DEPRESSION | anxietyandstress

Managing Depression

Depression often co-exists with anxiety disorders. Most recent research suggests that when both disorders are present, depression is usually a secondary complication of the primary anxiety disorder.

Depression is a health problem that touches every part of a person's life. All of us know what it is like to be stuck in a depressed mood that is temporary. However, as many as 1 in 4 women and 1 in 8 men will at some point in their lives experience a much more severe and persistent episode of depression.

Symptoms of depression include:

1. Ongoing sadness or irritability

2. Loss of interest or enjoyment in daily activities, including sex

3. Decrease or increase in appetite and weight

4. Poor sleep or sleeping too much

5. Feeling restless, anxious or worried

6. Feeling tired or like you have no energy

7. Feeling hopeless, helpless, worthless or guilty

8. Trouble concentrating or making decisions

9. Physical symptoms that don't respond to treatment

10. Thoughts about death, maybe including thoughts about suicide

If your physician or your psychotherapist believes you are significantly depressed, this does not mean that you are "crazy," or "weak," or that you have failed somehow.

Some people seem to be more likely to get depressed because it runs in their family, even when they don't seem to have a compelling reason to be unhappy. Other people seem to be more prone to depression because of poor self-esteem, perfectionism or a persistently pessimistic outlook about life. Still others become depressed in the midst of dealing with an ongoing stressful situation, a traumatic incident or a significant loss which may be either the literal loss of a loved one or a more figurative loss.

Even if your depression clearly began after some very upsetting life event, certain physical changes take place within you that exert a powerful effect on your body, mood and thoughts. The thinking patterns you have when depressed tend to keep you in a "rut" that becomes self-perpetuating and that makes it hard to cope effectively.

Although depression can be devastating to both individuals and their families, the good news is that depression does tend to respond to treatment. There is impressive literature to support the effectiveness of both cognitive-behavioral psychotherapy (see below) and antidepressant medications.

Psychotherapy is most likely to be effective if it focuses on changing distorted thinking or the reaction to such thinking, rumination, behavioral habits, ineffective problem-solving, emotionally-skewed beliefs, or relationship conflicts that contribute to or help to perpetuate an individual's depression. Evidence suggests that a successful course of such treatment cuts the risk of a recurrence of depression compared to treatment with medication only. Treatment of depression with psychotherapy may not provide relief as quickly as medication, but the results may be more durable.

There are at least 15 commonly used medications that seem to have significant antidepressant effects. Your doctor and your therapist can provide you with more specific information if medication is recommended for you. In general, no single antidepressant is more effective than any other antidepressant in most grouped data. However, for a given individual, there may be marked differences in effectiveness across drugs. After several medication trials, results may range from partial improvement of symptoms to truly transforming effectiveness. (No, antidepressants are not "just a crutch" and, no, you cannot get "addicted" to them.)

If medicine is part of your treatment, be sure to take it as your doctor instructs. These medicines are not effective if you take them only when you are especially upset. You must maintain a fairly constant blood level of the medicine for it to help you.

You may notice some positive changes during the first week of taking a medicine; however, it is likely that you will have to take a medicine for at least four weeks at an adequate dose before you can really judge whether it might help you. Do not despair if the first choice of medicine does not work well for you. Switching to a similar drug or switching to a chemically distinct drug often results in significant improvement after a "failed" first or second trial of medication. Follow your doctor's instructions and be patient.

Choices about medications are often driven by side effect profiles. Most side effects of antidepressants tend to improve with time as your body adjusts to the drug. However, some people may experience persistent side effects (e.g., gastrointestinal upset, activation or sedation, diminished sexual arousal or performance, headaches, weight gain). Side effects can usually be minimized by working with your doctor toward finding the best medication for you, switching medications, adjusting the dose, or taking an additional medication that either augments your antidepressant response at a given dose or diminishes the side effects.

There is some evidence that "natural" supplements like St. John's Wort or SAMe may be helpful for mild to moderate depression. Calling these substances "natural" does not mean that they are somehow better for you, entirely safe, won't have side effects, and won't interact with other drugs. (For example, note the concerns about liver damage with kava, once thought to be a benign, natural treatment for anxiety.) Be sure to discuss this decision with your doctor before starting anything and keep your doctor informed about what you're taking. At a sufficient dose, such substances may be nearly as expensive as prescribed antidepressants.

There is continuing debate about whether psychotherapy and medication combined is more effective than either approach alone. There is evidence both supporting and contradicting such a recommendation based on grouped data. However, some individuals simply do not respond unless treatment efforts are combined. There is also some evidence that individuals who don't respond well to one approach still have a good chance of responding to the other. All research data notwithstanding, effective treatment for depression must be tailored to the individual.

There is considerable evidence that regular exercise has antidepressant effects that may even be comparable to the effects of antidepressant medications (see below). Check with your doctor before starting any rigorous exercise program. Start slow: 15-20 minutes of outdoor walking or walking on a treadmill regularly is a good starting point.

Consider keeping a journal as a means of getting your thoughts and feelings outside your head so that you can see them more objectively. It may be especially helpful to divide the pages into three columns and record daily examples of: 1) upsetting situation or event, 2) resulting thoughts, feelings and meanings, and 3) challenge the content in the second column by writing more objective, less distorted, and more rational alternatives in the third column, even if you don't always believe what you're writing. This technique sounds simplistic, but depressed individuals who commit to doing this on a daily basis nearly always report that it is beneficial.

Be very careful about your use of substances while depressed. Alcohol and sedatives can bring on depression or make it worse. Depression may also prompt you to drink more coffee, smoke more cigarettes or take other drugs that may compound feelings of agitation, restlessness or irritability that are part of your depression.

If you are having suicidal thoughts, do not keep this information from your doctor or a loved one. Keeping such thoughts secret can be fatal. When depressed, you may well rationalize that loved ones will be better off without you. Quite the contrary, the suicide of a loved one usually devastates others in a way from which they never fully recover. Allow your doctor and your loved ones to help keep you safe while you recover.

In addition to psychotherapy, antidepressant medication and/or exercise, it is important to read about depression and about practical, self-help methods for treating depression (see below).

Cognitive Distortions Contribute to Depression:

Irrational Beliefs Contribute to Distorted Thinking and to Depression: We often cling to irrational beliefs that distort our thinking about ourselves and about stressful situations, thus contributing to depression. Learn to recognize some of your "favorite" irrational beliefs that can contribute to errors in your thinking and to a depressed mood.

Depression is a Vicious Cycle that Effective Treatment Can Interrupt:

(Wright)

Traditional CBT focused on changing

irrational thought content.

Evolving CBT focuses more on mindfully noting

and accepting thought content.

The former has a 30-year tradition; the latter has a 2500-year tradition.

When CBT was closely examined, the benefit was less a result of changing toxic thoughts and more a result of a changed relationship with toxic thoughts. (Segal, Williams, and Teasdale, 2002)

Evidence of a "changed relationship with depressing thoughts" or "cognitive de-fusion" (Hayes, 2004) might include thoughts like:

"Yes, this self-critical thought is part of me, but it's not ALL of me."

"Yes, this really sucks right now. But it will pass and it won't ALWAYS feel this way."

"My thoughts are just my thoughts. They're often irrational. They're not the litmus test of reality."

"Oh, my mind is criticizing me again." "Who's life is this anyway, mine or my mind's?" "Is this thought really useful right now?"

"This is just a story I tell myself."

Use of "creative hopelessness" (Hayes):

"I really CAN'T change how I feel right now, but I'll probably feel differently tomorrow."

Or, like the Yiddish saying, "The situation is hopeless, but not serious."

Practice acceptance but stay engaged in your day: "This is what it is. I do not have to make it go away. I do not have to go to bed because of it. I'll go on with my day and take note of changes in how this feels."

Becoming an observer of one's thought process ("Oh, there's that guilty thought again") repeatedly over time has a very different emotional impact. Compare this to participating in the same thought over and over with no intellectual distance until it seems to be the only reality possible and becomes the primary driver of your depressed mood.

"A 'negative thought' mindfully observed will not necessarily have a negative function" (Hayes, 2004) Eastern writers have long noted: "If I can take something under awareness, then I am not that."

Regular practice of mindfulness-based meditation may have a role in treating active depression (e.g., Finucane & Mercer, 2006) as well as treatment-resistant depression (Kenny & Williams, 2006) and quite clearly has a role in preventing future depression (Ma & Teasdale, 2004), and in overall stress management (e.g., Grossman, et al., 2004).

Being truly disciplined about regular mindfulness-based meditation practice is a challenge for most people. However, any person can disengage from automatic thinking by watching a breath for a full inhalation and exhalation, or can become more aware of inner experience by stopping activity for a few minutes and asking, "What am I feeling? What is occurring at this moment?" (Germer, 2005)

Re-directing one's focus and energy to the things that truly have meaning can allow toxic experiences or thoughts to become the background rather than the foreground of awareness. Depending on one's spiritual beliefs or values, there may be many different ways to implement this. For example, if one's job or health situation seems inherently depressing, one might refocus on being the kind of person their loved ones need. For another person, it might mean pursuit of their spiritual leanings or contributing their time, effort or money to someone who needs it.

Antidepressant Effects of Exercise:

10 weeks of supervised exercise followed by 10 weeks of unsupervised exercise in elderly (mean age =71) with major depression or dysthymia: Compared to control group that attended lectures, there was significant improvement in depression scores that persisted at 26 month follow-up. (Singh, et al., 2001)

Older (> age 50) patients (n=156) with major depression received a 16-week trial of aerobic exercise alone, sertraline (Zoloft) alone or exercise + sertraline combined. Those who received medication alone responded most quickly, but at 16 weeks, all groups displayed improvement in depression without any significant differences among groups.(Blumenthal, et al., 1999)

After 10 months, however, remitted subjects in the exercise group had significantly lower relapse rates than subjects in the medication group. Exercising on one's own during the follow-up period was associated with a reduced probability of depression diagnosis at the end of that period. (Babyak, et al., 2000)

Both resistance training and aerobic activity can reduce symptoms of depression. All levels of exercise intensity can reduce symptoms of depression. Evidence is mixed as to whether exercise alone or true fitness is necessary for antidepressant response.(Dunn, et al., 2001)

Treadmill x 30 minutes x 10 days in middle-aged patients resulted in significant subjective and objective improvement in major depression.(Dimeo, et al., 2001)

However, this effect has been demonstrated most clearly in subclinical depression and anxiety.(Salmon, 2001)

Eight week, placebo-controlled trial of a daily 20 minute brisk walk outdoors + increase in daily light exposure + vitamin regimen in women with mild-moderate depression and not on medications: Significant improvement on five outcome measures and remarkable adherence.(Brown, et al., 2001)

After only 30 minutes on a treadmill, urinary concentration of phenylacetic acid increased by 77%. Might the reflected change in phenylethylamine levels explain the short-term antidepressant effects of exercise? (Szabo, et al., 2001)

Might increased stress resilience and reduced rumination explain the long-term effects of exercise?

An Intriguing Abstract:

Might both antidepressants and exercise treat depression by facilitating neurogenesis in the hippocampus?

Ernst, C, et al., Antidepressant effects of exercise: evidence for an adult-neurogenesis hypothesis?

Journal of Psychiatry and Neuroscience, 2006; Mar;31(2):84-92.

(Neuroscience Program, UBC Hospital, University of British Columbia, Vancouver, BC)

It has been hypothesized that a decrease in the synthesis of new neurons in the adult hippocampus might be linked to major depressive disorder (MDD). This hypothesis arose after it was discovered that antidepressant medications increased the synthesis of new neurons in the brain, and it was noted that the therapeutic effects of antidepressants occurred over a time span that approximates the time taken for the new neurons to become functional. Like antidepressants, exercise also increases the synthesis of new neurons in the adult brain: a 2-3-fold increase in hippocampal neurogenesis has been observed in rats with regular access to a running wheel when they are compared with control animals. We hypothesized, based on the adult-neurogenesis hypothesis of MDD, that exercise should alleviate the symptoms of MDD and that potential mechanisms should exist to explain this therapeutic effect. Accordingly, we evaluated studies that suggest that exercise is an effective treatment for MDD, and we explored potential mechanisms that could link adult neurogenesis, exercise and MDD. We conclude that there is evidence to support the hypothesis that exercise alleviates MDD and that several mechanisms exist that could mediate this effect through adult neurogenesis.

Light Therapy May Be Just as Effective for Non-seasonal Depression:

For many years, special full-spectrum light, typically for 30 minutes each morning, has proven effective for treatment of depression that occurs during the fall and winter months especially when marked by weight gain and diminished energy level. Recent systematic reviews suggest that regular light therapy is equally as effective for non-seasonal depression and that the effect size may be equal to antidepressant medications.

References:

Golden RN, et al. The efficacy of light therapy in the treatment of mood disorders: A review and meta-analysis of the evidence. American Journal of Psychiatry, 2005; 162:656-662.

Tuunainen A, et al., Light therapy for non-seasonal depression. Cochrane Database of Systematic Reviews, 2004;(2):CD004050

Martiny K. Adjunctive bright light in non-seasonal major depression. Acta Psychiatr Scand 2004; 110:7-28