Therese Borchard blogs, “Although I like to cling to the promise that my depression will get better — since it always has in the past — there are long, painful periods when it seems as though I’m going to have to live with these symptoms forever. In the past, there was a time when I had been struggling with death thoughts for what seemed like forever. The death thoughts did eventually disappear, but I’m always mindful of my depression. Every decision I make in a 24-hour period, from what I eat for breakfast to what time I go to bed, is driven by an effort to protect my mental health.” Read her entire blog here.
Some people who experience a single depressive episode will fully recover, never to experience another. (Sign us up for that, right?)
For about 40-60% of us, however, depression is a chronic illness that will come back. By the time most people get treatment, they have experienced multiple depressive episodes already.
Good news: with treatment, recurrences can be less severe, occur less frequently and not last as long.
So why does depression seem to rear its ugly head over and over again for most of us?
Saying you have depression is like saying you have a terrible headache, in that you have disabling symptoms, but it says nothing about the cause of those symptoms.
For instance, in the case of a headache, you may have a migraine, a tension headache, a stroke, a brain tumor, a concussion, or something else. The underlying cause informs the prognosis and treatment of your headache, whether it will come back and the best course of treatment.
With depression, we are just beginning to understand the underlying causes and contributors – which could be medical, neurological, psychological or social – many of which are ongoing and lead to a propensity for depressive episodes.
Depression has a genetic basis, but whether that’s because of biological differences in brain chemistry or temperament or something else, we don’t know yet.
We do know that people in stressful situations or lifestyles have more depressive episodes. This could be stress brought on by work, it could be relationship-related, a traumatic or neglectful childhood, or an unsafe living or work environment.
Recurrence can be caused by psychological makeup – much of which can be based in how we view ourselves, others and everyone’s place in the world. Studies have shown that psychotherapy can change this brain makeup to positively influence our outlook.
There’s still so much to learn about the disease. We need to recognize that for many, it’s a biopsychosocialspiritual illness with multiple contributing components that must all be addressed to create the highest likelihood for treatment to work.
Psychotherapy remains the most effective treatment for depression, and should be part of every patient’s plan for recovery.
Someone with chronic, disabling depression may also benefit from a comprehensive evaluation at a center that respects all contributors to the illness to treat the whole person in an individualized, comprehensive way. One place to do this is at The Retreat at Sheppard Pratt, which also specializes in treatment-resistant depression.
Depression is an intensely personal experience. When pursuing treatment, be sure that you are being understood, and obtaining the level of support you need. For some, particularly those working in a highly stressful environment, that could mean getting away for a short time to focus on recovery, even though it can be a tough decision to make. Be open to all levels of care.
It can be disheartening to realize that your depression will likely come back. Know that you’re not alone, as about 6.7% of the U.S. population have had at least one depressive episode in the past year.
Keep working on your recovery, talking about it to reduce stigma, and supporting those who are studying mental illness. One day, we will know more.
By Thomas Franklin, M.D., Medical Director, The Retreat at Sheppard Pratt
Dr. Thomas Franklin is the medical director of The Retreat at Sheppard Pratt. He is a clinical assistant professor of psychiatry at the University of Maryland School of Medicine and a candidate at the Washington Center for Psychoanalysis. He is Board Certified in Addiction Medicine and Psychiatry and has extensive experience in psychotherapy, psychopharmacology, and addictions and co-occurring disorders. Dr. Franklin previously served as medical director of Ruxton House, The Retreat’s transitional living program, before assuming the role of medical director of The Retreat in 2014.
A common misconception about depression is that it is something people can just “snap out of.” Unfortunately, for those people who experience major depression disorder, it’s not that simple. While depression can be serious, it is far from hopeless. There are effective treatments and actions people can take to overcome this disorder. There are certain truths about depression that are important to understand; as we target this debilitating disorder that often spans generations.
1) Depression is a more than just a bad mood.
It’s important for friends and relatives of those struggling to understand that people who suffer from depression can’t just feel better. People experiencing a major depression really need professional treatment. Depression is a mind/body issue and should be treated with the same self-compassion and treatment-seeking with which we would treat any major illness. Different forms of therapy and/ or medications work for different people. According to the American Psychological Association (APA), psychotherapy can benefit depressed individuals by helping them uncover the life problems that contribute to their depression, identify the destructive thinking that makes them feel hopeless, explore the behaviors that exacerbate their depression and regain a sense of pleasure in their lives.
2) Depression is affecting younger people.
In what’s been referred to in the field of psychology as “the greening of depression,” younger people are reporting increased levels of stress and depression. According to the Federal Center for Mental Health Services, “depression affects as many as one in every 33 children and one in eight adolescents.” APA’s additionally reported that higher numbers of college students are seeking treatment for depression and anxiety, with the number of students on psychiatric medications increasing by 10 percent in 10 years.
As I highlighted in my recent blog “Depression in Mothers,” babies born to women who struggled with depression while pregnant have “higher levels of stress hormones … as well as other neurological and behavioral differences.” Thus, whether it’s based on biological factors or new social and academic demands, the vulnerability among younger people makes it all the more essential that we target depression earlier and more effectively. Studies have shown promising results to early intervention among school-age children who showcased symptoms of depression.
3) Mindfulness helps with recurrent depression.
There are a lot of great treatments out there that have proven effective for dealing with depression. Research by psychologist Mark Williams, co-author of The Mindful Way Through Depression, has shown that mindfulness-based cognitive therapy (MBCT) can have a positive effect on preventing relapse in recovered depressed patients. His research indicates that if you teach people with recurrent depression mindfulness skills, such as meditation and breathing exercises, it reduces their chances of having another depressive episode.
Mindfulness practices don’t change our feelings or thoughts, but they do change our relationship to our feelings and thoughts. This enables a person who has a tendency toward depression to not get swept up in the thoughts and feelings that contribute to his or her depression. Another way mindfulness skills can benefit people struggling with depression is by helping them to be better able to regulate and tolerate emotion.
4) Anger often underlies depression.
Often, one strong emotion behind depression is anger. Anger can be a hard emotion to deal with, but it is actually a natural human reaction to frustration. Getting angry may seem like it would only make you feel worse, but when you don’t deal with anger directly, you tend to turn it on yourself. It is important to allow yourself the freedom to fully feel your feelings, but at the same time, to control yourself from acting them out in any way that is harmful. You can recognize and accept your anger in a healthy way that releases the emotion without allowing it to fester or be turned into an attack on yourself.
5) Depression is fueled by an inner critic.
We all have an inner critic, what my father, psychologist Dr. Robert Firestone, refers to as your “critical inner voice.” For people who are depressed, this critical inner voice can have a powerful and destructive influence on their state of mind. It may be feeding them a distorted commentary on their lives: You are too fat to leave the house. You are so stupid. No one will ever love you. You aren’t capable of being happy. You will never succeed at anything. The critical inner voice may then persuade you to act in destructive ways: Just be by yourself; no one wants to see you. Have another piece of cake; it will make you feel better. You shouldn’t even try for that job; you’ll never get it. Finally, once you’ve listened to its directives, the critical inner voice will attack you for your actions: You are such a loser, staying home alone on a Saturday. You messed up your diet again. What is wrong with you? You’ll never get a decent job. You’re so lazy.
To combat depression means taking on this internal enemy. This may involve looking into your past to help determine where these critical thoughts came from. How do these thoughts affect the actions you take in your life? How can you challenge these “voices” on an action level? On Oct. 8, I will be hosting a free online presentation on “Overcoming the Inner Enemy that Causes Depression,” which further explores how your critical inner voice leads to depression.
6) There are active steps you can take to alleviate depression.
One of the worst symptoms of depression is a feeling of hopelessness. This very feeling can inhibit someone suffering from taking the steps that would help them combat their depression. In my blog “Eight Ways to Actively Fight Depression,” I outline a series of actions people can take to fight depression. These include:
- Recognizing and challenging your critical inner voice
- Identifying and feeling your anger
- Engaging in aerobic activity
- Putting yourself in social or non-isolated situations
- Doing activities you once enjoyed, even when you don’t feel like it
- Watching a funny movie or show
- Refusing to punish yourself for feeling bad
- Seeing a therapist
For people struggling with depression, it’s important to have compassion for yourself and to take actions to overcome this state, including seeking help. Remember that no matter what your critical inner voice may be telling you, the situation is far from hopeless. There is good help available and many active ways to treat your condition. For more help or information visit the National Institute of Mental Health.
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. She 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.
When it comes to depression treatment, setbacks can occur – even if you’re following your treatment plan. These strategies can help you get through them. Read the Blog
I’ve always been fascinated by all sorts of weather calamities. But none holds my attention more than a hurricane. Though I’ve never been in one, I marvel at their power and size; spinning vortexes of blistering wind manipulated into different colors on The Weather Channel’s satellite video.
Many who are struck by major depression feel like they’re in a hurricane. They may have sailed in navigable waters much of their lives (the average age of onset of major depression is about 40). But then the skies darken. And the large swells begin. The winds go from buffeting to battering their ships of their lives. A type of emotional and neurochemical hurricane goes on in their brains and pulls apart their sense of self and neural connections needed to run their lives.
Just like a hurricane, major depression doesn’t last forever. It dissipates. The seas eventually calm. People come out of their of their deep troughs of sorrow. The average length of depression is about six months – sometimes shorter, sometimes longer.
The speed at which one recovers may be accelerated by treatment: especially medication and talk therapy. However, many people do not get help when they really need it. They don’t call the coast guard when they’re in trouble. They ignore the warnings, either dismissing it as “the blues” or maybe drinking too much or drugging themselves to blot out the pain.
To have a good shot at long-term recovery, it’s critical to not only get help but to recognize that this ongoing assistance will be part of a new way of life. The afflicted to develop and be persistent about self-care habits that go a long way to warding off future depressives episodes. Avoiding future outbreaks of depression is critical. And this is because mental health care experts know that the more depressions you have, the likelihood you’ll have ones in the future goes up dramatically. It is also usually highly recurrent, with at least 50% of those who recover from the first episode of depression having one or more additional episodes in their lifetime, and approximately 80% of those with a history of two episodes having another recurrence.
One of the best ways to get out of the eye of depression’s storm is a support group. They combat the stigma and loneliness that wrap around the bones of a depressed person. In such support, sufferers find a kinship. As Ernest Hemmingway once wrote, “He knew too what it was to live through a hurricane with the other people of the island and the bond that the hurricane made between all people who had been through it.” The bottom-line is that there’s strength in numbers. Check out the Depression and Bipolar Support Alliance’s website to find a support group near you.
So don’t get caught in the hurricane of depression. Get help. And once you recover, develop a strategy that you can and do stick with to stay well.
One study suggests that spirituality or religion appears to have a protective effect primarily against the recurrence of depression. Read the Blog
From the blog Una Bella Vita (A Sweet Life), a depressive’s piece about rejoicing when there has been a break from the heavy weight of depression. Read the Blog
There are many myths and misconceptions about clinical depression. One of the most tiresome is that depression is just being down in the dumps – in my experience, it’s more like being down in the abyss. Or, that depression is just everyday sadness. Who doesn’t get sad, after all, in today’s crazy world?
But depression isn’t normal sadness – not by a long shot. Everyday sadness – which is part of the human experience for everyone bar none — is usually a reaction to some sort of loss whether in real-time (you just lost your job) or in your mind (you have a sad memory). After some period of time, our ability to adapt kicks in and our emotional world levels off; we regain a sense of emotional balance and are ready to face life challenges.
In contrast, clinical depression is persistent sadness (according to experts, something that last two weeks or more – see a list of other symptoms from the DSM- IV as laid by clicking the link above). This sadness does not go away. We do not adapt. We do not return to an emotional balance without some sort of treatment — whether it’s therapy, medication, life style changes (e.g. a committed exercise regimen) or some combination of all three.
Many folks with depression may also have an absence of the normal range of emotion – particularly the ability to experience joy. There is a flat affect – an emotionally deadening; tears are replaced by simply torment. Our emotional range, if you will, our palette of colorful emotions, is reduced to variations of grey or black. Purples, greens and yellows are simply unable to bloom in depression’s arid soil.
The predominant feeling that all depression sufferers endure, if you could call it a feeling, is unadulterated pain; a sense of darkness that sets up residence in the core of our humanity like a burned out sun that has lost its sense of heat and light.
Some people recover from depression and go into complete remission. For many that fall into this group, their depression is contained by medication, therapy, life style changes and/or some combination of all of these. Depression does not return, thank God.
Others – in my experience many – do not per se recover. They have periods of recovery and episodes of relapse. Or, their depression goes from being Major depression (a truly crippling condition where daily functioning is all but impossible) to Dysthymia (a milder, but more chronic form of depression). The biggest difference between the two is that Dysthymia does not usually incapacitate someone and thoughts of suicide are absent.
Stress can trigger the mercenaries of depression to return during a relapse and assault our mind’s garrisons – – a big problems if you’re a lawyer. Too much stress, too many triggers and a lawyer who had been doing pretty well finds herself or himself falling into the basement of despair. This underscores the importance of learning about the patterns of depression in our lives so as to head it off at the pass.
It’s as if each person’s depression (while sharing some common features – hence the DSM IV) has its own personality, like the classic children’s book Where the Wild Things Are. We must learn read the habits of our depressions because we will then be able to recognize the signs of the trouble brewing inside our heads.
Like a storm seen in the distance from the shore, those who’ve been through a depression can sense the barometric pressure dropping and see the threatening clouds approaching. We may not tell others of this sense of foreboding because we don’t want to concern others, feel that they wouldn’t understand or conclude that they can’t do anything to help anyway.
Other signs begin to appear as the storm moves closer to shore: we don’t have the energy to return calls at the office (our voicemail box becomes digital chunks of impatient clients or opposing counsel calling back for the third time), a fragmentation of our ability to think and concentrate and a strong desire to isolate ourselves and wait – for God knows how long – for the storm to pass.
Just as storms form because of a combination of climatic condition, so too does depression.
For law students, their personality types (often neurotic, perfectionist and overachieving), run head on into the pessimistic thinking style they learn in law school – the buzz saw of learning to “think like a lawyer.” This pessimistic style, finds trouble everywhere it looks. It may make us good lawyers, but often unhappy – and depressed – human beings.
For practicing lawyers, the qualities they took into and learned from law school meet head on with the extraordinary demands of a modern law practice. We’ve come to name those who grew up and fought in World War II “The Greatest Generation.” Perhaps today’s lawyers might be thought of as “The Driven Generation.” Law has become less of a profession and more of a business.
For a lawyer who has goes through a relapse of depression, it’s often befuddling to them why they’re they are going through all this shit again. But regardless of the reason, there you are in the thick of it; the vaporous stink of depression has fallen on you like used up coffee grounds. It seems, most assuredly, unfair. Yet, there it is.
Here are some thoughts about preventing relapse and how to keep you feeling well:
- Learn about how your depression expresses itself. When you start to experience the early warning signs of a depression, talk about with a professional. Read 5 Depression Relapse Triggers to Watch For which should give you some further signs to watch for.
- Watch your thoughts. In myself, I can see a shift from a relatively optimistic outlook to a pessimistic one. I am quicker to judge others and assume the worst about them and their behavior – as well as myself. When not in this space, I am likely to be more forgiving and – I am sure my wife would agree – easier to hang out with! Read, Therapy Better Than Antidepressants at Heading Off New Bout Triggered by Sadness.
- People who relapse are often people who stop taking their medication. They do so because they’ve been taking it for awhile, feel better and decide they just don’t want to take it anymore. This can often have disastrous consequences: a return of depression or even suicide. Beware of this and carefully plan out with a professional how to taper off medication if that’s where you would like to go. Read, What is Depression Relapse and Can It Happen to Me?
There was a powerful article about one woman’s battle with life-long depression in last Sunday’s edition of The New York Times Magazine.
Depression, which she describes as a “thick black paste” and “the muck of bleakness”, can be a chronic and reoccurring condition for many sufferers (as it was for this woman). The research bears this out. Sixty percent of people who have had one episode of major depression will have a recurrence. With each episode, the risk of recurrence increases from 60% to 70% after two episodes, to about 90% after three. Further, studies show that when symptoms continue, recurrent episodes can be longer and more severe, with less time between episodes. Scientists have recently found that long-term treatment with antidepressants can be beneficial.
My view is that it is critical to cut depression off at the pass before it gets a foothold in our lives. That is why I encourage lawyers who are in the midst of their first depressive episode to hit it with everything they’ve got: medication, talk therapy, exercise, a spiritual practice and support groups. If we do not, we run a significant risk of the depression returning.
As the old Japanese proverb goes, “Falls seven times, stand up eight.” Winston Churchill, who suffered from depression his whole life, had a modern take on this ancient wisdom: “If you are going through hell, keep going.” Take action, be determined and trust that you will get better.