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

Suggested steps to take to better respond to your depression

by Tom Cloyd, MS, MA - Counselor / Psychotherapist - Cedar City and St. George, Utah , Utah (435) 272-3332 - email: tc (AT) tomcloyd (DOT) com (please read about content licensing)

(Have you read - Depression self-management - I: Initial considerations?)

Depressed mood inclines one to inaction - our intuition becomes distorted, inaccurate, and misleading. When depressed, it is wise not to listen to one's intuition, for if we respond actively to depression with intelligence, focus, and a sense of purpose, rather than merely enduring it, we can "move the mountain", obtain relief, and work to craft a fix to the problem. Here's how to make that happen.

FIRST - check your assumptions: Are you really depressed?

Non-professional use of the word "depression", as we'd expect, tends to be more casual than precise. Distinction between the depression which visits each of us at times and clinical depression, which warrants profession intervention, is usually not made. Moreover, depressed people often don't recognize their problem until the problem is well-advanced - if then. Finally, when depression is present, men are probably significantly less likely to admit to it than are women, and children are essentially incapable of recognizing the affliction at all.

Self-recognition of depression is also made much more difficult because (a) there are many ways to become depressed and (b) depression is often a secondary symptom of some other primary condition, which may be receiving most of our attention - or, in contrast, may NOT be when it should! (I address this last problem below.)

Getting your bearings - the "language" of depression-related disorders

People who get seriously involved in a problem often evolve a specialized language for talking and thinking about it. Mental health professionals have done this with depression. If one reads much about the topic, encountering this evolved language is unavoidable. This can be confusing. Where non-professionals use the single term depression, professionals more typically distinguish clinical depression (or "depression" for short) from subclinical-depression. [1]

So, here's a quick introduction to fundamental professional language used in talking about depression and related topics. You will benefit from learning a bit more about each of these terms.

• Mood - A core idea, but a bit hard to pin down. Put simply, it is one's persistence emotional state. "Emotion" is the problem word, here, of course. What is really meant is feeling, not emotion [2].
• Depression - A condition of objectionably low mood. (Sometimes referred to as "unipolar depression".) This can get tricky, as a depressed person can respond by becoming rather active - something probably seen most often in adolescents. This activity is not mania (see next term), but simply a way of combating the depression. Done consciously, this can be a smart response, as I will explain.
• Mania - A condition of objectionably high mood. People with mania are typically hyperactive, and may sleep little. They may have extravagant ideas about what they can achieve. They will typically be either irritable or euphoric - sometimes alternating. Various substances (legal and illegal) can, of course, induce manic-like states.
• Bipolar (an adjective, as in "bipolar depression", but often used casually as a noun) - A condition in which one has problems with both depression and mania, alternatively. This is generally considered to be more likely due to a fundamental organic neurological condition than is either depression ("unipolar depression") or mania.
• Clinical (an adjective, as in "clinical depression") - A problem becomes a "clinical" concern in professional mental health when formal treatment is justified, due to its persistently disrupting some major life function relating to self, intimated, family, social connection, leisure activities, or work. [3]
• Mood problem - The "mood" aspect is seen as varying along a continuum from extremely low (very sad, very lethargic, etc.) to extremely high (very irritable, very elated or euphoric, etc.). The "problem" aspect is seen as varying along a continuum from "mild and brief" (non-clinical) to "serious and persistent" (clinical).
• Mood disorder - This is the "family" of problems of which "depression" is a member. A mood disorder is a clinically diagnosable condition which involves the presence of a verifiable mood episode, plus some other qualifying conditions, which vary according to the disorder under consideration. Note this especially: since depression occurs in relation to virtually ALL of the mood disorders (of which there are ten), if depression is present they must all be considered as possible diagnoses. (As a non-professional, consider: are you really able to do this? Probably not.)
• Mood episode - Think of this an objectionable persistent mental state, involving either or both of these issues:
  • one's perceived and apparent (to others) level of energy, and
  • one's feelings (on a "sad"-to-"happy" continuum).

If "mood problem" is a concept, a "mood episode" is a particular instance of a mood problem in a person's life, in association with some additional formal criteria. It's a kind of unhappy story ("episode"). For a mood disorder diagnosis to be made, one or more mood episodes must be found in a person's history - including present time. The formally distinguished mood episodes [4] are these:

• major depressive episode (manic mood cannot also be present)
• manic episode (depressed mood cannot also Goldbe present)
• mixed episode (criteria are met for both manic and depressive episodes)
• hypomanic episode ("hypo" means "not-quite-fullblown")

So, now you can understand better than ever that you can be experiencing depressed mood without qualifying for professional intervention. You can also qualify for such intervention, but not qualify for certain levels of treatment. The lowest forms of depression are most responsive to self management, but even more serious forms can respond to what you do, personally, to elevate your mood.

Rule out obvious organic problems first - the non-psychological causes of depressed mood

It's silly to engage a psychological intervention if your depressed state is due to an easily identified problem in your physical body or environment. So, before going any further, make sure your depressed mood doesn't have an obvious cause to which you can respond in a fairly obvious and sensible way. Almost everyone skips this step, and that's a bad idea.

For years, I have asked my clients to take themselves through what I call "the five rule-outs", when they feel bad. Before going any further, consider the matters taken up in this brief article, and deal with any which appear to be affecting you: First considerations - Five Organic Rule-outs.

Self-assessment tools for depression

Depressed people usually feel unhappy or tired, and often both. The "unhappy" form is present if nothing you do pleases you or makes you happy. The "tired" form is present if you simply have trouble doing much at all.

First, you should understand that self-diagnosis is always risky. You alone bear responsibility for any consequences deriving from the decision to self-assess. In a professional context, we never accept the results of any assessment "test" or tool as doing more than suggesting a diagnosis. You must adopt the same caution. Final determination must always be done by an appropriately trained and experienced clinical professional (and even then the outcome cannot be 100% certain).

OK, so you just can't be held back! Most of us do like self-assessment tools - myself included. Relative to depression, there are a number of options. I offer some good ones below. I've carefully reviewed all of them and believe they are as good as you can find anywhere. One good way to use them is to assess yourself using two or more tools. Multiple measurement usually increases accuracy.

These two self-assessment tools are in books which you ought to be able to find in the reference section of any library (for quick access, ask the library for the titles).

• Komaroff's 10-item Depression Questionnaire [5] - quick, simple, thoughtful (not formally validated).
• Howard's Symptom List assessment [10] - a list of 15 symptoms, from two different professional sources. Having 4-5 of them daily for two or more weeks suggests a depression is ongoing (not formally validated).

The following are available online, as of the date of this writing:

• Pfizer Inc.'s PHQ-10 - The goal of this tool is to identify symptoms, if present. A verbal summary of the meaning of your symptom profile is offered after you have assessed yourself. You have the chance to print out the questions and your answers, to take to a professional, should decide to get help. (not formally validated)
• NYU School of Medicine's Online Depression Screening Test - Another 10-item symptom assessment tool, but with a more sensitive response scale than the PHQ-10. Otherwise, it functions the same way: You are offered a verbal summary. If it indicates depression, you are advised to seek a consultation. (not formally validated)
• Goldberg Depression Questionnaire - An 18 item assessment tool, with response scaling set up more sensitively (i.e., with a more finely divided response scale) than most other such tools. It is suggested that you also use this to track your progress in treatment.

SECOND - do a self-assessment of personal safety

For all ages combined, suicide is in the top ten most common causes of death. [6] As previously discussed, suicide is especially a risk in the context of depression. Most depressed people don't attempt suicide, but a disturbing minority of they do. If only because of the awful effect a suicide has on other people, it is wise for you to do a careful assess of your situation, to insure that you are not in that minority.

I would be especially concerned about your safety if, while feeling depressed, any of the following were true for you:

1. You have recently felt so bad that you've thought about suicide. (If you answer YES to this question, you really should contact your health care provider without delay. Do not get an appointment - get a person on the phone, or drop by. Just do it!)
2. You have any previous history of attempting suicide.
3. You or anyone around you considers your depression to be serious.
4. You have had one or more previous non-trivial depression episodes.
5. Your depression has persisted for two weeks or more.
6. You suspect, or have ever been told, that you might be bipolar. (See Getting your bearings, above for explanation of what this means.)
7. You presently feel, in addition to depressed, persistently restless, agitated, and/or anxious.
8. You have ever received treatment for any mental health disorder, and especially if you have ever been hospitalized for psychiatric treatment. (The most risky psychiatric disorders are major depression, panic disorder, and schizophrenia. [6])
9. You presently have a diagnosed or suspected co-occurring diagnosis of panic disorder or schizophrenia. Coupled with depression, these disorders tend to seriously multiple, rather than merely add to, suicide risk.
10. You are currently a user to excess (chronic or binging in pattern) of alcohol or other psychoactive substance. "Excess" means your use bothers you or anyone who knows you.
11. You are male, and middle-aged or older. (Distressed males over 85 are the highest risk group for suicide. Males in general are more at risk, if they attempt it, because they use more dangerous methods.)
12. You have recently been impacted by one or more serious stressors, such a major illness or threat of illness, major losses or deaths, a seriously humiliating experience in your life,
13. You are socially isolated or living in a group environment in which those living with seem unsympathetic or hostile to you.
14. You have a history of acting impulsively, or of being hostile toward others.
15. You are convinced you have cancer, heart disease or other serious illnesses, and have been unable to get this confirmed by a qualified health care provider.
16. You hear voices other people do not hear, and they are telling you to harm yourself.
17. You are using a drug which you have been informed can cause serious depression.
18. You are experiencing a painful, chronic, or disabling physical condition - especially if you were formerly healthy.

If you respond YES to any of these, you have an elevated level of risk and should get help to assess you situation. If you have more than one of these factors in your life, it's especially important that you to seek, from a qualified health care provider, a screening for diagnosable depression, as well as a personal safety risk assessment. Trust me on this, OK? I've done a large number of suicide risk assessments, and I take self harm risk very seriously. Don't fool around if you have evidence that your risk level is non-trivial. See someone as soon as possible - and explain to them at the time you make the appointment WHY you need to see them. If you responded YES to #1, doing this is an urgent matter.

THIRD - consider seeking professional consultation

If the personal safety assessment you just did above did not suggest that you need to get professional help, consider the question of how serious you are about being successful in resolving your depression. It's frankly a bit difficult to climb out of the hole depression puts you and then work to fill in that hole, all by yourself.

The more serious your depression, and the more persistent, the harder self help will be. If you previous episodes, even if they never fell to the level requiring professional help, you may find it more difficult to self-correct.

If you are, at this point, uncertain about getting help, you can take one of two courses, either of which may make adequate sense (and you have to be the judge of this):

• Plan on engaging in the self-help actions I discuss below, BUT seek professional help anyway, for as assessment of the seriousness of your depression and the situation in which it occurs. Professional involvement actually increases the chances of your self help's being successful, if only because you won't be acting alone.
• Hold the "professional help" option in reserve. Act now to start a self-help intervention with your depression. If you find you're not getting results, or they are not coming quickly enough, activate your reserve option.

FOURTH - act! Here's what to do...

Have realistic expectations about self-managed interventions

It is a well accepted principle in clinical psychology that adjusting one's expectations in the direction of reality will improve the chances of a good outcome, in most activities, so let's use this principle here.

If your depression is at all serious or persistent, as previously stated, self-help outcomes will likely be modest. Self-help in the context of recurring depression is also problematic. However, in virtually all cases one can think of, self-help activities are advisable, and have a good chance of improving your situation. It is an amazing fact that we humans respond quite well to even a little improvement - it feeds hope, and our world tends to definitely brighten as a result.

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 necessarily appropriate to rely solely upon self-care to achieve it.

I'm a big believer in self-managed interventions with depression. If you can take action at all, I strongly belief it wise to do so. To help you have realistic expectations of results, let's consider factors which I have found tend to influence self-managed intervention outcomes.

Factors which suggest intervention outcomes will be modest

• You have one or more of the risk factors from the self-assessment for safety list above.
• Your present environment is particularly depressing (this may be physical, familial, or cultural environment - there is pretty good evidence that most depression is environmental in origin [7]).
• You come from a culture, social strata, or family, which is not especially psychologically oriented.
• You have tried self-managed interventions in the past and not gotten good results.

Factors which suggest intervention outcomes may be more generous

• You have none of the risk factors from the self-assessment for safety list above.
• Your present environment (physical, familial, or cultural) feels supportive, to you.
• You come from a family, social strata, or culture which is notably psychologically oriented.
• You have tried self-managed interventions in the past and gotten good results.

Let me repeat: regardless of your circumstances, I think you do well to whole heartedly enter into one or more self-managed depression interventions. I just want you to do this with a sense of realism.

Choose your interventions, and get going!

Here begins the buffet. You can pick and choose from the following list of personal depression interventions, engaging those which appeal most to you, or about which you know the most, or which you simply think are most likely to help you. As with any intervention, people tend to respond in rather individualized ways. At the same time, there are some rather predictable general outcomes, else such a list would simply not be possible.

• Cultivate your motivation - it's absolutely critical. Motivation is the key to any action you will take, and motivation's the very thing that depression attacks. This means that you very likely will have the most trouble with your self-management at the beginning. This trouble may hit you regularly at certain points every day, in fact. How will you handle this? Some ideas:
  • Look up the lives of some of your heroines or heros (Wikipedia is a great place to do this). Study the challenges they faced, how it affected them, and how they responded.
  • Write down a brief paragraph of where you want to be in a week, a month, six months. Draw lines heading toward and into the paragraph, like the spokes of a wheel. Each is a part of your future. At the very end of each line, make a dark dot - this is where you are today. As you make any progress on any of the paths to your goal, make a new dot, closer to the hub of the wheel. (You can label and date each new dot.) Keep working to put new dotes on your wheel of life. Just keep walking forward.
  • Cut from any newspaper or magazine you have pictures of people who you know about who you know are struggling with real challenges, or have faced and embraced major challenges in their lives. If you can find anything they've written about their struggles, find it and read it. Notice how they handle their situation.
• Exercise - get moving. This is one of the cheapest, most effective things you can do, assuming your physician approves. You can expect not to want to exercise (that's probably your depression talking to you), but do it anyway, unless you have good physical reasons not to. You'll like the effect. Start gently, if you don't exercise regularly. Aim for twice a day, beginning with a 10 minute exercise period each time.
  • A brisk walk is an excellent option - walk like you're late to an appointment. For best results, walk outdoors, in a rural or park setting.
  • Stress produces harmful chemicals in the brain (including cortisol - the "stress hormone"), while exercise reduces them [11]. It is ideal to exercise after major stress episodes, to reduce their effect, and before you need to be mentally alert.
  • Exercise has a number of effects. It increases speed of recall, and probably amount of recall as well. General mental function is improved as well. Similar to relaxation, it leads to a state of alertness in your cortex (the thinking part of the brain). This may be due at least partly to the improved cerebral blood flow which exercise produces.
  • Exercise appears to act to prevent depression, as well. People who exercise regularly have half the rate of depression who do little or no exercise.
  • Exercise is efficient. A moderate amount - walking two miles in forty minutes or less, five times a week is recommended by leading authorities.
  • Exercise helps moderate appetite, by raising crucial neurotransmitters which have this effect. [9]
• Address and reduce overwhelming challenges. When life throws big problems at us, and we come to feel overwhelmed, depression is a likely response. Depression has a lot to do with feeling overwhelmed, and when that happens it can be critically important that you break big problems into groups of small problems. It often helps to do this in an orderly way, on paper, so you can see that things are getting smaller. It also often helps to do this "problem breakdown" with a friend or consultant. They can help you see things more clearly.
• Prioritize your challenges. Reducing your focus to what's most important right now acts to reduce your sense of being overwhelmed by it all. I offer suggestions for how to set up priorities in a section of my Increasing personal productivity. It's a simple process, and it works, and it's one of the best ways to fight a sense of being overwhelmed.
• Set modest objectives for each day, and write down each significant task you complete. Keep a list with your modest accomplishments so far today. Carry it with you. Start making the list as soon as you arise for the day. It's purpose is to cultivate a sense in your mind of your ability to move, act, and produce. It will help to change your perception of yourself. Pay attention to the list, and not to the darkness in your mind. Keep adding items to the list.
• Push yourself to connect with people. Depressed people tend to isolate themselves. We all need them, and they are rich sources of the kinds of stimulation that help us to feel most human. But choose your engagements carefully. Move in the direction of people who are active, optimistic, and people centered. Connect with them by asking them questions. Inquire about their welfare. Listen, and share your own feelings, without being overwhelming. Pay attention to indications that they value their connections with you. Ignore all else.
• Reconnect with what has stimulated you in the past. Depressed people tend to starve themselves relative to the very things they most need. Act to go against this tendency.
• Harness your motivation and your best ideas by setting up a structured daily schedule. This will help you by giving you something to do, especially in the difficult parts of the day, when your motivation is lowest.
• Psychotherapy. A self-managed intervention? Certainly! It'd better be. First of all, it's your choice - to do it or not. If you do, you should always be in charge of your therapy. Begin by being an informed consumer. Ask questions at all points. Do your homework, if any. Assess outcomes. Ask more questions. MAKE it a self-managed intervention. Make the best possible use of the expert you hire.

Guidelines for action

• Depression's like a sinking boat - you need to respond early and fast. Keep at it. Throw bucket after bucket of water overboard. Don't quit.
• Nurture your supply of motivation. Feed your passions, small though they may be in the beginning. People who are not depressed often need to do this. For depressed people it's far more important. Don't let this critical issue slip from your awareness. It's just as critical as remembering to eat, or to keep your car's gas tank topped off.
• Aim for steady progress - just keep going. You might think of getting out of depression as something like building a brick wall. Lay down one level of solid activity and thinking, get some exercise and sleep, then get up and do it again. Avoid the extremes of expecting instant results or of doing nothing.
• Always remember that depression distorts your perspective. This is well documented by cognitive research. A depressed brain almost always adopts an unrealistically dark and limited point of view. Therefore, try to avoid making any major decision when you're depressed. When you feel better, you'll simply make better decisions.

Interventions to approach with caution

Any intervention which does not have research support

If research clearly indicates an approach does not work... If the bulk of any research you or anyone else reviews says that an approach does not work, find another approach. Negative evaluation, if based on multiple research efforts, should not be ignored. On the other hand, if research is conflicted, this can indicate several things, among which is that an approach does work for some groups of individuals, which have yet to be adequately identified.

If research simply has yet to be done. Some interventions are too new or underutilized to have been examined empirically. This means only that we don't yet have impartial evidence of their degree of effectiveness. They may not work. They may work only because of induced belief in their effectiveness ("placebo effect:). They may be the best intervention yet developed. We just don't know. You can try the approach out and come to your own conclusion, if you like, but there may be more certain bets available.

An example: Consider the medication lithium: it's a genuinely dangerous substance (the effective dose is close to the lethal dose), yet it's used successfully to treat many bipolar individuals, because solid research have shown its effectiveness in comparison with other interventions, and because careful monitoring of blood levels has been shown to reliably keep people alive. Research matters, so pay attention to it.

Socially acceptable substances such as alcohol and nicotine

Alcohol is a central nervous system depressant. Drinking it when depressed acts to deaden anxiety one may also be feeling, for the most part. But it also further depresses the brain. Doesn't make much sense, does it? It's also dangerous - you may well become addicted, and it increases suicide risk. It's likely to be especially risky for women.

Nicotine, on the other hand, is a stimulant (are carbohydrates of certain sorts). Depressed people tend to smoke more, as do the schizophrenic (possibly to treat their depression). However, you may have heard of the nasty side-effects of nicotine use. Find another drug, with the help of a professional. The first thing to do with your brain is to think, and only then employ chemicals, if they really make sense. Which brings us to...

Medication

The use of medication alone is questionable. Used alone, one has to deal with side-effects, and more importantly either with ongoing costs or the 60% plus relapse rate which impacts those who use only medication and then stop. The best results in treating depression ("best" here means fewest side effects, best treatment compliance, and lowest relapse rates) have been reported to be with cognitive behavioral psychotherapy, with drugs not being used at all. [8] The late night ads for antidepressants, from the big pharmaceutical companies, don't tell you this. Honesty doesn't sell medication which profit these companies hundreds of millions of dollars annually.

Herbal and other non-mainstream remedies

Some of these remedies do have some research support, but many have only anecdotal support at best. It's wise to make an informed decision, as many of the substances are chemically complex. Both drug interactions and side effects need to be considered, in advance. An excellent reference to consult, often available in stores which sell herbal remedies, is the annually updated PDR for Nonprescription Drugs, Dietary Supplements, and Herbs, which summarizes the best information available.

Additional resources

The Internet is virtually awash with links leading to depression topics. As with all health-related topics, it pays to check the source of the information. Be wary of anything which does not cite adequate (and reputable) references, or is written by people who appear to be merely dabbling in the topic. Depression is not a topic for amateurs - it's too complex. You shouldn't take medical advice from a non-professional, and the same applies to mental illness diagnosis and treatment. I obviously have a bias on this topic, but it's a well-considered one. I think it's sound advice.

Notes

Citations are given in full in References.

1. The primary reason for this specialized language, other than the need to talk, think, and act with precision when diagnosing and treating disorders, is that mood disorders in particular are complex.

2. Non-professionals, and many mental health professionals as well, use emotion as a blanket term covering three distinct things: affect, feeling, and emotion. For a careful, detailed discussion of this and related topics, see my Deepening self-awareness in the early stages of psychotherapy.

3. This allows for considerable unusual behavior which is, nevertheless, not considered a "clinical" mental health issue.

4. The formal criteria for diagnosing each of these are fully spelled out (see American Psychiatric Association. (2000). Training is required to accurately apply these criteria.

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

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

7. Howard, P. J. (2000), pp. 335-336.

8. Antonuccio, D.O., Danton, W.G. & DeNelsky, G. (1995).

9. Howard, P. J. (2000), pp. 157-159.

10. Howard, P. J. (2000), pp. 334-335

11. Knowing that cortisol acts to facilitate the work of insulin, and thus to raise blood sugar levels, helps us to understand why exercise is so important for diabetics.

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 ed. Utah, D.C. (The diagnostic bible 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.)

Antonuccio, D.O., Danton, W.G. & DeNelsky, G. (1995). Psychotherapy vs. medication for depression: Challenging the conventional wisdom with data. Professional Psychology: Research and Practice, 26(6), 574-585.

‡ Berkow, 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.)