up.

I think the presence of social media is also helping, because people can see past their own culture. In the past, all you knew was yourself and what was around you. But now you can just sit in your house, open up your phone, and see what’s happening in London, in France, and in other places. If you can see that other people are going through these challenges, it becomes more normalized.

Another stigma that I found when I was growing up was a saying that depression is a white person’s disease, that Black people don’t have time for that. They have their own challenges and the other things they’re doing, so they don’t have time to sit in a corner and be depressed. That’s obviously not true, and that’s another misconception that I hope honest conversations can correct.

Kevin Pho: Now, how do you balance writing with your professional life as a physician, as well as your home life?

Nneka Oluoha: Well, here’s the interesting thing. Before I started writing, it was already very challenging balancing my job and my home, being there for my kids and going to work. Sometimes it’s very long hours, as I’m sure you already know. I was feeling like I was approaching burnout at some point. I would come home, and no matter how long I rested, I felt like I wasn’t well rested going back to work. That was when I started writing.

I remembered that when I was younger, writing used to be almost therapeutic for me. I would spend almost an hour every day, right before bed, writing. Once I put my thoughts down on paper, my mind felt clear. It’s like mindfulness. My mind felt clear, I was no longer going over different things from the day, and I would lie down and sleep right away. That was how it used to be when I was much younger.

At some point, I convinced myself that I was too busy to write: going through medical school, the long exams, the rigorous hours. I told myself, “There’s no time. I can’t do it. I have to wait until later.” And later never came. It just never came.

Then one day, I think this was during maternity leave, I said, “OK, you have some time now. You’re home with the baby. Let’s start writing when he’s sleeping.” So I started doing that, and I found that my sleep was a lot better, because I was putting my thoughts down on paper. It was almost a healing process for me.

When I went back to work, I said, “Oh, I’m back at work now. I probably can’t write anymore.” But no, I started taking a few minutes before bed with my tablet, or sometimes my phone, and writing down a few words. Sometimes it’s a page, sometimes a few pages. Some days there are no words at all; I just stare at the page and nothing comes. But I started doing that again, and I found that my sleep is better now, too. At some point, I was almost thinking I might need sleep aids, but now that I’m back to writing, I no longer need anything like that. Once I’m done with writing, I’m able to sleep very well.

Kevin Pho: We’re talking to Nneka Oluoha. She is an internal medicine physician. Today’s KevinMD article is “The signs of depression a husband almost missed.” It’s an excerpt from her novel, Live for Me, Nkem. Nneka, let’s end with some of your take-home messages for the KevinMD audience.

Nneka Oluoha: My take-home message: If you’re someone out there who is struggling, don’t be afraid to reach out for help, because it’s always there if you reach out for it. And also, be a safe space for someone else who might need you.

Kevin Pho: Well, thank you so much for sharing your story, time, and insight. Thanks again for coming on the show.

Nneka Oluoha: Thank you so much, Kevin. I’m very happy to have been here.

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