You're not disgusting. You're depressed.

It was Devon's third week at the methadone clinic. Because he had reported previous psychiatric treatment to his counselor during the psychosocial assessment, I was asked to meet with him and refer him for outside treatment since we did not have a psychiatrist on staff.

“I'm fine,” he told me immediately; “I don't need a psychiatrist.” He looked and sounded well: appropriately dressed, good hygiene, alert and lucid.

“You might not need one,” I said, “but I'm just checking in with you. You did report a history of trauma and depression. Have you ever seen a psychiatrist?”

“I did, back when I was depressed,” he said, his face creasing in disgust. “I was so gross back then.”

“Gross how?” I asked. Devon looked away, shoulders slumping at the memory.

“I went for days and days without taking a shower or brushing my teeth,” he explained. “I could smell myself. I smelled so bad. I was just disgusting.”

“You sound pretty annoyed at yourself,” I said.

“It's weird,” Devon responded. “Now keeping myself clean is easy. But when I'm depressed, it's like I just don't want to be clean, like I don't care how disgusting I get.”

“Why do you think you don't care?” I asked him.

Devon shrugged. “I don't know. If I cared, wouldn't I do something about it?”

“Let me ask you something,” I said. “If you broke your right arm, would it be more difficult to brush your teeth?”

Devon eyed me quizzically. “Of course it would. That's my dominant arm. I do everything with it.”

“But if it weren't working, you'd have more trouble, right?” I asked.

“Yes, of course,” said Devon. “That's obvious.”

“Well, one thing that might not be as obvious is the role your brain plays in brushing your teeth,” I said. “When you decide to brush your teeth, that's only the first step. After that, what do you have to do?”

“Pick up the brush,” said Devon, patiently, as though speaking to someone slow on the uptake. “Put toothpaste on it. Brush your teeth.”

“First you have to take the cap off the toothpaste,” I said.

“Yeah, so?” asked Devon

“So, all of those interim steps happen almost automatically when your brain isn't depressed,” I told him. “You don't really have to think about them; you just do them. But when you're depressed, it's like a short circuit in your brain. All those steps that normally happen in sequence so effortlessly don't flow naturally because your brain cells aren't communicating well with each other. So every step in the sequence is slowed down or stops. Moving from one task to another is difficult or impossible.

“Did you ever find yourself standing at the sink with toothpaste on the brush, but not moving the brush up to your mouth?” I asked.

Devon stared at me and nodded slowly. “I'd be standing there just looking at the brush and it was like I didn't know what to do next.”

“That's the effect depression has on your brain,” I said. “It doesn't mean you're stupid or lazy or disgusting. It means your brain is having trouble moving you from one almost automatic step to the next. Many, many people who are depressed have problems bathing or brushing their teeth for this reason.”

I asked Devon a few more questions about his current mental state. He wasn't suicidal or harboring homicidal ideations; he was eating and sleeping well, especially since he'd reached his optimal methadone dose. Depression and insomnia can be symptoms of opiate withdrawal.

“If you decide later on that you'd like to see a psychiatrist, let me know and I'll help you find a good one,” I said. “But right now I agree with you: you're not depressed. And when you were depressed, you were never 'disgusting.'”