True Stories: A Wife’s Pain Over Her Husband’s Struggle With Depression During His First Year of Law School

“True Stories” is a new series of guest blogs I am running; this is the fourth in the series. Here is a heartfelt story from Katie, who writes about her husband’s struggles with depression during his first year of law school.

Three years ago, my husband became a first-year law student at a state school with an excellent reputation. After several years of waffling between pursuing medicine, law, military, and scientific research careers, he opted for law and was admitted to a number of schools, accepting his best offer. We relocated so that he could attend, moving from the sunny Southwest to the frigid winters of the Mid-Atlantic. He was excited at first, eager to begin a new chapter of his life, and enthusiastic to embark on a learning journey; he loves to read and study politics, economics, business, and law, and I felt that this endeavor would help him fulfill his potential both personally and professionally.

You Can Recover From Depression

I am 57 years old. I am a lawyer. And I struggle with depression.

I was diagnosed when I turned forty.  I didn’t know what was happening to me. But I knew something was wrong. I was crying quite a bit.  My sleep became disrupted. It became difficult to concentrate.  I felt no joy in my life.

Ultimately, my family doctor diagnosed me with major depression and provided me with the help I needed. I started going to therapy and was put on anti-depressants. This saved my life.

Since being diagnosed all those years ago, I have learned to live with depression as have many of the 20 million people who are living with this illness right now in this country.

Recovery from Depression: The Power of Expectation

Recovery from depression depends in part on what you believe is possible for the future. If you are to recover at all, you have to take action at some point. It could be a series of small steps about your daily routine – eating breakfast, walking out the door to get fresh air and natural light, making a point of talking to someone each day.

Or it could be much larger, like going to a psychiatrist and starting treatment, regularly meditating, exercising frequently, taking long walks. Whatever it is, you need to feel motivated to overcome the inertia, to stop the loss of warming energy to the cold stillness of depression.

To feel motivation, you need to believe, however tentatively, that you can change for the better, to expect recovery from the worst symptoms. You’re likely to hit a lot of barriers, though, that make it hard to keep up positive expectations.

When you expect to fail, it often happens that you stop taking action to help yourself recover. The deeply ingrained habits of depressive thinking and belief can quickly take over. You might start making rules and setting goals.

If recovery is not total and permanent, it’s not recovery. Treatments can’t fail, depression relapse can’t happen. You can’t be recovered if you’re still on medication. You have to get better in six months or a year, or some fixed period of time.

Of course, the rules and goals are entirely your invention, but they’re part of the expectations you feel in your gut. If you can’t meet them, the disappointment confirms your deepest conviction that you can never succeed.

Travels With George: Depression Takes a Backseat

A year ago, I started volunteering at a Church on the East Side of Buffalo, the poorest and most segregated section of town rife with a high crime rate, violence, drug trafficking, and prostitution. And right in the middle of it all is St. Luke’s Mission of Mercy.

St. Luke’s was an abandoned Catholic Church twenty-five years ago that had become empty and useless after the Polish immigrants who built it in 1930 left for the suburbs.  Into this void came Amy Betros, a big woman with an even bigger smile and hug, who owned a restaurant where college students hung out.  Amy decided, moved by something deep inside her, to chuck it all and do something for the poorest of the poor.

So, she sold her restaurant and, together with a guy named Norm Paolini, bought the broken-down church. It quickly became a place where people could sleep on the church’s floor to get out of the elements and get some hot food.  But just as important, that got some food for their souls. They got big servings of hope and seconds if they wished.

St. Luke’s has since grown into a huge community with an elementary school, a food and clothing shelter, and one of two “code blue” places where desperate street people can go to find warmth and a cot to sleep in the transformed for the emergency school cafeteria.

Dan’s Tips for Weaving Together A Recovery Plan to Heal Your Depression

What will make the pain of depression stop?

Sometimes the ache is dull, other times sharp. It can last a few hours, days, or weeks.

This is ground zero for depression sufferers. What can I do to feel better?

The answer is often elusive.  Many don’t know where to get help, let alone walk the path of healing. Recovery starts and sputters for others: they feel better on a med, then it stops working. Or, they start a bold new exercise regimen, only to see it fizzle.

What to do?

There is no one-size-fits-all cure for depression. That what makes it so exasperating.  It isn’t like having a bad cold where Nyquil will do the trick for most.  Rather, depression is an illness of the body, mind, and soul that doesn’t lend itself to simple fixes.  Because we’re all humans with bodies and brains, some things will generally work for everyone; exercise comes to mind.  But because we’re also unique, we need a tailored recovery plan to get and stay better.

We need a quilt of healing.

The Role of Anger in Depression

Sigmund Freud used to refer to depression as anger turned inward. While many people may regard this as an overly simplistic approach to the most common mental health disorder in the world, there is no doubt that anger plays a significant role in depression. As one study from 2016 found, when it comes to emotional disorders in general, the presence of anger has “negative consequences, including greater symptom severity and worse treatment response.” Researchers concluded that “based on this evidence, anger appears to be an important and understudied emotion in the development, maintenance, and treatment of emotional disorders.” When it comes specifically to depression, science seems to be further supporting Freud’s theory, showing more and more how anger contributes to symptoms. A UK study from 2013 suggested that going inward and turning our anger on ourselves contributes to the severity of depression.

Having worked with depressed clients for more than 30 years, these findings were not surprising to me. Many of the people I’ve worked with who struggle with depression also share the common struggle of turning their anger on themselves. As much as I try to help my clients express their anger rather than take it on and turn it inward, I witness first-hand how hard it often is for people to interrupt this process. It’s a challenge for them to recognize the nasty way they treat themselves; they are significantly more critical of themselves that they are of others.

People who suffer from depression often have intense “critical inner voices” that perpetuate feelings of unworthiness and shame. When they listen to this inner critic, they not only feel more depressed, but they also find it much more difficult to stand up to their depression. This includes acting against their critical inner voices, taking positive actions that could help them feel better about themselves (like engaging in activities they enjoy), and being more social.

Getting angry at these “voices” can be liberating, but that means getting in touch with our core feelings of anger rather than aiming it at ourselves. Dr. Les Greenberg, the founder of Emotionally Focused Therapy, describes an important difference between adaptive anger and nonadaptive anger. Anger is an adaptive response when it motivates you to assertive action to end a violation. For example, when we may feel angry at the cruel way we treat ourselves today, we’re in touch with our adaptive anger, and we feel like we’re on our own side. Letting ourselves feel and express adaptive anger can help us feel less burdened, freer, and more in touch with our real self.

Maladaptive anger, on the other hand, affects us negatively. For one thing, it can contribute to feeling victimized, sulky, or stuck in a feeling of being wronged. Examples of maladaptive anger turned inward can include feeling overly critical toward ourselves, hating ourselves, or seeing ourselves as powerless, pathetic, or helpless. The generally dysfunctional responses that result from maladaptive anger are based on emotional schema from traumatic experiences in our past. Often, our critical inner voice is at the root of maladaptive anger, driving us to remain in a state of frustration and suffering.

We can almost feel the difference between maladaptive anger dragging us down and deeper into a state of anxiety or depression and adaptive anger relieving us of a heavy burden, lightening us emotionally, and contributing to our taking constructive actions. While it can feel scary to face these deeper, core emotions, we must access adaptive emotions to transform our maladaptive emotions. This can be a vital process in helping us deal with depression.

One study by Dr. Greenberg showed that Emotionally Focused Therapy can transform maladaptive emotion through the process of expressing it and eliciting the response of an adaptive emotion, i.e. adaptive anger. This approach was especially effective in improving depressive symptoms, interpersonal distress, and self-esteem. As Dr. Greenberg described it, the process “aims within an affectively attuned empathic relationship to access and transform habitual maladaptive emotional schematic memories [articulated as critical inner voices] that are seen as the source of the depression.” Transforming these maladaptive emotions may, therefore, be one of the keys to fighting depression.

Our approach to transforming anger turned inward, which has some similarities to Greenberg’s approach, is to have the person verbalize their critical inner voices as though someone else was telling them these angry thoughts. We also encourage the person to express the feeling behind the thoughts. Often, when people do this, they express a lot of rage toward self. By saying the thoughts in the second person (as “you” statements), they begin to get some separation from their harsh, critical attitudes, and often have insights about where these thoughts come from. It sets the stage for them “answering back” to these attacks and taking their own side. The goal is also to help the person develop more self-compassion and a kinder, more realistic point of view toward themselves.

As we externalize our negative thoughts and the accompanying anger, we can better stand up to our inner critic and take a compassionate stance toward ourselves, treating ourselves as we would treat a friend. This doesn’t mean denying our struggles and setbacks, but it does mean embracing the practice of self-compassion. Self-compassion, as defined by researcher Kristin Neff, involves three key elements: self-kindness, mindfulness, and awareness of common humanity. Research has shown that the practice of self-compassion can significantly reduce a depressed mood. As one study pointed out, maladaptive or irrational beliefs underlie the development of depression, however, when high levels of self-compassion helped to counteract these negative thoughts, there was no longer a significant relationship between irrational beliefs and depression. This same study showed that it is “especially the self-kindness component of self-compassion that moderated the irrational belief-depression relationship.” Thus, the primary aim for someone struggling with resolving their emotions around depression is to treat themselves and regard their feelings the way they would a friend. It’s not about feeling sorry for ourselves, but about feeling strong and worthy and less afraid to make mistakes.

Ultimately, accepting that anger plays a role in our depression should be an empowering tool in our fight to feel better. When people express anger outwards in a healthy adaptive manner, they feel less depressed. Accessing and expressing this anger isn’t a matter of acting out, being explosive, or feeling bitter toward our surroundings. In fact, it means exactly the opposite. It’s an act of standing up for ourselves and accepting that we are not who our “voices” are telling us we are. It’s a process of facing up to the things that hurt us but also facing off against the inner enemy we all possess that drives us deeper into our suffering. The more we can take our own side and resist our tendency to turn our anger on ourselves, the more compassionate and alive we can feel in facing any challenge, including depression.

Lisa Firestone, Ph.D., is a clinical psychologist, author, and the Director of Research and Education for the Glendon Association. She studies suicide and violence as well as couples and family relations. Firestone is the co-author (with Robert Firestone and Joyce Catlett) of Conquer Your Critical Inner Voice, Creating a Life of Meaning and Compassion, and Sex and Love in Intimate Relationships. Firestone speaks frequently at conferences including the APA, the International Association of Forensic Psychology, International Association of Suicide Prevention, the Department of Defense and many others. She has also appeared in more than 300 radio, TV, and print interviews including the BBC, CBC, NPR, the Los Angeles Times, Psychology Today, Men’s Health and O Magazine.

 

 

SHUTDOWN: WHY PEOPLE WITH DEPRESSION FEEL SO NEGATIVE

Depression is a state of shutdown in which an individual’s psychological system shifts toward negative feeling states and diminishes the positive feeling states. The hallmark features of a depressive episode is a high negative mood state (characterized primarily in terms of depressed/demoralized/defeated/despairing feelings and secondarily in terms of anxiety, irritability/defensive hostility, and guilt/shame) and a diminished positive mood state (loss of interest, pleasure, energy, desire, and excitement).

Why do people get depressed? The primary reason people enter depressive shutdowns because they cannot obtain the necessary psychological nourishment needed to energize their behavioral investment system. Think of it as being akin to a state of starvation, only instead of physiological nutrition, the individual is lacking psychological nutrition. What is psychological nutrition? The fundamental principle that underlies psychological organization is that of behavioral investment. The psychological system is organized to direct mental energy and action toward investments that offer a return on those expenditures. When one is a getting a good return on one’s investments, then one feels fulfilled, energized and engaged. However, when one is not getting a good return, one begins to feel frustrated, anxious, irritable, or disappointed. If one cannot find an effective pathway for getting one’s needs met, one begins to enter into a state of psychological shutdown called depression.

So what are the core psychological needs that people have that need to be nourished? There are many different possible classification systems of needs (and motives and goals that people seek fulfillment around, see, e.g., here). I offer five categories here that overlap loosely with Maslow’s classic hierarchy of needs.

Safety and Security Needs. First and foremost, the psychological investment system is concerned with basic safety and survival. If one’s physical safety is chronically threatened, if one is in constant pain, if one is chronically hungry, and so forth, the attention of the system will largely be focused here.

The Base Pleasures. Good sex, tasty food, relaxing on a warm summer day on the beach after working hard. The “hedonic” pleasures serve as a fundamental reward and signal positive investments (at least in the short term). Good investment systems are generally characterized by meaningful effort and hard work toward a productive goal, followed by short periods of relaxing and enjoying the base pleasures.

Relational Needs. Our core psychosocial need is to be known and valued by important others. Most notably, this includes being known and valued by members of our family of origin, friends/peers, romantic partners, and community. Needs for relational value are reflective of one’s degree of social influence. And folks go about achieving social influence and relational value in different ways. For example, see here for power and achievement needs relative to belonging and intimacy needs.

Developmental Growth Needs. We can think about an individual’s psychological system as being akin to an investor’s portfolio. An investor has resources that have the potential for growth and loss. An investor with a diverse portfolio whose investments are growing in a way that is exceeding expectation is flourishing. The same is true for an individual. Each individual will have “personal projects” that are engagements they are involved in that afford opportunities for growth (hobbies, interests, creative and playful endeavors, meaningful work projects, etc.). If an individual is chronically stuck and not growing or is largely cutoff from their growth pathways, or is frequently failing to meet expectations, or is deeply investing in pathways based on extrinsic reasons that are not consistent with their underlying emotional/motivational needs (or intuitive sense of potential), then the investment system is vulnerable.

Existential/Transcendental/Virtuous Needs. Adult humans are meaning-making creatures that need to have a narrative for how their lives and personal projects make sense. As Victor Frankl notes in his timeless classic Man’s Search for Meaning, if they cannot place their suffering, personal projects, virtues and relationships in the context of a larger narrative that provides meaning, then they will be vulnerable to developing a nihilistic attitude, which is the belief that their lives or actions really don’t matter, because really nothing matters. A nihilistic narrative can undercut the emotional value that folks get from engaging in such projects, leading to existential crises or depressions.

Why do people have trouble getting their psychological needs met? Sometimes the answer is obvious. For example, consider the city of Aleppo in Syria. The people of that city have been completely brutalized and many folks there undoubtedly feel depressed. (As an interesting aside, it is worth noting that the field of psychiatry/clinical psychology is divided as to whether such individuals should be considered “clinically depressed”). In other obvious cases, folks get depressed because of chronic pain or illness, or death of a loved one or because they get addicted so substances that ruin their lives or because they are abused or isolated.

Other times the issue is much more complicated. Consider that there are many people that live in nice houses and seem to be surrounded by caring people and are achieving in their lives, yet they also get depressed. Indeed, despite the fact that we have more and more technology and more and more resources and control over our environment, we seem to be struggling more than ever with feelings of depression and anxiety. What is going on in these cases?

The short answer is that I think the modern, fast-paced society is placing many new, unusual stressors on our emotional system. And I don’t think people have been well-educated about how to appropriately process negative feelings. People have been given much more freedom to acknowledge negative feelings than in past generations (read this story to see what I mean), but there has not been good education on how to learn and grow from such feelings (see here or here). What I see in my clinic is that individuals try to avoid negative feelings, and wish everything would just be fine. They often try to act publicly like everything is fine, but they have no idea how to maturely process and learn from their negative feelings. Instead, they enter into an intra-psychic battle with their negative feelings, often working to banish them, or criticize themselves out of their feelings or try to “stay positive”. This creates a powerful “split” in their psychological systems. Namely, their feeling system is sending one signal, their internal narrator is in conflict with that signal, and they are trying to publicly present a totally different image than their inner conflict. All of this sets the stage for a “neurotic breakdown”.

In addition, I see many parents who value their kids, but who do not know how to guide their children in processing negative feelings. Instead, too many have been caught up in “self-esteem nation” and act in an overprotective way, essentially communicating both that their kids are fragile and that others are responsible for keeping you happy. Another group teaches their kids to repress and minimize their feelings. I am not blaming parents here. The modern world is complicated and psychologists and psychiatrists have generally not done a great job being clear about the nature of emotions and relational needs.

At the societal level, we need to recognize both the dramatic changes the information technological revolution has brought to our world and how many of the institutions that provided guidance for the good life are breaking down. Religious systems have lost much of their authority. The political system has broken down into a polarized way. I think our educational system is broken in the way it assesses performance and fails to teach character values. Science often seems to characterize the world as an amoral, meaningless physical system. In other words, in terms of our existential/transcendental understanding, there seems little that supports the deep-seated need that many people have for true meaning making. So, we live in a fast-paced, high-stress world in which we are overloaded with choice, we regularly observe massive amounts of inequity in power and resources, we give lip service to negative feelings but often characterize them as disease states and provide very little real education about human emotions and needs, and institutions that provided deep meaning making systems have lost their authority.

The bottom line is that depression arises, in most cases, when people do not receive the necessary psychological nourishment from their investments. This arises because of brutal environments and injury from traumas, diminished capacities to meet growth expectations, intrapsychic and interpersonal conflict with important others. Unable to find a path forward folks shutdown and, unfortunately, getting depressed in modern society likely creates more problems than it solves. So folks get trapped in neurotic depressive cycles.

There is clearly no easy fix, as depression is a massive health problem. But I do believe there is much that can be done. We need (and can achieve) a much better shared understanding of human psychological needs and nourishment. We also need a clear recognition from institutions like the World Health Organization that depression emerges as a function of psychological malnourishment, rather than being brain disease stemming from neurological malfunctions.

My ultimate vision is for the development of a holistic meaning-making system that harmonizes the natural sciences, the social sciences, and the humanities in a way that affords an understanding of our human natures such that we can have a more effective guide toward fulfillment during these rapidly changing times.

Gregg Henriques, Ph.D., author of A New Unified Theory of Psychology, directs the Combined Clinical and School Psychology Doctoral Program at James Madison University. He is a licensed clinical psychologist with expertise in depressionsuicide, and the personality disorders. He has developed a new meta-theoretical system for psychology articulated in many professional journals and is now applying that system to researching well-being, personality, and social motivation, and he and his students are working on the development of a general system of psychotherapy. Henriques received his M.A. in Clinical/Community Psychology from UNC-Charlotte and his Ph.D. in clinical psychology from the University of Vermont. He also completed several years of post-doctoral training at the University of Pennsylvania under Aaron T. Beck exploring the effectiveness of various cognitive psychotherapy interventions for suicide and psychosis. Henriques teaches courses in personality theory, personality assessment, social psychology and integrative adult psychotherapy.

 

Depression and Suicide: A Catholic Perspective

As a psychiatrist, I had been aware, prior to his death, that Robin Williams struggled with a severe mood disorder – major depression and bipolar disorder, depending on the source of the reporting – along with related problems and drug dependence.

The vast majority of suicides are associated with some form of clinical depression, which in its more serious forms can be a sort of madness that drives people to despair – leading to a profound and painful sense of hopelessness and even delusional thinking about oneself, the world and the future.

I knew all of this, and yet this death still shocked and surprised me, as it shocked and surprised so many others. Williams seemed to be the consummate humorist, the funny man who would be just so much fun to be around. Unlike some comedians who trade only on irony and cutting humor, Williams appeared to us as a warm, big-hearted, endlessly fun, brilliantly quick, incredibly talented man. Though he was a celebrity, he was the kind of person that people felt like they knew – like the cousin, everyone just adores and hopes will show up at the family reunion.  Williams was the kind of guy that people wanted to be friends with, the kind of person that one wanted to invite to the party.

This is not the typical stereotype of mental illness, which why the typical stereotype must be relinquished: Quite simply, it is false.

Mental illness can afflict anyone, of any temperament and personality. In the wake of his death, the strange truth gradually began to sink in: In spite of outward appearances, Williams’ mind was afflicted by a devastating disorder that proved every bit as deadly as a heart attack or cancer. He suffered in ways that are difficult for most people to imagine.

Why couldn’t Williams see himself as other saw him – as a person of immense gifts and talents, a man who stood at the pinnacle of achievement in the world of comedy and entertainment?

Why couldn’t he see himself as God saw him – as a beloved child, a human soul of immense worth, a person for whom Christ died?

This is the tragedy of depression, which is so often misunderstood by those who have not suffered its effects.

Novelist William Styron – whose memoir Darkness Visible represents one of the best first-person attempts to describe the experience of depression – complains that the very word “depression” is a pale and inadequate term for such a terrible affliction.  It is a pedestrian noun that typically represents a dip in the road or an economic downtown. Styron prefers the older term “melancholia,” which conjures images of a thick, black fog that descends on the mind and saps the body of all vitality.

Indeed, the title of his book – Darkness Visible – comes from John Milton’s description of hell in Paradise Lost. We’re not talking about hitting a rough patch in life or the everyday blues that we all experience from time to time. We are talking about a serious, potentially fatal, disorder of mind and brain.

Fortunately, in most cases, depression is amenable to treatment. Because the illness is complex – involving biological, psychological, social, relational and, in some cases, behavioral and spiritual factors – the treatment likewise can be complex. Medications may have a very important role, but so do psychotherapy, behavioral approaches, social support and spiritual direction.

In some cases, hospitalization may be necessary, especially when an afflicted individual is in the throes of suicidal thinking or when one’s functioning is so impaired from the illness that he or she has difficulty getting out of bed or engaging in daily activities. For the severely depressed, even brushing one’s teeth can seem like an almost impossibly difficult chore.

This level of impairment is often puzzling to outsiders – to the spouse or parent who is trying to help the loved one. Unlike cancer or a broken bone, the illness here is hidden from sight. But the functional impairments can be every bit as severe.

I recall one patient, a married Catholic woman with several children and grandchildren, who had suffered from both life-threatening breast cancer and from severe depression. She once told me that, if given the choice, she would choose cancer over the depression, since the depression caused her far more intense suffering. Though she had been cured of cancer, she tragically died by suicide a few years after she stopped seeing me for treatment.

Depression is neither laziness nor weakness of will, nor a manifestation of a character defect. It needs to be distinguished from spiritual states, such as what St. Ignatius described as spiritual desolation and what St. John of the Cross called the dark night of the soul.

Tragically, even with good efforts aimed at treatment, some cases of depression still lead to suicide – leaving devastated family members who struggle with loss, guilt, and confusion.

The Church teaches that suicide is a sin against love of God, love of oneself and love of neighbor.  On the other hand, the Church recognizes that an individual’s moral culpability for the act of suicide can be diminished by mental illness, as described in the Catechism: “Grave psychological disturbances, anguish or grave fear of hardship, suffering or torture can diminish the responsibility of the one committing suicide.”

The Catechism goes on to say: “We should not despair of the eternal salvation of persons who have taken their lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.”

Robin Williams’ death – like the death of so many others by suicide who have suffered from severe mental illness – issued from an unsound mind afflicted by a devastating disorder. Depression affects not just a person’s moods and emotions; it also constricts a person’s thinking – often to the point where the person feels entirely trapped and cannot see any way out of his mental suffering. Depression can destroy a person’s capacity to reason clearly; it can severely impair his sound judgment, such that a person suffering in this way is liable to do things, which, when not depressed, he would never consider. Our Lord’s ministry was a ministry of healing, in imitation of Christ, we are called to be healers as well. Those who suffer from mental-health problems should not bear this cross alone. As Christians, we need to encounter them, to understand them and to bear their burdens with them.

We should begin with the premise that science and religion, reason and faith are in harmony. Our task is to integrate insights from all these sources – medicine, psychology, the Bible, and theology – in order to understand mental illness and to help others to recover from it. In cases where recovery proves difficult or impossible, we pray for the departed and never abandon those who still struggle.

Aaron Kheriaty, M.D., is associate professor of psychiatry and human behavior at the University of California-Irvine School of Medicine. He is the co-author with Msgr. John Cihak of The Catholic Guide to Depression.

The Blues Is Depression. Should You Treat It With Pills?

What people refer to as the blues is usually depression.  Depression, or the blues, is an unpleasant emotional state characterized by what therapists refer to as “the negative cognitive triad.”  That’s 1) negative thoughts about oneself, which are the voices of your inner critic harping on you for what you supposedly have done wrong, should have done differently, and on and on 2) negative thoughts about others that lead you to see what you don’t like in them instead of heeding their virtues and enjoying them, creating relationship problems and 3) negative thoughts about the future.

Some people describe the blues, and also depression, as feeling like there’s a dark cloud over you.  Others refer to depression as seeing the world through dark glasses.  Feelings of hopelessness and helplessness are another indicator.

How can you get rid of your blues and your inner critic by treating the underlying depression?

There are four main strategies:

  1. Change your feelings.Take pills or use one of the newer treatment methods that change your bluesy mood by changing your inner body chemistry and brain functioning.
  2. Change your thoughts.  Eliminating the inner critic may get rid of the depressed, bluesy feelings.
  3. Change your actions. Get exercise.  Go out and be with people.  Express more gratitude.  Do acts of kindness.
  4. Identify and address the problem that initially triggered your depressed feelings and thoughts.  Find a new solution and both the negative feelings and the negative thoughts will evaporate.

Why do people take antidepressant medications?

There are four main reasons why people who may be distressed by something in their lives end up defining their depression as an illness and taking medication.

First and foremost, depression is a terrible feeling that sufferers sorely want to get rid of.

Second, most folks have not been fully informed of the medications’ downsides. I’ll elaborate on drug dependency below.  In addition, these medications can cause serious weight gain, a significant drop in libido (ability to enjoy sex), hazy thinking, and a general emotional numbness that blocks feelings of joy in addition to feelings of depression.

Third, people who take the medications may not have been informed of their relatively low rate of effectiveness.  They can be effective if they work, but they only work for something like about 60% of people who use them.

Fourth, most people who take anti-depressant medications have not been informed by their doctor about alternative treatment options.  To a man with a hammer, the world is a nail.  Physicians know about illness and prescribe medications.  As psychologist Martin Seligman has explained, depression is a relatively normal, if quite unpleasant and often self-defeating, response of giving up in response to a challenging life circumstance.

What are the downsides of assuming that depression is an illness and therefore needs pills? 

As mentioned above, two particularly negative side effects of medication that doctors do not sufficiently explain include potential weight gain and decreases inability to experience sexual arousal. Doctors may mention them but often do not clarify that both extra pounds and decreased interest in sex can have strongly negative impacts on personal self-esteem, on attracting a mate and on sustaining a marriage.

The other significant risk that doctors may or not fully explain is that users may have a hard time getting off these medications.  When a drug company says that their anti-depressant medication is not addictive, strictly speaking, they are telling the truth.  A strict clinical definition of an addictive substance or activity is one that induces both dependency and craving.  Antidepressants do not induce craving.  Over time they do, however, make users drug dependent.

Craving is a familiar feeling to anyone who has fallen in love.  The intense sexual desire that drives someone in love to find every way possible to be near the object of their desire is a craving.  Someone who craves alcohol similarly may wake up in the morning already urgently wanting a drink.

What does “drug dependent” mean?   Drug dependency is the state a body goes into when it has adapted to the presence of a chemical to the point that the body requires steady doses of the substance to maintain normal functioning. We are all, for instance, chemically dependent on water.

Our society is highway-dependent.  Many of us have become accustomed to having highways that enable us to drive to work from the suburbs.  Having bought a house in the suburbs on the assumption that we can take the highway to work, we have become highway dependent.  It’s unlikely that anyone has a craving for highways.  Many of us though have become highway dependent.

If you for some time have been taking an antidepressant medication, the odds are that your body has become drug dependent.  That means that if you should decide today that as of tomorrow you will no longer take the medication, starting tomorrow, you are likely to discover that without the pills that you normally take your body will plunge into a serious depressive state.

Does this depression mean that you need after all to stay on your meds because the pills are all that have stood between you and the depths of despair?   Not at all.  To the contrary, this depression means that your body has become dependent on the antidepressant pills.  Is this addiction?  No, but it is drug dependency.

I am not saying that no one should ever take antidepressant medication.  They do help some people.  Some people experience relatively few to zero negative side effects.  My point is just that if you are considering taking these medications, or have for some time been using them, you deserve accurate information about the factors to take into account in your decision, including information about other treatment options.

Here are six vital points to consider.

1) There now are multiple excellent alternatives to medication for working your way out of depression, including various kinds of talk therapies such as CBT, energy therapies such as Bradley Nelson’s Emotion Code and Body Code, acupuncture, exercise, electrical stimulation of the brain, the visualization you can download for free from my website, or read about how to do on one of my other blogposts, couples therapy, and more.

2) Depression is induced by a situation in which you have experienced insufficient power. If you close your eyes and picture whom or what you may feel angry at, you will see an image of the trigger person or situation. Fix that situation, and your depression will be likely to go away.

3) If your doctor is recommending medication as a short-term fix, use the pills until you feel better. Use your renewed energy to address the power-loss situation. Then begin the medication-weaning process asap.

4) Wean slowly. Consult your prescribing doctor for an appropriate weaning schedule for the particular medication that you are taking.

5) Be aware that research has shown that the most powerful way to overcome depression and keep it far from you, in the long run, is the combination of therapy and medication. Medication alone and psychotherapy alone have very similar effectiveness rates, but medication has an impact more quickly, and psychotherapy tends to have more longer-lasting impacts.

6) There is a visualization exercise that you can do with a therapist, a friend, or on your own that may help you conquer the depression in just a few minutes.  See my posting on A New Treatment for Depression.

6) In my clinical experience, I find that most depression is a response to relationship problems. Look into marriage educationcouples counseling, or a combination of both to upgrade your relationship. These treatment routes can make you a double winner.  You can both end the depression and simultaneously gain a vastly more gratifying marriage or romantic partnership.

Susan Heitler, Ph.D., a Denver Clinical psychologist, is an author of multiple publications including From Conflict to Resolution for therapists, The Power of Two and poweroftwomarriage.com for couples who want to strengthen their relationship. Dr. Heitler’s most recent book is Prescriptions Without Pills, with a free companion website at prescriptionswithoutpills.com.

 

How Exercise Reduces Depression, Anxiety, Cynicism, & Anger

Exercise is good for you. If you’re procrastinating a run or putting off a walk, then we recommend that you close your computer and get outside, content in the knowledge that you have fully grasped the thesis of our article. If you are still here, then we assume that you would like to know more.

First, let’s review exercise’s benefits for the body.

Individuals who exercise a total of 7 hours per week have a premature mortality rate 40 percent less than those who exercise less than 30 minutes per week. Physical activity also appears to reduce your risk for colon and breast cancers. Furthermore, there is evolving evidence that physical activity may also reduce your risk for endometrial and lung cancers.1–3

Research also suggests that health benefits may be appreciated from even modest exercise programs. As little as 2.5 hours of exercise per week significantly reduces your risk of type 2 diabetes and cardiovascular disease. When it comes to exercise, half a loaf really is better than none. In fact, physical inactivity is estimated to cause one in 25 deaths worldwide each year.1–3

And yet despite all that is known about the health benefits of exercise, a little more than 50 percent of Americans do not meet the current CDC recommendations of 2.5 hours of moderate-intensity (50-70 percent maximal heart rate) or 1.25 hours of vigorous intensity (70-85 percent maximal heart rate) exercise per week.1

For reference, maximal heart rate can be calculated by taking 208 – 0.7 x age (an older, unvalidated version of this equation used 220 as the base).4 As an example, a 30-year old’s maximal heart rate is calculated to be 187 beats per minute (“bpm”). This means that in our 30-year old example, a moderate-intensity activity should achieve a heart rate of at least 94 bpm while a vigorous-intensity exercise should aim for a target of at least 131 bpm.

We will return to these parameters in a moment, but for now, let’s turn to the benefits of exercise for the brain.

Before diving in, it is necessary to review the concept of effect sizes. An effect size expresses the difference between two groups; usually between a treatment group and a control group. Effect sizes are calculated as numbers but can be represented categorically as “small,” “medium,” “large,” and “very large.”5–7

Very generally, a medium effect size should be able to be “seen” by the naked eye. For example, in Professor Jacob Cohen’s pioneering work on the subject, he cited the difference in average height between 14-year-old and 18-year-old females to be an example of a medium effect. As an example of a large effect, Professor Cohen cited the difference in IQ between a “typical” college freshman and a “typical” Ph.D. holder.5 For the purposes of our discussion, the larger the effect size, the more likely it is that the treatment (e.g. exercise) is better at treating depression than the control condition (e.g. no exercise).

With our introduction to effect sizes out of the way, let’s study the effects of exercise on the brain.

Studies have demonstrated a strong antidepressant effect for exercise. For example, one meta-analysis that examined well-controlled studies of exercise as an intervention for clinical depression found a very large effect size when compared to nonactive control groups. Notably, previous work had demonstrated a large effect size for study populations of undifferentiated clinical and non-clinical subjects with depressed mood.8

We wish to pause at this point to put these antidepressant effect sizes for exercise in perspective. Let’s turn briefly to effect sizes associated with various psychiatric and general medical pharmaceuticals and treatments. We will use the most optimistic estimates of efficacy for the various classes of interventions so as to level the playing field as much as possible. We fully acknowledge that we will not be comparing apples to apples. The following discussion is not meant to be a definitive statement regarding the efficacy of various treatments. Instead, we hope that the comparisons will help place the magnitude of exercise’s effect size in context.

To begin, let’s compare exercise’s large or very large effect size with antidepressant medication’s small effect size in acute depressive episodes.9 Psychotherapeutic interventions have similar effect sizes to psychopharmacologic medication in the treatment of depressive episodes. However, the combination of psychotherapy and psychopharmacologic medication yields a medium effect size; a value notable for its superiority to either intervention offered in isolation.10 Electroconvulsive therapy for an acute depressive episode has a large effect size.11

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There are numerous potential confounding variables in this very brief comparative overview. Despite every effort to control for the various confounds, it is likely that depressed cohorts who were able to exercise were qualitatively different in some ways from some of the populations included in electroconvulsive trials for example. Researchers have employed various techniques to try to eliminate these confounds, and there are reasons to treat much of the data as valid, but caution is certainly warranted.

Antipsychotics for acute psychosis, antihypertensives for high blood pressure, and corticosteroids for the prevention of asthma exacerbations all have similar medium effect size. Whereas, antibiotics for ear infections and metformin for diabetic mortality have small effect sizes. To find a general medicine medication with an effect size on par with exercise we have to turn to proton pump inhibitors and their large effect size in the treatment of esophagitis.9 In fact, the mean effect size for all general medical medications corresponds to a small effect.10

Research has revealed benefits for exercise in other domains of mental health as well. Meta-analytic reviews have found a small effect size for exercise on state or trait anxiety.8 However, upon closer examination research reveals that exercise has a stronger effect on state anxiety than on trait anxiety.12

Evidence also suggests a broader application of exercise beyond strictly pathological states.13–15 One large non-clinical population-based study demonstrated that individuals who exercised more than two times per week experienced reductions not only in depressive symptomatology, but also in cynical distrust, anger, and stress when compared to individuals who exercised less often.15

There is also significant evidence for a dose-response relationship between exercise and mental health. Exercise regimens with higher intensities, greater frequencies, and longer durations tend to lead to greater response rates in depressed populations. Interestingly, depression remission rates seem to peak at moderate levels of intensity, frequency, and duration suggesting that sustainability of a regimen is an important ingredient to consider when developing a program.8

The setting that one exercises in also appears to play a role. Research has demonstrated that exposure to nature and so-called “green space” exerts powerful effects on mood and self-esteem. Exercising outdoors in a natural setting with trees and plants appears to be superior to exercising in an environment devoid of such “green” qualities. The positive effects rapidly develop with even just five minutes of outdoor time offering a very achievable goal even for busy individuals.3

Interestingly, natural settings with bodies of water present (e.g. streams, rivers, lakes, etc.) appear to offer enhanced benefits over and above those seen in other natural settings.3 Natural settings seem to exert their positive effects on health through a variety of mechanisms; however, it should be noted that the effects are not fully explained by the association of green space and exercise.16 In fact, greater exposure to nature, in general, has been associated with as much as a 12 percent reduction in all-cause non-accidental mortality!17

How does exercise exert these far-ranging effects?

There are many gaps in our understanding of the mechanisms by which exercise exerts its anxiolytic and antidepressant effects. There is some evidence that exercise may increase turnover of serotonin, leading to an adaptive downregulation of the serotonergic 5-HT2C receptor. Activation of the 5-HT2C receptor seems to inhibit dopamine and norepinephrine release. Thus, a downregulation at the 5-HT2C receptor leads to an increase in availability of dopamine and norepinephrine. This effect is thought to be particularly important in the prefrontal cortex and is hypothesized to contribute to the anxiolytic and antidepressant effects associated with exercise.8

In addition to increasing serotonin turnover exercise seems to trigger a release of beta-endorphins. Endorphins are part of the brain’s endogenous opioid system and also tend to produce anxiolytic and antidepressant effects when released.8

From a more macroscopic scale exercise, like antidepressant medication, helps restore sleep patterns frequently disrupted in the setting of depression. Furthermore, evidence suggests that activity in the prefrontal cortex is reduced during exercise and that this modification of cognitive processing may correlate with the subjective anxiolytic and antidepressant effect of exercise.8

Finally, exercise engages an individual in an activation and approach set of behaviors that are diametrically opposed to passive and avoidant cognitive strategies classically found in depression and many other psychopathological states. In this way exercise seems to operate on a similar theoretical framework as the psychotherapeutic technique known as behavioral activation. Behavioral activation targets behavior first rather than cognition as many other forms of psychotherapy do.18 It must be noted that although exercise may be a component of a behavioral activation treatment regimen, the psychotherapeutic technique utilizes many other activation strategies to catalyze change.8

Let’s be optimistic and imagine that the preceding discussion helped you move from the contemplative to the preparatory stage of change and that you are preparing to make a change in your exercise habits.19 How much exercise do you need to get before you can appreciate the mental health benefits?

Evidence suggests that an optimal exercise program is about 30 minutes in duration, has a frequency of 2-4 times per week, and is of such an intensity level that an individual achieves 70-80 percent estimated max heart rate.8

Recall that our maximal heart rate from our 30-year old example was calculated to be 187 bpm. This means that the targeted intensity level of exercise for mental health should achieve a heart rate between 130-150 bpm.

Finally, the individual should commit to at least four weeks of the new exercise program to optimize the chances for long-term habit formation. Evidence suggests that while 70 percent of individuals maintain a short-term exercise program, only 50 percent maintain the program for six months.8

We have covered a lot of ground in our exploration of the varied health benefits associated with exercise.

We began by discussing the significant benefits of exercise for our general medical health. We learned that exercise reduces rates of mortality, some cancers, type 2 diabetes, and cardiovascular disease. For more on the mortality benefits of exercise visit our website Neuraptitude.org.

We next turned to exercise and mental health, studying depression as our archetype condition. We found that exercise can be considered a valid “antidepressant” or augmentation strategy in the treatment of depression and that its effects are comparable to antidepressant medication and psychotherapy.

As we discussed before, we are not comparing apples to apples, and direct comparisons between techniques are not fair outside of a given trial. Our point is not to assert the unrivaled superiority of exercise to psychopharmacologic agents, psychotherapeutic techniques, or other therapeutics. Rather, we wish to elevate exercise from a healthy lifestyle habit to an adjunct treatment.

And finally, let’s recall that exercising in natural outdoor settings, ideally in close proximity to a body of water, may enhance the health benefits associated with exercise.

The most effective treatment for a given mental illness is almost certainly to be pluralistic rather than singular. A holistic treatment strategy that targets biological, psychological, and sociological substrates of disease offers a significant synergistic advantage over a singular approach.

By Matthew Mackinnon, M.D.

Dr. MacKinnon is a psychiatric resident physician at the University of Washington who researches and writes about the neuroscientific intersection of mental health and mental illness. Dr. MacKinnon runs Neuraptitude.org, an online scientific publication dedicated to uncovering the natural capacities of the human mind by exploring topics that reveal, bit by bit, the intrinsic enormity latent within the brain.

 References

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