Self-Help for Depression?

Summarized by Robert W. Griffith, MD
August 23, 2002 (Reviewed: August 20, 2004)

Introduction

Experts say that by the year 2020 depression will rank second only to heart disease as the most disabling disease. The reasons include: failure by patients to recognize they're ill; their failure to seek help; incorrect diagnosis by the physician; inadequate treatment; poor response to treatment; and, in those that respond, the risk of recurrence. Little wonder that depression is a scourge, a label applied by the author of the review that we summarize here.

The renowned Menninger Clinic in Topeka, Kansas, has developed an education program for people with chronic, treatment-resistant depression. Its purpose is to help patients understand why recovery is so difficult. "All the things that people must do to recover from depression are made difficult by virtue of the symptoms of depression". The main ways of coping with this Catch-22 situation¹ are summarized below.

General Principles

Set modest goals and don't rush. But here's another Catch-22 -- slow progress to your goals is itself depressing! So begin with modest short-term goals, and save the long-term goals for later. Tackle the following areas one by one.

Physical Health

Sleep and eat well. Follow good sleep hygiene rules (see first link below), and, if necessary, ask for medication to help.

Exercise (especially aerobic exercise) is a good antidepressant, and a good anti-anxiety agent. But, if you're depressed, you don't have the energy or inclination to be active. So, get up, get dressed, eat breakfast, and then go and do something active -- e.g. walk for 15 to 30 minutes. Once you've got this far once, hold to a regular schedule every day, increasing your activity as you feel better (see second link below).

Seeking Pleasure

Try to experience more pleasure. You can't force yourself to feel pleasure, but you can create the opportunity. As anxiety interferes with pleasure, you should learn and practice relaxation techniques, if this is a factor (see third link below). The core of depression is low positive emotion, so that it's hard to experience pleasure.

Start by making a list of all the activities that have provided pleasure to you in the past, and make a plan to do some of them again in a regular, systematic way. To begin with, you'll probably feel only a spark of interest or involvement, which may not last long. Just go ahead slowly with your plan. But watch out for increasing the frequency and duration of one pleasurable activity too much; it's known that depressed people can become addicted to a particular activity, so that instead of being pleasurable it becomes stressful and all-consuming.

Thinking

Everyone has negative thoughts, but depressed people have them all the time. It becomes automatic for them to see the worst in every situation. So the first step is to question negative thinking, and try to realize that there are often alternative outcomes.

Then try to focus on your main negative thought -- accept that it exists, and try to see how it could be addressed, without letting it become globalized into total negativity or feelings of worthlessness. This is much harder than it sounds, because you're depressed -- another Catch-22. But the important thing is not to get stuck in your negative morass.

Mentalization, or 'thinking about thinking', will also help you make your thoughts more flexible. Try to see the same thing from several points of view, or understand how someone else is thinking. Awareness of other people's mental state will make you more sensitive, even compassionate, to them, and towards your own state of mind.

Waking from a nightmare and realizing "it was just a dream" is mentalizing. Flashbacks after a traumatic event are usually ended by mentalizing -- understanding that a flashback is a reliving of an event in the mind, not actually happening. Failure to mentalize can lead to a paranoid state, when your imagination takes over, and you think other people are talking about you critically, or you that will be attacked.

Failure to mentalize is also the reason why depressed people who have made a mistake develop feelings of worthlessness, and slip into self-hatred, even getting suicidal thoughts. Mentalization allows them to break this chain of thinking at an early stage.

It's possible to train for mentalization, using a technique called mindfulness meditation (see the second link below). It's very effective, along with cognitive therapy, in preventing recurrence of depression. (Cognitive therapy is not normally used during the depression phase). Again, mindfulness meditation is a difficult technique to master, but the results are extremely worthwhile.

Relationships

This is the most complex area to be tackled. Problems in relationships (conflicts, divorce, abuse, loss) can trigger depressive episodes. Yet supportive, caring relationships are an important feature of recovery. Depressed people are often advised to seek support from friends and family, but a major symptom of depression is withdrawal and self-isolation. Contact with others is stressful, so your behavior may result in rejection, ending in an intense feeling of being let down.

As with other remedies, go slowly! Don't follow friends' urging to go to a lively party -- this can backfire, and you'll just feel worse. Go to a movie with someone; you don't have to talk all the time. And find someone who has a good tolerance for depression. You can tell them you are doing all right and making progress, so that they don't feel unduly pressured to solve all your problems for you.

Probably the helper's greatest support is just 'being there'. The worst thing they can do is become critical ("If you'd just get out and do something . . ."). When this fails, as it certainly will, the supporter will withdraw, leaving the depressed person feeling totally abandoned. The depressed person can tell the helper what they would prefer in the way of support; it's often difficult for the helper to receive and act on this, but it will produce the best result.

Comprehensive Treatment

The steps outlined above to address the Catch-22 situations encountered in depression are, of course, additional to the treatments prescribed by your physician. Medication, electroconvulsive therapy (ECT), and cognitive-behavioral therapy will deal with many of the symptoms of depression that make your own efforts at recovery so difficult. One of the most common problems in treating depression is when treatment is stopped prematurely. Medication should be continued well after recovery has occurred, and tapered off gradually. At times of stress, a return to psychotherapy may help ward off a recurrence. And mentalization will prove a useful tool in dealing with those periods of stress that seem to trigger more menacing negative thoughts. If you had trouble with it during depression, return to it again when you're feeling better -- it's worth it!

Source

• Coping with the catch-22s of depression: a guide for educating patients. JG. Allen, Bull Menninger Clin , 2002, vol. 66, pp. 103--144

Footnotes
1. "Catch-22" is a novel by American writer Joseph Heller (1923-1999). The Oxford English Dictionary defines the title concept as "a set of circumstances in which one requirement, etc., is dependent upon another, which is in turn dependent upon the first."

Related Links
Walk Away from Depression?
Meditation Moves into the Mainstream

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