Depression self-management - I: Initial considerations

A basic understanding of depression is essential for an effective response

by Tom Cloyd, MS, MA - Counselor / Psychotherapist - Bellingham, Washington (360) 920-1226 - email: tc (AT) tomcloyd.com (please read about content licensing)

Depression threatens us all

Depression affects many people, sooner or later - and at all times of the year. If it doesn't affect you personally, it's still likely to affect someone important to you. If it does happen to you, there are a number of ways you can respond, many of which are immediately available at little or no cost. Because it is so common, it makes sense for us to have a sound, basic understanding of what it is, who it affects, and how we might deal with it.

At any given point in time, a formally diagnosable mood disorder (major depressive disorder, dysthymic disorder, or bipolar disorder) afflicts one person in ten in the United States, often co-occurring with one or more other mental disorders, such as anxiety, substance abuse, or PTSD. It is significantly more common in women than in men. [1] Among those individuals who enter the mental illness system (outpatient or inpatient), it is the most frequent primary problem one may expect to see. [2]

In their entire life, one person in six will experience a depressive mood episode (the link takes you to a definition, in Part II). [6] Women are twice as likely to become depressed as men. [7] In treatment settings, depression can be the focus of as much as 50% of the caseload. [3] "Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44." [1]

The nature of depression

A depression is a low spot. That just about says it all...but not quite. In truth it can be more like a pit, and to get out of that pit we need some hard won and rather specific knowledge.

Depression is painful. Life's satisfactions become harder and harder to access, or one's essential energy feels drained and inadequate. Sometimes both problems happen at the same time.

Depression is natural. It's a reasonable response either to insufficient organic energy resources or to the perception of being confronted with an unsolvable problem. Depression has two faces - natural, normal depression, and that which we consider pathological. It's important to realize that in its natural setting depression helps us to conserve our resources. It's a good thing - but only if it has a basis in reality, and serves to support our welfare.

Natural depression is common. Skip breakfast and you're likely to encounter it before noon, usually in a mild form. The same can be said for what happens when we go without enough sleep, or overdo physical exercise or work. We feel tired, drained, possibly even sleepy. It's also a natural response to disappointments and losses. All in all, it's usually a message that it's time to take corrective action, to recharge our energy stores. We should respond to this message.

Depression can be pathological. When it occurs inappropriately or unnecessarily, it only robs us of our life, and brings us nothing good in return. Our brain is somehow not coping with the challenges in our life, and the result is distressing, often on multiple levels.

Depression can also be a natural, but injurious side-effect of other mental disorders. It is, in fact, the most common diagnosis give to people who have Posttraumatic Stress Disorder, when they are not diagnosed correctly (which happens all too often).

Depression, as a mental disorder, demands respect. In its gravest forms, depression is both very disabling and dangerous. Clinical depression, formally diagnosed, greatly increases the risk of suicide. In the general population, the lifetime risk of suicide is 1 in 100. In the population of those with diagnosed depression, the risk is increased more than tenfold, to 15 in 100. [7] Of all those who attempt suicide, more than half are depressed. [9]

Clinical depression (the kind professionals get involved with) is considered to come in three levels of severity: mild, moderate, and severe [5]. Professional use of these qualifiers often confuses non-professionals, as someone diagnosed with "mild" depression almost always feels rather awful, and "mild" seems like an incorrect characterization. But, it is not until function in daily life becomes challenging that one has entered the zone of "moderate" depression, and "severe" depression essentially always requires major intervention - usually hospitalization. Of those individuals who are hospitalized for depression, one in six will eventually suicide. [6]

A wide range of people have struggled with depression. The great Harvard psychologist William James wrestled with it all his life. Model and actress Brooke Shields has been outspoken regarding her postpartum depression. England's Princess Diana was afflicted with depression, co-occurring with eating disorders. Talk show host Dick Cavett, playwright Tennessee Williams, quarterback Terry Bradshaw, actor Harrison Ford, president Abraham Lincoln, folksinger John Denver, prime minister Winston Churchill, artist Vincent Van Gogh...and many many others have wrestled with pathological depression. [4]

William Styron, notable author of several novels - Sophie's choice (1979), The confessions of Nat Turner (1967) (1968 Pulitzer Prize winner), and others - wrote an important and well received book about his very serious struggle with depression - Darkness visible (1990). Actress Patty Duke has written an important memoir of her struggle with bipolar disorder - A brilliant madness: Living with manic depressive illness (1992), New York: Bantam Books), and excellent resource for anyone involved in anyway with disorder..

Responding to pathological depression

Pathological depression is almost always treatable. Medication is usually not the best, first response. (The clear exception is what clinicians refer to as the "moderate" and "serious" forms of clinical depression, and particularly bipolar disorder.) Mild depression often doesn't respond to medication. Secondly, medication takes days and often weeks, to have any effect at all. If the drug you try first does't work for you, you must start the process all over again with another drug. Meanwhile, the suffering continues.

Medication CAN be a very appropriate response. When your depression is seen by a mental health professional likely to have some organic basis (for the most part, this means "bipolar depress"), or to be serious enough that it may be medication responsive, medication should be seriously considered. It may be life-saving. Depression medication is fairly safe. Serious depression itself isn't, as it carries with it one of the highest rates of self-harm attempts (and successes) of all mental illness diagnoses.

Medication also has an important role to play in heading off major depression relapse. With a history of one episode of clinical depression, those not taking medication have a 50% chance of another episode. With two episodes, the risk without medication rises to 70%. With three episodes, the risk rises to 90%! [8]

Quick relief from depression is available for many people, but.... By actively changing your thinking and your actions, you can experience relief more quickly than, say, when you take an aspirin for a headache. NO medication for depression works this quickly. At the same time, realize that relief is not cure. Feeling better doesn't equate with feeling as good as you'd like to. Full relief usually is not a quick process, nor is it appropriate to rely solely upon self-care, unless the depression you experience is so mild that professional intervention is not justified.

Self-directed action to obtain quick relief from depression can help you make progress with other forms of depression relief. It can greatly improve your response to psychotherapy, for example. When you're less depressed, you simply get more done, and this generalization includes psychotherapy. If your depression is primarily situational, getting some quick relief can help you act more quickly and decisively to change your situation for the better. If it's not, quick relief can help you to set up supports in your life to help you minimize or resolve your depression.

Depression affects your intuition, making it less trustworthy. You'll feel tired, for no real reason. You'll feel unmotivated. Where others see hope, you'll see little or none. This is all your depression talking. It's pervasive, persistence, and sometimes deadly. To combat this demon, you'll have to learn to ignore your intuition and your feelings, at times, and rely primarily on your own careful thinking and that of others, until you get some relief.

You're going to have to do something out of the ordinary, to change how you feel. What you usually do has gotten you where you are now. For new outcomes, you must engage new actions.

You have two avenues of action: thoughts and perceptions. The first is how you look out at the world. The second is how the world appears to you - how you experience it. Cognitive reworking can change your thoughts. Behavioral interventions can change your perceptions. Please read those two sentences again, for they are the key to change.

Your actions will need to be carefully targeted. Good results come from thoughtfully focused action. When you act, it will be for a specific purpose, and you must monitor the situation to see that this purpose is accomplished sufficiently. If this all sounds like work, be assured that it is. Depression is a problem requiring a fully adult response.

You can be a victim or you can be a fighter. It's your choice. If your depression is persistent, and noxious, you have a real problem. Denial of this reality won't help. Looking for a "magic bullet" solution won't help. Get angry about your depression. Anger is energy, and that's an antidepressant. Get thoughtful about your depression. Study up. Make a plan. Implement it and learn from the results. Study some more - and get a consultant if at all possible, someone who understands depression and who has worked with it successfully.

It's up to you. There is no depression tooth fairy. You must decide to do something. You're going to have to act, to get out of the hole you're in, but you don't have to do it ill-informed, or even alone.

NEXT: Depression self-management - II: What to do, what to expect

Notes

Citations are given in full in References.

1. The Numbers Count: Mental Disorders in America. (2006 rev.). The ratio is striking: women have about double the rate of depression found in men.

2. Morrison, J. (1995), p. 549.

3. Morrison, J. (1995), p. 189.

4. I have seen many lists of famous people afflicted with depression. One of the more recently compiled ones is here: http://depression.about.com/od/famous/Famous_People_With_Depression.htm

5. American Psychiatric Association. (2000). These qualifiers are specified in the formal description of the varieties of depression used for diagnosis. My first job in professional mental health was as the Director of Admissions for the major psychiatric hospital in Portland, Oregon. There, I had direct experience with "moderate" and "serious" depression. I observed that the "serious" sort of depressed person usually would have trouble completing sentences, and would initiate little speech and less action. The gravity of their depression was visible. Some "moderates" ended up in the hospital, and some didn't - often it was a matter of history. If one had a history of progressing to serious depression, hospitalization could act to halt this progression, and might thus be employed.

6. Howard, P. J. (2000). pp.332-333.

7. Komaroff, A. L. (1999)., p, 397.

8. Komaroff, A. L. (1999)., p, 396.

9. Berkow, R. (1997). The Merck manual of medical information (home edition). New York: Pocket Books.

References

Here are some of the authoritative sources I consulted in writing this piece - and I encourage you to consult them as well. For the most part, they are fairly accessible to non-professionals, and some are written specifically for such folks, which is why I list them here.

Resources preceded by "‡"are considered especially useful for site visitors who are not mental health professionals.

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, 4th ll. Washington, D.C. (The diagnostic noble of the profession. Each section has an extended introduction which may both inform and overwhelm non-professionals. Much worth considering by non-professionals, if one can read selectively.)

‡ Below, R. (1997). The Merck manual of medical information (home edition). New York: Pocket Books. (A home version of a medical classic. Rich in solid, usable information.)

‡ Howard, P. J. (2000). The owner's manual for the brain. Atlanta, GA: Bard Press. (Over 800 pages of highly useful information, on a wide range of topics. I have disputes with the author on several points, but no matter...this is still a treasure trove.)

‡ Komaroff, A. L. (1999). Harvard Medical School Family Health Guide. New York: Simon & Schuster. (This reference is remarkable. Highly informative, thoughtful, and useful, I think it should be in every home.)

‡ Morrison, J. (1995). Mood disorders. in DSM-IV made easy: The clinician's guide to diagnosis. New York: Guilford. (Non-professionals with some background in psychopathology will get much from this volume. The author is a academic psychiatrist with a real interest in making the ideas in his profession accessible to others.)

‡ The Numbers Count: Mental Disorders in America. (2006 rev.) Retrieved 2007.08.24 from http://www.nimh.nih.gov/publicat/numbers.cfm#Mood