In-Depth: Living with Depression
Living with depression is like living with a 40 ton weight on your chest — you want to get up and move, but you just feel like you can’t.
– David J.
After coming out the other side of depression, I felt like a part of my life was stolen from me. I will never get those 3 years back.
– Julie P.
After receiving a diagnosis of major depression, you might feel relieved to have a name for your emotional pain and you might feel overwhelmed about the treatment at hand. However, you’re not alone. Between 10 and 25 percent of women and 5 to 12 percent of men will have a major depressive disorder in their lifetime. And, though it might seem impossible at first, depression is effectively treated and your mood and life will improve.
Here’s a rundown of what you can expect from treatment, how to boost your chances for effective treatment and general tips for reaching relief and recovery.
Before understanding how treatment works, it’s important to ensure you received the right diagnosis through a comprehensive evaluation. This typically consists of a careful interview, including questions about symptoms and current stressors, a standardized questionnaire (such as the Patient Health Questionnaire or PHQ; Beck Depression Inventory or BDI) and suicide assessment. The practitioner also might conduct related blood tests to rule out a medical condition.
Even though depression is extremely common, misconceptions still abound. These are some common myths:
- Depression isn’t a serious condition. Many people mistakenly view depression as a “moral failing,” said Allen J. Dietrich, M.D., co-chair of the MacArthur Foundation Initiative on Depression & Primary Care, whose goal is to help primary care physicians diagnose and treat depression. Others also view being depressed as a weakness, said Christopher Martell, Ph.D, depression researcher and clinical psychologist in Seattle.
Nevertheless, depression is a serious clinical disorder “characterized by a complex integration of biological and environmental vulnerabilities, life events and patterns of thinking and behaving that lead to the clinical presentation,” said Martell. The cause can vary for each person. But whatever the contributing causes for your depression, all practitioners agree that depression requires treatment.
- “I should just toughen up and take it.” It’s important to realize that “depression isn’t a natural consequence of living life; it’s an aberration that doesn’t have to be tolerated,” said Steven D. Hollon, Ph.D, clinical psychologist and depression researcher at Vanderbilt University.
- “I’ll snap out of it.” Letting depression go untreated in hopes that it’ll go away can actually exacerbate the episode, make it last longer and increase the risk for suicide.
- “I’ll be like this forever.” The biggest misconception patients have is that their depressed feelings, fatigue, irritability, inability to concentrate and loss of interest will last forever; that there is no relief in sight, said Rosalind S. Dorlen, Psy.D, ABPP, New Jersey clinical psychologist and New Jersey public education coordinator for the American Psychological Association. Fortunately, however, thanks to effective treatment, patients do find relief and recovery.
Telling Others about Your Diagnosis
Many people wonder how much they should disclose about their depression to everyone from loved ones to co-workers. “The level of intimacy in answers is an individual decision,” said Mark E. Oakley, Ph.D, director and founder of the Center for Cognitive Therapy in Beverly Hills, California.
You can reveal more details to loved ones who are supportive. For co-workers or anyone who’s less supportive, you can simply say that you’re “going through a difficult time,” and feel free to provide “as little information as possible,” said Martell. You also might want to say that you’re working on the problem. Sometimes people feel that they need to make suggestions about what you should do. Saying that you’re getting help or working through your problems might minimize that response, he said.
What To Expect from Treatment
Treatment can consist of medication, psychotherapy or a combination of the two. Various practitioners, including psychologists, psychiatrists, licensed professional counselors and social workers, and primary care physicians can treat depression. Which professional and which treatment you choose is up to you.
“In our experience, fully half of patients can be managed exclusively in primary care. Many others would benefit from mental health consultation and some may need or prefer to be managed in mental health,” Dr. Dietrich said. Taking medication “can work on its own, is more accessible to many people and may require less frequent visits,” he said.
However, as Hollon points out, medication doesn’t correct the underlying propensity for depression or address the negative thinking and behavior. This can be especially problematic for patients with chronic depression.
Whatever the limits of medication and psychotherapy, each is effective in reducing depression symptoms. Some research has shown that a combination of the two is particularly powerful.
There are many types of psychotherapy; however, not all approaches are created equal. So it’s important to understand what approach your therapist is going to use. Whereas generic talk therapy has not been proven effective in treating depression, research consistently shows that cognitive-behavioral approaches and interpersonal therapy are successful.
“Depressed patients typically make specific errors in thinking and engage in unproductive behavioral patterns that lead to, maintain and can worsen depression,” said Oakley. When they walk in the door, clients typically have lots of evidence that they’ve screwed up in life and tend to blame themselves, said Hollon. It is these errors and evidence that cognitive behavioral approaches address.
Contrary to popular belief, these therapies don’t focus on the power of positive thinking. “I’d much rather see people be realistic instead of falsely optimistic,” said Hollon.
A large part of cognitive-behavioral approaches is investigating patients’ slew of negative evidence. “Patients learn how to examine the accuracy of their own beliefs, so they don’t get stuck with self-fulfilling prophecies,” said Hollon. For instance, instead of saying, “I didn’t get into college because I am stupid,” a patient examines the evidence and might realize that he didn’t get accepted because he only applied to one school or didn’t correctly complete the application.
Length of treatment ultimately depends on the severity of the depression, but cognitive-behavioral therapy (CBT) typically lasts from 12 to 24 sessions. “Patients can usually expect to see incremental changes in mood usually by the 12th session,” Oakley said.
In Hollon’s experience, patients typically start feeling better after a week or two, though the gains aren’t lasting. If Hollon doesn’t see “good improvement between four to six sessions” (if the depression isn’t severe or chronic), he wonders what’s missing. If you aren’t getting better, always ask why and don’t blame yourself, said Hollon. “It might be that your therapist isn’t pushing you forward.”
Overcoming Common Obstacles in Psychotherapy
Various hurdles can hinder progress in therapy. Here’s how to overcome them.
- Be honest. Though it’s tough opening up to someone you don’t know about your innermost feelings, being honest with your therapist helps you make progress. If you aren’t comfortable disclosing information to your therapist, ask yourself why. If it’s the therapist who makes you uncomfortable, you might want to see someone else.
- Be willing. It’s important to enter therapy with an open mind. For instance, even though you might experience a loss of interest in all activities, your therapist will encourage you to experiment with “things that previously brought joy, a sense of meaning or accomplishment,” said Oakley. Be willing to try these and other activities.
- Remember you’re a team. Successful treatment involves both the patient and the therapist; it’s a collaborative process. “Patients assume an active participation in treatment, and assignments that are designed to build skills are an integral part of effective treatment,” said Oakley.
- Speak up. A common obstacle to CBT is when patients don’t complete their assignments between sessions. “If your therapist is suggesting homework that seems like too much, discuss this with your therapist, who will most likely be open to the feedback and will work with you to make the between-session work manageable,” said Martell.
- Consider your belief system. For some people, an ingrained belief system can impede treatment. For instance, an individual might feel that he’s doomed to a life of depression because of a family history of the disorder.
- Remove mood from the driver’s seat. A common trap for depressed individuals is that they aren’t motivated to participate in activities that improve their mood. They become inactive and withdrawn, which worsens and maintains their depression, Oakley said. This is where it’s key not to let your feelings dictate what you do, he added.
Research shows that antidepressants are effective in reducing depression symptoms. But it’s important to understand that medication doesn’t work instantly or produce dramatic results. Most people will feel a positive impact in one to two weeks, but they won’t experience the full impact for one to two months, said Dr. Dietrich.
In the meantime, while you wait for the medication to start working, Dr. Dietrich suggests disciplining yourself to do the activities you used to enjoy. For instance, if you enjoyed visiting with friends before your depression, commit to inviting a friend over. He added, “You don’t need to be overly ambitious, but just get back in your groove.”
Keep in mind that the first medication you try may not be the right one for you. “Most people who start on one hypertension medicine will need to take a different or an additional medication. It’s not that much different for depression,” Dr. Dietrich said. In fact, trying several antidepressants and adjusting dosage is something doctors expect. So it’s important not to get discouraged if the first medication doesn’t work.
Common Concerns about Medication
Be sure to discuss with your doctor any concerns about taking medication. Some common worries are listed below.
- They have significant side effects. All medications, whether they’re for depression, hypertension or the common cold, have side effects. However, “there are enough different choices of medication to find a minimal pattern of side effects” for each individual, Dr. Dietrich said. Also, your doctor can help shrink the impact of some side effects. For instance, if you have trouble sleeping, the physician might advise you to take your medication in the morning.
- I’ll have to take them for life. It’s actually less common for people to take medication long-term. Instead, for most people depression is an acute, intermittent episode, which requires medication for six to nine months, Dr. Dietrich said. Those who have experienced more than one depressive episode may need a longer course of medication.
Individuals who “achieve remission stay there for a period of time. If two to three years later, life becomes difficult, you just need to have treatment again,” Dr. Dietrich said.
- They’re addictive. These medications don’t cause physical or psychological dependence or withdrawal symptoms. However, abruptly stopping medication can result in “discontinuation syndrome,” which occurs in about 20 percent of patients who take antidepressants for at least six weeks, according to the American Family Physician.
Discontinuation syndrome is a series of symptoms such as flu-like symptoms, anxiety, dizziness, insomnia, blurred vision and hallucinations. The severity of these symptoms varies by person.
- They increase the risk for suicide. Antidepressants do carry a black box warning, indicating an increased risk for suicidal thoughts and behaviors. However, this seems to be true for patients in their teens and early 20s and less true for adults, Dr. Dietrich said. Though patients should be monitored closely, he believes this risk is “short term, not very common and overplayed.”
What You Can Do To Ensure Effective Treatment
There are several key ways you can increase the chances that your medication will work more effectively.
- Take medication as prescribed. Follow your doctor’s specific instructions on taking your medicine. Also, because newer antidepressants have tolerable side effects and work so well, patients tend to want to stop taking them, said Hollon. Discontinuing medication abruptly on your own, however, can be risky: You can return to feeling depressed and go through discontinuation syndrome. If you’re interested in discontinuing, talk with your doctor, so he or she can properly guide you through tapering off the medication.
- Speak up. Raise any concerns or questions with your doctor. Tell your doctor about how the medication is working. Are you feeling any better or worse? What kind of side effects are you experiencing? Being open helps your doctor provide you with the best treatment.
General Tips To Overcome Depression
In addition to medication and psychotherapy, there are many things you can do during and after your treatment to boost your results and prevent future episodes.
- Try doing the opposite. “If things aren’t going the way you want them to go, do the opposite,” said Hollon. He’s referring to Dr. Marsha Linehan’s concept of “opposite action,” part of dialectical behavior therapy, which teaches patients how to change their emotions. For instance, instead of isolating yourself because you’re feeling sad, call a friend, have dinner with a loved one or invite company over.
- Establish and maintain relationships. Build a social network and surround yourself with meaningful relationships.
- Practice good self-care. Many know that a healthy lifestyle — including eating well, exercising, getting enough sleep and resting — is important for our mental health. The same is true for discouraging depression. If these habits seem overwhelming at first, take it step by step. Think about small changes such as cutting out junk food, taking a 20-minute walk or aiming for an extra hour of sleep every night.
- Build your resilience. The APA defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or even significant sources of stress — such as family and relationship problems, serious health problems, or workplace and financial stressors. It means “bouncing back” from difficult experiences.”
The APA lists 10 ways to cultivate your resilience so you’re better prepared to bounce back after trying times. Some of these suggestions include changing how you view and respond to stressful events; developing realistic goals; finding opportunity in obstacles; and nurturing your confidence in solving problems.
- Help others. Whether it’s assisting at the food bank or reaching out to a loved one who’s going through a difficult time, it’s important to support others in addition to yourself.
- Put things into perspective. “Even when facing very painful things, look at the situation in a broader framework,” said Dorlen. Similarly, avoid catastrophizing, or anticipating that negative events will occur. This kind of thinking creates harmful self-fulfilling prophecies: If you think you’ll fail, you just might help yourself get there.
- Maintain a routine. “A routine gives life structure,” said Dorlen, who works with her patients to keep daily routines. For instance, your morning routine might consist of enjoying a brisk walk, reading the paper while you eat breakfast and taking a shower before you head to work.
- Have a psych checkup. People have regular medical and dental checkups, but a psychological checkup also is essential, Dorlen said. For instance, after having cancer treatment, a patient is never just sent on her way with a goodbye and good luck; she goes in for regular checkups, Dorlen said. You can conduct the check-up yourself. Consider how you’ve been feeling lately. Are you taking good care of yourself? Have you fallen into bad habits?
You can see a mental health professional for this if you prefer. It’s not uncommon for Dorlen to see her patients for an occasional “tuneup,” which typically lasts several sessions. By “keeping tabs on yourself, you don’t wait until it’s too late, till you’re lying in bed unable to do anything,” Dorlen said.
- Use your tools. Rather than retiring the tools and concepts you’ve learned in treatment once you’re in remission, make sure to practice them regularly.
- Watch for signs. Similar to your psych checkup, “keep your eyes open to early symptoms to stave off a real serious episode,” Dorlen said.
- Purge your perfectionism. Originally, depression was defined as “anger directed inward,” said Dorlen, who commonly sees the devastating effects of self-criticism and perfectionism. Learning to be less critical and cutting yourself some slack tremendously helps individuals, she said.
The MacArthur Initiative on Depression & Primary Care includes handouts about treatment for both clinicians and patients.
Families for Depression Awareness helps families recognize the warning signs of depressive disorders and manage them.
Depression Is Real aims to help people living with depression, their loved ones and the public understand the facts about depression.
National Alliance on Mental Illness focuses on support, education and advocacy in helping people with mental illness and their families.
National Institute of Mental Health focuses on mental health research and contains the latest information on all mental disorders.
Tartakovsky, M. (2016). In-Depth: Living with Depression. Psych Central. Retrieved on December 4, 2016, from http://psychcentral.com/lib/living-with-depression/