Dear Alice,

I am actually asking for a friend of mine since this situation is getting worse, and I don't know how to help. The problem is that my friend is very depressed, and has very, very low self-esteem. While sometimes able to be cheerful and "happy," he claims to rarely feel that way and mostly just hates himself. He has mentioned suicide, although I think this is more an expression of the extreme self-hatred he feels than anything. I comfort him and often tell him how wonderful he is — what a good person, good qualities, etc., but I suspect he does not believe me at all. This has been going on for a long time now, and I think it stems from a somewhat unhappy childhood and adolescence. I don't know how to help him and I don't know what to do. I feel like being strong for him is just not enough, and I can't quite convince him that counseling may do some good. It seems to me that, recently, he has been feeling even worse about himself, to the point where nothing will comfort him. He cannot afford counseling, and he has no health insurance. Is there anything you can suggest for me to tell him or suggest to him? Any help will be greatly appreciated, because I just don't how to help him. Thank you so much.

— A friend on-the-line

Dear A friend on-the-line,

Your friend is lucky to have such a caring pal in you. Sometimes friends such as yourself need to reach out for more information and assistance in helping a buddy — so kudos to you on that front. Getting back to your friend: everyone feels "blue" at certain times during their lives. In fact, feelings of sadness or discouragement are perfectly normal, especially during difficult times. However, there’s a difference between being bummed and living with depression. Folks experience depression in different ways, but certain signs may be a red flag that a person is dealing with more than just low-spirits. You also state that your friend has mentioned suicide — and as someone who cares about this person, it’s critical to address it directly. Further, helping in your role as a friend involves some of the strategies you’ve already described: recognizing signs of depression, responding to a friend in crisis, and making referrals to resources that can provide more support for your downtrodden comrade.

Before talking more about the signs of depression, it’s crucial to talk about how to handle disclosures of suicidal thoughts. Though you may think that your pal is really just down, it’s vital to take any talk of a friend disclosing they wish to end their life seriously. If you hear a person talk about suicide or if you notice any other warning signs, it’s wise to ask them directly “Have you thought about ending your life?” or “Do you have any plans to end your life?” Getting clarity on what they’re communicating to you is key so that you’re not guessing about their intentions. If you believe they're at an immediate risk for self-harm, staying with them (if it's safe for you to do so) and reaching out for help is advised. You can do this by calling the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or by calling 911 if there’s an immediate emergency.

With that said, it sounds like you’ve noticed that your friend is having a hard time right now. While you say that your pal is very depressed, keep in mind that depression can only be diagnosed by a mental health professional or health care provider. But, there are some signs and symptoms to look out for that are commonly associated with a depressive episode (though not all features are present in every episode or for every person):

  • Feelings of sadness, tearfulness, emptiness, or hopelessness
  • Angry outbursts, irritability, or frustration, even over small matters
  • Loss of interest or pleasure in most or all normal activities
  • Sleep disturbances, including insomnia or sleeping too much
  • Tiredness and lack of energy, so even small tasks take extra effort
  • Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and weight gain in some people
  • Anxiety, agitation, or restlessness
  • Slowed thinking, speaking, or body movements
  • Feelings of worthlessness or guilt, fixating on past failures
  • Trouble thinking, concentrating, making decisions, and remembering things
  • Unexplained physical problems, such as back pain or headaches
  • Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts, or suicide

List from Mayo Clinic.

If you’ve observed any (or all) of these features in your friend, he may benefit from getting help. Depression is treatable and many find that talk therapy, medication, or a combination of treatments do wonders to help them feel more like themselves.

With this knowledge in mind, you may decide to have another conversation with your friend, approaching your next chat with a slightly different angle. Because you have an established friendship and you’ve observed a concerning pattern in your friend, it may be worth it to take time to think about how you want to discuss your concerns. First, you may start by finding a time and space to talk that maximizes privacy and comfort and minimizes disruptions for both of you. When you find a time to talk, let your friend know you care about him and that you’re coming from a place of concern because you value your friendship. This can help reassure your friend that you’re on his side and want to be helpful.

Next, you can discuss the pattern of what your friend has shared with you and what you have observed him do or say — with your own eyes and ears. Reflecting on what you have directly experienced that has been cause for concern. You could also let him know in what way this has affected you and your friendship. You may spend some time considering what that means to you — is it that it has caused you to be worried about your friend? In what ways has this affected your relationship with him? Then, you can ask your friend if he can understand where you’re coming from with what you shared. This can help you both get on the same page. You may not be sure how he’ll react to what you've shared, but considering how you might respond in the event that he agrees or disagrees may be a part of your preparation.

If your friend is in agreement with you about what you’ve shared, you could ask your friend if he’d like to do something about it. If he does, it’s key to be ready with some resources to share. You mention that your friend can’t afford counseling and doesn’t have health insurance. If your friend is a college student, he may be able to access care with a mental health professional on his campus — campus counseling services are often available at low or no additional cost to students. Does his campus have a helpline that can connect students in crisis with resources? Perhaps there are low or no cost counseling services in your community.  Again, doing a little research beforehand can help (check out Finding low-cost counseling for tips in your search). You might also want to have thought about in what ways you can support him in his decision. If he’s open to it, you could offer to go with him to a mental health professional’s office or perhaps you could just sit with him while calling a helpline. It’s key to think creatively, but it’s just as critical to let your friend guide any course of action.

If your friend responds that he doesn’t want to do anything about it or if he doesn’t agree with your observations, being a supportive pal often means respecting his decision. The choice to address what he’s experiencing (or not) must be left to your friend. However, if he isn’t ready to address it now, one positive takeaway is that he’ll likely have a better idea of who he can reach out to in the future (you!) if he does decide to take action.  

Ultimately, it’s good to remember that it’s up to your friend to make a change. It sounds like you’ve been a great source of support to your pal so far, even if it doesn’t always feel like you’re being heard. And, as much as you want to help, there’s only so much a friend can do. Seeking out additional assistance is totally okay and it may be time to involve other people (such as a member of your friend's family, a mutual friend, residential staff member at your friend’s campus, or a professional staff member at the student health services) if you feel like your friend isn't heeding your concerns and particularly if you feel that he’s at serious risk for harming himself. No matter what happens or how this conversation goes, it’s key to make sure your needs are also met in the process. You might consider speaking with a mental health professional yourself to address how you may be feeling and to talk further about how you might help your friend. 

Best of luck as you continue to support your pal,

Alice!

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