No one should be ashamed of being depressed. But we are. As Kathy Cronkite (1994) points out, people who openly discuss going to Betty Ford’s Clinic for alcohol abuse will carefully conceal their depression. About 1 in every 10 of us will be seriously depressed sometime in our lives. Baby boomers are having even more episodes of depression, perhaps because the high hopes of the 1960′s were crushed by the economic troubles of the 1970′s and beyond. Remember, there is serious depression which is beyond ordinary sadness; in this condition you may have no appetite, no pleasure, no energy, no hope. And, there is being “down” or in a bad mood for a few days; it may involve crying, social withdrawal, being irritable, having no ambition, being pessimistic, etc. These two conditions are probably two different things. Both should be treated but the really severe major depression must be taken very seriously; 15% kill themselves, many more attempt it. Depression is not your fault; you are not a terrible or hopeless person. Unfortunately, 70% of people suffering depression never seek treatment. Please be among the 30% who go for help and stay with it. Depression is one of the most treatable emotional problems–psychotherapy can help you, drugs can, and you can.

Note If your depression is serious (disabling or suicidal), seek professional help immediately. If you are in therapy or a group, be sure to tell the therapist how much you are hurting. If not in therapy, call a therapist or your mental health center. Do not delay by trying to treat yourself or by hoping you’ll get better. Serious depression and manic-depression seem to have genetic, hormonal, and/or chemical aspects that are activated by stress and upsetting life events and thoughts. Thus, when the depression is serious, you always need to be evaluated by an MD, who will decide if you need medication.

If your depression is primarily chemical, psychological coping techniques are useful but not sufficient. Likewise, if your depression has psychological causes, drugs may be useful but not sufficient. There is usually no way to tell if your depression is chemical or psychological, so consider both.

If you’ve read parts of the chapter relevant to you, you probably already have some ideas about how and why you have responded with sadness. Therefore, certain self-help methods in this section will seem more appropriate for you to use. Fine, try two or three and see if they work. If not, try something else. In general, gaining some optimism about getting better, having an easy going disposition, and utilizing family support, along with selected self-help methods, will lead to a better recovery from depression.

The methods for coping with depression are arranged by levels in this section. Quickly read or skim the entire list of methods before you select a few to use. This is a preview:

1. Behavior–increase pleasant activities, avoid upsetting situations, get more rest and exercise, use thought stopping and reduce your worries, atone for wrong-doings, seek support, and use other behavioral changes,
2. Emotions–desensitize your sadness to specific situations and memories, vent your anger and sadness, try elation or relaxation training, etc.,
3. Skills–learn social skills, decision-making, and self-control to reduce helplessness,
4. Cognition–acquire more optimistic perceptions and attributions, challenge your depressing irrational ideas, seek a positive self-concept, become more accepting and tolerant, select good values and live them, and
5. Unconscious factors–read about depression, learn to recognize repressed feelings and urges that may cause guilt, explore your sources of shame (perhaps even going back to childhood).

The Use of Anti-depressants

Anti-depressants have been a major part of the pharmacological era in psychiatry. In the last twenty years, psychiatric practice has changed in major ways, namely, the shift from talking to giving pills. Many factors have contributed to this treatment revolution: (1) the development of safer drugs with fewer side effects, especially the SSRI anti-depressants. These medications may not reduce depression better than older drugs but they are less likely to kill you when an over-dose is taken. (2) The pharmaceutical companies have advertised intensely, turning consumers into drug advocates and permitting drug sales representatives to target primary care physicians rather than the much more rare psychiatrists. Moreover, (3) HMOs have realized their profit-margins can be greatly increased when the drugs are dispensed by a family physician requiring only brief and occasional follow-up visits rather than by expensive psychiatrists. The distribution of drugs got much easier: just tell your regular doctor that you have been feeling down or tired and have had some crying spells, and you immediately get a prescription for anti-depressants paid for without question by your health insurance. Millions have started taking anti-depressants and while they may have shifted from one brand to another, many have been satisfied. Nevertheless, it is generally recognized that anti-depressants take about 30 days to work and about 30% of depressed patients get little benefit from anti-depressants.

During the last two decades, the stigma against taking psychiatric drugs seems to have been considerably overcome but the stigma against “seeing a shrink” (psychological or psychiatrist) is still strong. Moreover, while Cognitive-Behavioral therapy has developed during this period, it hasn’t had a breakthrough in terms of highly publicized effective techniques or in terms of cheap or easy treatment. In other words, anti-depressant drugs haven’t had a lot of competition. Also, most people do not realize how little training and experience primary care doctors, in general, have in dealing with serious psychological disorders, including depression. Yet, as you know, if you have read the rest of this chapter, depression is a very complex and potentially dangerous disorder. It isn’t something to be diagnosed in a few minutes. Since anti-depressants take 30 days before having full impact, a significantly depressed person needs frequent and careful monitoring immediately and during the first several weeks. The treating physician needs to get a detailed mental health history (mental problems or illness often accompany depression) and he or she should strongly encourage the patient to also get psychotherapy as well as drugs. Depression is not an easily treated disorder. The doctor/therapist should be expected to maintain long-term contacts with their depressed patients, at least every week for a few months and maybe much longer. Depression frequently comes back.

Ideally, a health care service for depression would have enough coordinated psychiatric and psychological specialists to carefully diagnose each case of depression, assessing the possible psychological, personal, circumstantial, interpersonal and physiological or genetic causes of the disorder. As a part of this evaluation there should be a careful assessment of the risk of self-injury (see earlier sections of this chapter). This initial evaluation is not a trivial frill; it is crucial. This process should usually involve psychological testing and a detailed history as well as medical tests. The general practitioner is not this kind of specialist. (Light cases of depression could, I suppose, be handled more casually—but how can anyone identify a light case just by talking to a person for a few minutes?)

Another serious problem is that the general public has NOT understood or paid close attention to the research about the frequency of suicide and the obvious connection between depression and suicide. For instance, we often don’t like to think about suicide as being an integral part of depression. Suicide is the eighth leading cause of death in the US. It is the third leading cause in 15 to 24-year-olds and the fourth most common cause of death between ages 10 and 14. This is serious—60% of high school students have had thoughts about killing themselves, 9% have tried. At every age, especially in old age, depression must not be dismissed and taken lightly. The “just take these pills and call me in three months” is not acceptable treatment.

Not only has the risk of suicide underlying depression been taken too lightly, the generally positive public opinion about the effectiveness and safety of anti-depressants seems to have a major disconnect with the scientific evidence. There have been many, many studies. Of course, some of the studies have shown anti-depressants to be effective, sometimes. These drugs, however, are big sellers–among the best-selling medicines in the world, with such names as Prozac, Serzone, Wellbutrin, Zoloft, Remeron, Celexa, Effexor, Lovox, Paxil, and others—all similar in chemical composition. The total sales world-wide are about 20 billion dollars per year. In 2002 alone about 11 million prescriptions were written just for children and teens in the US. Let’s think about why is it difficult to honestly know the effectiveness of anti-depressants (or any other treatment).

People come to see doctors and therapists because they are feeling badly, often their discomfort has gotten gradually worse, and they are seeking help at the height of their depression. If so, the chances are (for a variety of reasons) that the problem will later get better rather than staying awful or getting worse. This amelioration process is observed so often when scientists re-assess unusually high or extreme conditions; this going back towards normal (for you) is called “regression to the mean.” So, you see a doctor with a bad cold, an aching back, a tension headache, etc., and soon in the natural course of things you begin to feel better (closer to average for you).

There is another process that also makes it hard to evaluate the effectiveness of a treatment method—the suggestion or placebo effect. It is well known that a sugar pill can help many people feel better (if the doctor suggests it is very effective medicine and will take care of the problem in a couple of days or weeks). If such a suggestion is made or just implied when actual medication is given, then the placebo effect and the drug effects combine together and both may be working. To prove the effectiveness of a drug (or any treatment) the amount of improvement shown to be due to the drug alone has to be significantly greater than the placebo effect by itself. Note: according to testimony given in the fall of 2004 to the Congressional Energy and Commerce Committee, about half of all studies of anti-depressants have not shown in adults that the SSRI drugs are significantly more effective than a placebo alone. Even worse, insignificant results were found in two thirds of the studies in which children were given anti-depressants and compared to children given a placebo. This is not well understood by the general public. Please note that these research findings certainly do not prove that anti-depressants are entirely ineffective (in fact, half the studies may suggest anti-depressants yield some benefits), but these results cast considerable doubt on the effectiveness of the drugs. Psychiatrists know the effectiveness of anti-depressants is limited; they commonly point out that anti-depressants do not help about 1/3 of their depressed patients.

In addition to these difficulties interpreting the results of research, more recently there is a new and very disturbing possible problem with using anti-depressants, especially with children and teens. Over several years, there have been occasional clinical reports of suicide and violence associated with taking anti-depressants. For instance, it was reported that Eric Harris, one of the suicidal shooters in Columbine High School, had been taking an anti-depressant (Luvox). Parents have described the sudden, out-of control suicide of a college student after taking a regular dose of anti-depressants (http://www.nypost.com/news/nationalnews/30505.htm). Britain prohibited prescribing anti-depressants to children and teenagers in late 2003 (a year before the US considered such action). Even more alarming, Shankar Vedantam of the Washington Post reported on September 10, 2004, that testimony was given at a congressional meeting that two internal FDA analyses showed that anti-depressants, given to children and teens, were associated with increased suicidal thoughts, actual self-harm, and hostile behavior. How much of an increase? FDA recently estimated that these drugs might double the risk of suicide in children. This sounds very risky but if the risk of suicide without drugs is 1% and with drugs 2%, there the anti-depressant doubles the risk. But if the 1% higher risk of suicide is associated with taking an anti-depressant that reduces depression in 60% of patients (compared to 35% who improve taking only a placebo), then you would probably take the drug if you are miserable. Bigger and better controlled recent research has yielded results about like that example (The Journal of the American Medical Association study of Prozac also confirmed an increased tendency towards suicidal thoughts and action). So, taking a drug that slightly increases the very low suicide rate, which sounds terrible, could be a very reasonable thing to do. We need a lot more information.

The suicide prediction problem is an increasingly important part of the decision to use anti-depressants or not. Also, the patient and his/her parents, if a child or teen, should be involved in the tough decision-making about the use of drugs, the kind of psychotherapy needed, the precautions to take, how to measure progress, etc. It isn’t just a question of what approach offers the most hope for improvement but also what methods have helped and not helped in the past, how desperate the situation is, the patient’s level of motivation, etc. If I am feeling terribly miserable, I’d be willing to take more chances with a risky drug…just the same as when risky surgery is an option.

Please remember I am not a physician. I have no expertise concerning drugs. My review is just a summary of the relevant available about anti-depressant research which suddenly seems very important. The data and my comments should in no way be interpreted as opposing the use of anti-depressants. There surely are circumstances in which it is a very good judgment to give anti-depressants to children and teens. This new information about anti-depressants with children just makes it critical that case studies and treatment plans are done at the highest level of professional competence.

I strongly recommend each depressed patient (and his/her parents, if the patient is a minor), with the help of his/her physician (the prescription writer), explore the pros and cons of taking anti-depressants. It is not a simple decision. If the prescribing physician is not a psychiatrist or a psychotherapist, then a therapist (Psychologist or Social Worker) should permanently join the team. At this time (fall of 2004), only about 15% to 20% of children and teens being treated for depression are prescribed anti-depressants. If research continues to find suicide risks are associated with anti-depressants, surely a number of changes are likely to be made in the treatment of depression. Probably many family doctors will avoid prescribing drugs having a strong warning label. Certainly, since therapists know more about the potential for suicide, they will increase the safe-guards used against the risk of suicide.

We will need to know the rate of suicide in certain types of patients in specific circumstances depending on whether they are taking anti-depressants or not. Science needs to map the high risk points for depressed patients on and off medication. Certain dangerous times have been known for many years, like when released from a hospital, but we need to know more. For instance, Wessely, Kerwin & Kaye (2004) found that the most dangerous times for adults and children taking anti-depressants were in the first nine days of treatment (a four-fold increase in non-fatal suicide behavior). The risk is also three-fold higher during days 10 to 29. What if they were not taking anti-depressants? We don’t know. Other high risk times for children and adults are when anti-depressants are started at a high level or when suddenly stopped. Start anti-depressants at a low dose and gradually increase. Reduce doses gradually. It is important that the doctor, the patient, and others around him/her know the high risk times so everyone can be especially vigilant, looking for extreme restlessness or agitation (can’t sleep), violent outbursts, psychotic behavior, talk about suicide and so on. Close supervision is really important–usually there are warning signs that people dismiss. If you think you see a warning sign, consult with others, including school counselor, close friends, and others who might know more. The patient and family members or others who are with the depressed patient should have the therapist’s cell phone #.

A recent study at the University of Colorado by Valuck, Libby, Giese & Sills (2004) illustrates the crucial need for more research into the risks of self-harm for adolescents taking antidepressants. These researchers followed 24,000 depressed adolescents for six years. The risk of a suicide attempt, in their sample, was not greater for young people given antidepressants than for those not getting antidepressants. Of possible additional significance, the adolescents given antidepressants for at least 180 days made fewer suicide attempts than adolescents taking the drug for less than 55 days. Standing alone, these results are difficult to integrate with the above studies: Do different outcome measures (suicide attempts, near-lethal acts, and suicide rates) yield different results? What factors correlate with being prescribed antidepressants? Why did some subjects take medication much longer than others? The authors suggest that the quality of health insurance may influence what medication one gets, who administers the antidepressant, who gets antidepressants alone, who gets only psychotherapy, and who gets both? Many, many studies are needed to answer these vital questions.

In summary, moderate or serious depression carries with it a threat of self-injury. This risk requires special precautions. Taking anti-depressants must be considered carefully because the drugs may slightly increase the risk of agitation and suicide in some young people while the drug may effectively relieve depression in other people. The prescribing doctor, the collaborating psychotherapist, the patient, and the parents of a child or teen should be involved in making the treatment plans. The prescriber and/or the psychotherapist must see the patient frequently, probably weekly or more for an hour, especially during high risk or high stress or high agitation times. The FDA’s concern is now high enough that all anti-depressants must display a warning label about the increase risk of suicide if used with children or teens. For unexplained reasons, the news reports describe the manufacturers as being more eager to have a blunt, rather scary label placed on their medications than was the FDA.

COPING WITH DEPRESSION

A review by levels of the useful Psychological Methods

Self-observation

Although depression frequently seems (to the depressed person) to come from nowhere, i.e. isn’t related to daily events, that isn’t true in most cases. The Lewinsohn research has clearly shown that positive events or activities lead to positive moods; negative events to depression (Grosscup & Lewinsohn, 1980). The depressed person must become aware that this is true in his/her life too. So rate your mood on a 1 to 10 scale (see chapter 2) and keep a log or a diary every day of positive events and activities. It is likely that your mood will reflect what is happening in your life.

As we have seen, depressed people tend to focus on negative events and overlook positive ones. They don’t know they are doing this. So, it is important that they “give careful recording a try and see what happens.” Look for and record all pleasant events and activities, even small, trivial, seemingly unimportant pleasant events. It is vital that you learn, again, to see the beauty, feel the warmth, and smell the roses. Don’t forget ordinary things: a cup of coffee, a walk, seeing a bird, reading a book, helping someone, watching kids go to school, watching the news, reading an advice column, going shopping, listening to music, making yourself attractive, visiting a neighbor, completing a chore, calling a friend, daydreaming, playing with children, expressing an opinion, getting a long kiss, getting or giving a compliment, etc., etc. Record in your diary (3 or 4 times each day, otherwise you’ll forget them) a brief description of these pleasant events.

After about a week, plot your daily mood rating and number of pleasant events for that same day on the same graph (see chapter 2). See if your mood doesn’t go up and down according to how many pleasant events occurred that day. If so, this is a powerful argument to increase the number of pleasant events in your life and to appreciate the nice things that happen.

This is a simplified version of a “behavioral analysis” (method #9 in chapter 11) in which one would look for the antecedents and consequences of good and bad moods. The objective is to find cause and effect relationships that can be used to increase happiness and reduce sadness. I would recommend a behavioral analysis because it explores the causes of the depression as well as the sources of satisfaction.

Look to the future

Like procrastinators, when we become depressed we tend to focus on the past or to see primarily the immediate consequences, not the long-term results of what we are doing now. We hurt, so we focus on immediate relief, disregarding activities that might be stressful but very important to our future, like getting training for a new career. To increase your awareness of the effects of your activities, do one “outcome analysis ” each day of some activity, i.e. estimate the short and long-term, both positive and negative, outcomes. Examples:

The objectives are (a) to encourage realistic, long-range planning, (b) to see the lasting consequences–or the wastefulness–of certain daily activities, and (c) to make some important but uncomfortable activities more tolerable today because they pay off tomorrow. This is important for all of us to do, but it is even more important and difficult for a pessimistic person with low self-esteem to do.

One small step at a time

Earlier we learned that global thinking (or end goal wishing), e.g. “I need to get better grades,” overlooks the necessary details of how to get there. Also, unrealistic, perfectionistic expectations, e.g. “I’ll get all A’s,” may lead to disappointment and self-criticism. Thus, it is important to learn to have a plan, to set realistic goals and sub-goals, and to have some success experiences. It is important to be satisfied with small gains. So, decide on some practical, possible, important self-help project–dieting, increased socializing, more detailed and prompt record keeping at work, learning to play tennis, spending more time alone with spouse, or whatever. Then, for each project goal, set several clear, explicit, attainable sub-goals (small steps), perhaps things you could do every day or every few hours (see goal setting in chapter 2). Schedule the time, give it priority, and be sure you are successful. Record your progress in a diary, along with the positive outcomes.

Self-evaluation

When discouraged, we feel at fault when things go wrong and “just lucky” when things go well. Rehm has an exercise to help you realize your contribution to success and reduce your responsibility for failure:

• Think of an important recent event and describe it.
• In what ways were other people, chance, luck (good or bad), or fate responsible for this event?
• In what ways were you (your efforts, skills, abilities, experience, appearance, etc. or lack thereof) responsible for this event?
• What percentage of the responsibility for this event was attributable to you? _____%

Do this for several events, including both positive and negative ones. You have almost always worked for positive events and against depressing events. So, if you do not think you are truly responsible for more than 50% of the pleasant events, reconsider your explanation of those events and see if you aren’t causing more positive things than you thought. Factually based confidence in your self-control is a powerful antidote to pessimism and helplessness (remember depressed people underestimate their problem-solving ability).

Usually others or circumstances or just bad luck cause unpleasant events (the exception to this general rule is when our passive-dependency is the cause). So, if you see yourself as responsible for negative events–over 50% of the time–go back and see if others and chance aren’t more responsible. If your passivity is the problem, see chapter 8. Ideally, you will come to believe (accurately) that your general, stable abilities and traits, e.g. intelligence, personality, organizational, and communication skills, etc., cause good things to happen and uncontrollable, temporary external factors that you are not responsible for produce the downers. (You are correct if you are thinking this fits better in level IV. See #29 below.)

Self-reinforcement

Self-depreciating people feel that giving themselves overt self-rewards–going out for dinner–is being selfish, and they think giving themselves covert self-rewards–”I really handled that well”–is shameful bragging. These attitudes become barriers to using some of the most powerful self-control tools, such as self-reinforcement and self-praise (see method #16 in chapter 11). Rehm recommended making a list of assets–true positive traits. Read it frequently and add accomplishments to it. Make another list of possible rewards, as in method #16 in chapter 11, and use them in self-help projects. Depressed people need more good things in their lives.

Get active. Actually, research has shown that we do fewer fun things when we feel low, but simply doing more pleasant activities is no guaranteed cure-all (Biglan & Dow, 1981). Yet, actions do change feelings. Increase your activity level, get out of bed (or your chair or house), find interesting, fun things to do but, more importantly, undertake profitable, beneficial activities that solve problems, improve your situation or future, and replace sad thoughts. Start with easier tasks, work up to harder ones. Reward your progress.

Several therapists recommend that every major activity on your daily schedule be rated for “mastery” (how well you did it) and for “pleasure.” From these rating we can learn a lot, e.g. that we are getting more pleasure than we thought out of life, that we can do many things pretty well, that many activities are satisfying even though we aren’t very good at them, and so on. You may have to push yourself to be active. A book by McGrath (1994), stressing converting depression’s dissatisfactions into motivation to self-improve, could also prod you into constructive action. Examples: feeling like a victim may lead to correcting the situation, anguish about aging may encourage exercising, a poor evaluation may inspire us to learn more, etc. Deep depression makes it very hard to get active (in those cases medication may be needed).

Exercise promises long-lasting results. In just the last couple of years, there have been a couple of interesting studies showing that an aerobic exercise program–stationary cycling or treadmill–for 30 minutes 3 times a week reduced major depression as much or more than medication (Zoloft). After 16 weeks, the remission rate was 60% for both groups, but at follow up after another 6 months the exercise group had a higher recovery rate (than the drug group) and they were less likely to relapse (8% vs. 38% in the Zoloft group). The subjects in this study were middle-aged or older (Babyak, et al, 2000). Be sure to check with your doctor first, but exercise would be good for you in many ways, not just with depression. Seriously consider this. Even more recently, other studies report that daily exercise reduces depression by 1/3 or 1/2 within 10 days, that is faster than most people respond to anti-depressive medications.

The data keeps coming in. Please pay attention to this. Another well done study (Trivedi, M. , January, 2005, American Journal of Preventive Medicine) shows that exercise alone three or five times a week for 30 minutes reduces depression by about 50%. That is as good as taking antidepressants or as good as getting Cognitive-Behavioral psychotherapy. The study observed mild to moderately depressed 20 to 45-year-olds.

Avoid unpleasant, depressing situations. Take a vacation, get complete rest and lots of sleep (just for a week or two–not for months). Our interpersonal situation powerfully influences our happiness and depression. Barnett and Gotlib (1988) found that introversion, loneliness, dependency, and marital problems often precede the onset of depression. Avoid losses and these conditions if you can (of course, it can be a joy to lose a lousy marriage).

Change your environment. Try to change your depressing environments –working conditions, family interactions, stressful relationships and so on. Our mood reflects our surroundings.

Reduce negative thoughts. Reduce the negative thoughts that characterize depressed people: self-criticism (“I’m really messing up”), pessimistic expectations (“It won’t get any better”), low self-esteem (“I’m a failure”), and hopelessness (“There’s nothing I can do”). How do you stop or limit these depressing thoughts, memories, or fantasies? Try using thought-stopping, paradoxical intention (massed practice) or punishment (chapter 4). Or restrict unwanted sad thoughts to specific times or places, e.g. a “depression” chair; then reduce the time spent in the chair (see McLean, 1976). Or reward stopping negative thoughts; replace them with pleasant fantasies (Tharp, Watson & Kaya, 1974).

Have more positive thoughts. Make an effort to have a lot more positive thoughts: satisfaction with life (“Living is a wonderful experience”), self praise (“I am thoughtful–my friends like that”), optimism (“Things will get better”), self-confidence (“I can handle this situation”), and respect from others (“They think I should be the boss”). Even if you don’t feel like saying these things every hour, say them anyway. They will become part of your thinking.
Ask others to model for you how they control depressing thoughts and guilt producing ideas. What self-instructions do they use to “get out of a bad mood?” Practice talking to yourself out loud, then silently. See method #2 in chapters 4 and 11.

Become aware of any payoffs for depression or self-putdowns. Reduce these reinforcements: don’t complain or display sadness, ask others to ignore your sadness (but interact with you more during good times). Remember excessive talking about your depression may sometimes make you more depressed (don’t use this as an excuse for not seeking help).

Act happier. Practice smiling more, speaking in a less whiny voice, standing up straight with chest out, dressing up more and expressing compliments, feeling self-satisfaction, and acting as though the future will be better. Acting happier can change our mood.

Become a better self-helper. Become a better self-helper as you work on a variety of personal problems (Rehm, 1981). Learning to master a life–your life–is not easy. Read self-help books. Use the steps in my chapter 2 to make some self-improvements. Prove to yourself that you can change your environment, your behavior, your mood, and so on. Recognize your increased ability…but know your limitations. Both knowledge of useful psychology and self-confidence are important. Feeling in control of life is an important part of enjoying life.

Atonement. Figure out a way to make up to others or to society for the things you have done wrong (see discussion of guilt above).

Develop marital contracts. Develop marital contracts that provide each partner with a reward for changing in ways requested by the mate. See method #16 in chapter 11.

Seek support. Self-Help or Support Groups, Marriage Enrichment Programs, Parents Without Partners, Integrity Groups, Singles Groups, Emotions Anonymous, The Compassionate Friends (for bereaved parents), Neurotics Anonymous, Recovery, Inc., Theos Foundation (for widows), Widowed Persons, encounter groups, group therapy, church groups, or local groups of people in similar circumstances. Use the phone book and/or Mental Health Center to find the appropriate group for you (see discussion in chapter 5).