Allen, J - Coping With Catch-22s of Depression, (2002)

8/11/2019 Allen, J - Coping With Catch-22s of Depression, (2002)

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Catch-22s of depressionAllen

Coping with the catch-22s of depression: A guide for educatingpatients

Jon G. Allen, PhD

The author developed a protocol for educating patients about depression that focuses on the obstacles encountered in the course of recovery. These obstacles are construed as catch-22s, the gist of which is that all the things patients must do to recover fromdepression are made difficult by virtue of the symptoms of depression. After describing the evolution of the patient education

program and providing an overview of the content of the educational curriculum, the author presents the written material that is given as ahandout to the patients in the educational group. A guide to the

pertinent literature on depression is also included as an appendix.(Bulletin of the Menninger Clinic, 66[2], 103-144)

Depression is a scourge , estimated to have been the fourth most dis-abling disease worldwide in 1990 and anticipated to rank second only

to heart disease by 2020 (Murray & Lopez, 1996). And these may beunderestimates (stn, 2001). The increasing prevalence and stubbornpersistence of depression are only part of the problem. Depressed per-sons may not recognize that they are ill; if they do recognize they are ill,they may not seek treatment; if they do seek treatment, they may not beproperly diagnosed; if they are properly diagnosed, they may beundertreated; if they are adequately treated, they may not fully respond;and if they do recover, they are likely to suffer recurrence. Imagine whatthe story with heart disease must be!

This grim situation has fueled massive efforts at public education(Hirschfeld et al., 1997), but all this effort shows little promise of stem-ming the tide. Given the scenario sketched above, by the time we have a

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This article is based on a presentation at the 24th Annual Winter PsychiatryConference, held March 3-8, 2001, at Park City, Utah.

Dr. Allen is senior staff psychologist and Hirschberg Professor in the Child andFamily Center at The Menninger Clinic.

Correspondence may be sent to Dr. Allen at The Menninger Clinic, PO Box 829,Topeka, KS 66601-0829; E-mail: [email protected]. (Copyright 2002 TheMenninger Foundation)


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properly diagnosed patient to treat, the situation is relatively hopeful.Yet we are by no means out of the woods. Patients are highly prone togiving up on treatment prematurely at a point where residual symptomsremain, putting them at extremely high risk for relapse (Dawson,Lavori, Coryell, Endicott, & Keller, 1998). Patient education is essen-tial to the therapeutic collaboration needed to sustain treatment (Rush,2001). Communicating to patients that we understand theirplightand helping them to fully understand their plightmay enablethem to stay engaged in this arduous endeavor.

This article describes a patient education program implemented inThe Menninger Clinic. Befitting the patient population in a tertiary caresetting, the program focuses on relatively chronic, treatment-resistantdepression. A description of the evolution of the program is followed bythe written material that is given as a handout to the patients participat-ing in the program. Finally, an appendix provides a schematic guide tothe scholarly literature supporting the educational material. One of thegreatest challenges in educating patients about depression is educatingoneself. Given the vastness of this literature, developing even a modi-cum of expertise is a monumental task. The literature review is intendedto provide the reader with an inroad.

Evolution of the patient education program

My colleagues and I developed the educational approach to copingwith persistent depression in the course of educating patients aboutpsychological trauma (Allen, 1995; Allen, Kelly, & Glodich, 1997).Depression became a prominent topic, given the high comorbidity of depression and posttraumatic stress disorder (Kessler, Sonnega,Bromet, Hughes, & Nelson, 1995), coupled with the fact that trau-matized patients were typically admitted for the treatment of severedepression. As this educational work evolved, we developed an ap-proach to helping patients appreciate the challenges of coping withposttraumatic depression (Allen, 2001). In the process of educatingpatients who had struggled with trauma-related depression for manyyears despite extensive treatment, we gradually learned that solu-tions are elusive. As we presented various strategies required to re-cover from trauma, patients explained all the problems with thesestrategies. In the course of these discussions, we learned that wecould be most useful to patients by helping them understand why re-covery is so difficult, perhaps alleviating their depression somewhatby encouraging them to ease up on themselves regarding the persis-tence of their problems. We gradually pulled together this under-standing in formulating the problem of the catch-22s of

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depression, the gist of which is that all the things one must do to re -cover from depression are made difficult by the symptoms of depres-sion. A glaring example: Hope sustains recovery, and depressionbrings hopelessness.

Starting out in a relatively long-term specialized inpatient program(Allen, Coyne, & Console, 2000), the trauma education program washighly ambitious. The group met twice weekly to cover the full curricu-lum in an academic year. Even with long-term treatment, patients wereexposed only to a portion of the material in the group meetings. Thus itbecame necessary to have written material that would cover the fullcourse, which ultimately became a book-length manuscript (Allen,1995). When we subsequently implemented the trauma education pro-gram on an acute inpatient unit, we devoted even greater emphasis todepression, given that patients were typically admitted for acute exacer-bations. As we explained it to patients, severe depression becomes a toppriority in treatment because it is potentially fatal if associated with sui-cidal states, and at least partial recovery from depression is necessary towork productively on the problems that precipitated the depression. Inthe context of educating patients in acute treatment, we developed vid-eotapes on trauma and depression to provide patients with a quickoverview. A simple stress pileup model (Allen, 2001) served to pro-vide a quick, yet comprehensive, overview of the multiple pathways todepression.

Having refined the depression component of the trauma educationprogram, we then added this psychoeducational intervention to theProfessionals in Crisis Program, an inpatient program where patientstypically remain for a few weeks. The group meets onceweekly, and thecurriculum spans several weeks. Thus the written handout provides thefull course content for patients who attend only a portion of the ses-sions. The process is similar to that in the trauma education groups (Al-len, 2001) inasmuch as the leader presents some core concepts andpatients are encouraged to discuss how these concepts relate to theirpersonal experience. Plainly, given their extensive experience, the pa-tients are the experts. At their best, these group meetings become ratherdiscursive brainstorming sessions in which we pool our expertise todeepen our conjoint understanding of the challenges in recovering fromdepression. As we continue to expand our knowledge, I endeavor topass on whatever I learn.

What follows is the text that we have developed as a handout for pa-tients participating in a psychoeducational group on depression in theProfessionals in Crisis program at The Menninger Clinic. Citations andthe professional formulations behind that text are detailed in an accom-panying appendix.

Catch-22s of depression

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Coping with the catch-22s of depression

The plight of the depressed person is not fully appreciatedeven bymany persons who are depressed. Depression is often seen as an acuteillness: something bad happens, you get depressed, then you recoverfairly quickly. True, depression can be a relatively time-limited re-sponse to stressful events, and some persons respond relatively quicklyand fully to treatment. But thats not the norm.

Depression is a hard problem. Why does it take so long to recover?Why is it so difficult and painful?Heres the rub: All the thingsyou needto do to recover from depression are made difficult by the symptoms of depression! For example, if youredepressed, its likely that youve beenseverely stressed and feel exhausted. Therefore you must rest. But con-sider one of the most common symptoms of depression: insomnia. Acatch-22. There are many others: You should eat well, but depressiondecreases your appetite. You should be active, but depression robs youof energy. Above all, you should remain hopeful, but depression maybring hopelessness.

Heres another big problem. You may have become depressed be-cause you encountered one or more major stressful events. Chances are,you were facing many hard life problems. Then, on top of these hardproblems, you became severely depressed. Now not only do you haveall the hard problems that triggered depression, but you also have an-other extremely hard problem: depression. Moreover, the conse-quences of depression often lead to additional life problems, such asincreased marital conflicts, more difficulty at work, and financial bur-dens. But once youve become severely depressed, the depression be-comes the highest priority problem, for at least two reasons. First, whenyoure depressed, its extremely hard to cope with the problems thatbrought on the depression. Second, depression is potentially life threat-ening, if youve become suicidal. So you may need to recover from de-pression, at least to some degree, before you can tackle the problemsthat triggered the depression.

Contemplating the catch-22sof depression is risky. It might lead youfurther into depression. Keep in mind that it is not impossible to recoverfrom depression, despite the catch-22s. We know this, because the vastmajority of depressed persons recover. Recovery is difficult, but not im-possible. Making the distinction between difficult and impossible iscrucial to recovery. Recognizing the difficulty may be discouraging, butfailing to recognize it can be even more demoralizing. Minimizing theseriousness of depression leads to unrealistic expectations, enormousfrustration, self-criticism, and hopelessnessall of which add furtherfuel to depression.

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I believe that understanding depression and accepting the serious-ness of the condition puts you in the best position to cope with it. Un-derstanding depression and what it takes to cope with it can providea more hopeful view, based on more realistic expectations. Youmight need to set your sights on small steps, goals that you canachieve. Ideally, you might see depression as a challenge, a hardfight, or a struggle. But this is not an easy stance to take when youredepressed.

This article reviews the illness of depression and explains how youmay need to work on many fronts to recover. Each of these fronts en-tails catch-22s. Yet within each of these catch-22 areas you have someleverage over depression. The leverage is not greatyou cant justsnap out of it, no matter how much you wish to do so. Fortunately,we are not dealing with black and white but rather shades of gray (per-haps dark gray to black). You need to be motivated to recover. Youneedenergy to bemotivated. If youredepressed,you may have little en-ergy. But youre likely to havesome energy and some motivation. Itsthese shadesof grayhowever darkthat make thecatch-22 problemsvery difficult rather than utterly impossible. You have a little leverage inmany areas.

There are many different treatment approaches to depression: be-havior therapy, cognitive therapy, interpersonal therapy, and somatictherapies (e.g., medication and electroconvulsive therapy).Allareeffec-tive, to a degree, over time. You may well need to draw from many of them. All entail grappling with the catch-22s.

Theres even a catch-22 in learning about depression: You mightfindit hard to take in a lot of information when youre depressed. You mayhave problems with concentration and memory that make it difficult toread. This manuscript is packed with a lot of information, and it maynot be easy to digest. Ive broken it down into short sections so that youcan tackle it a bit at a time. And you can skip to the last part on thecatch-22s if you just want to focus on treatment.

The illness of depression

Depression is a common problem, especially among women. A repre-sentative study showed that 12.7% of men and 21.3% of women havemajor depression in their lifetime. In a given month, 3.8% of men and5.9% of women experience major depression. Moreover, the preva-lence of depression is increasing in the United States, and most alarmingis its increase among adolescents. Depression is common, and the seri-ousness of depression is all too frequently minimized. But facing up tothe reality of depression poses a dilemma.


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Between a rock and a hard placeThe rock: Itsnot that seriousif youd just . . . [dox], youd snap out of it. The hard place: Depression is a serious, persistent, mental-physicalillness. Lets first consider the rock. Many persons who have struggledfor a long time to overcome depression have been urged by others, If youd just . . . [eat right, go out and exercise, have more fun, stop isolat-ing, quit wallowing, etc.] . . . youd feel better. Ive come to think of just as a fighting wordits inflammatory to persons who have livedwith depression and have tried to fight their way out of it with limitedsuccess. Theres no single, simple solution to persistent depression. Youmust work on several fronts. It can be a long haul, even if youre able toput a lot of effort into it.

I vote for the hard place, because its realistic. Depression is a seriousillness, recovery may takea lot of time, and you remain vulnerable to re-lapse. This is a hard place, indeed, but sitting on the rock is potentiallycrazy-making: you should be able to snap out of it, but you cannot.Therefore you conclude that you are crazy, lazy, or some other depress-ing idea.

To say that depression is a persistent illness does not mean that youare destined to be severely depressed continuously. You may spendquite a lot of time, however, at different levels of depression, rangingfrom mild to more severe. I use the term persistent to emphasize thefact that you remain vulnerable to relapse, particularly in the faceof sig-nificant stress. In this respect, depression is much like other chronicphysical illnesses, such as hypertension or diabetes. The main implica-tion of persistent is this: You must take care of yourself over the longrun. Another catch-22 here is that you may feel like youre not worthcaring for if youre depressed.

Choosing to stay depressed?Some depressed persons are told that they are choosing to stay de-pressed, that they just want to be depressed, or they are wallowingin depression or self-pity. In part, such criticisms reflect the frustrationand sense of helplessness of others who find your depression distress-ing. If depression is a mental state, you should be able to do somethingin your mind to change it. Or you should change your depressed behav-ior. This can put you back on the rock. You should snap out of it orsomehow will yourself out of it. But how?

Is there any reason to want to stay depressed? Yes. You can take ad-vantage of depression, just as you can take advantage of any other ill-ness. Illness is a biological condition but it also involves a social rolewith certain expectations and obligations. A half-century ago, sociolo-gist Talcott Parsons described several aspects of the sick role, all of

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which apply to depression. Illness allows exemption from performanceof certain normal social obligations as well as being exempted from re-sponsibility for your ill state. As Parsons stated, the ill person cannot beexpected to recover by a mere act of will. Yet the ill person is obligatedto seek help, cooperate with treatment, and becomewell as soon as pos-sible. Plainly, lack of understanding of depression and unrealistic ex-pectations about recovery can create interpersonal conflicts about thelegitimacy of your illness. Those who believe depression is an acute ill-ness from which you can be expected to recover quickly may believethat youre just not making the proper effort. You also may believe thisif you fail to understand depression.

Depression can be an excruciatingly painful state from which a per-son would do anything to escapeeven including suicide. But there canbeanother side to depression as well. Depression involves a retreat fromproblems that have become overwhelming, and persons who have beendepressed for long periods of time often find it familiar, even comfort-able and safe in some sense. Being depressed can feel like being in hiber-nation or being in a cocoon. If youve become accustomed to it, gettingout of depression can be anxiety provoking. Recovering means facingthe world again, plunging back into the unknown. For somepersons, asbad as the depression is, recovery also can be distressing.

I think the idea thatyou are choosing to bedepressed orwallowing indepression is insulting and minimizes the seriousness of the illness, evenif there is a grain (or even a spoonful) of truth in it. On the other hand,we must believe that you havesome choice and some control over yourdepression. Otherwise there would be no point in trying to do anythingaboutit!Youwouldbetotallystuck.Thetrickistoacceptthatyouhavesomedegreeof choice, control, and responsibility for your state of mindand behavior without blaming or criticizing yourself for not doingbetter. Heres the irony: You have a greater degreeof choiceand controlwhen youre less depressed.

You cannot simply choose no longer to be depressed. You cannotjust make up your mind to be well and thats it. But, if youre not pro-foundly depressed, you can choose to take actions that will take youslowly along the path of recovery. Recovering from depression involvesa series of hard choices over a long period. It can be a hard choice to getout of bed, to take a shower, or to get dressed. You cannot choose to re-cover from depression at one moment, once and for all. Recoveringfrom depression requires making hard choices continually, one afteranother, day after day, month after month. Its like climbing a moun-tain, with ups and downs, gains and setbacks along the way. The moredepressed you are, the harder the choices, and the harder the climb. As


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you respond to treatment, the choices become easier, and you havemore strength and ability to climb.

Keep in mind the catch-22s. Its hard to climb a mountain whenyoureexhausted. One of the mostdemoralizing aspects of depression isits persistence and recurrence. Many persons have worked hard andsuccessfully over a long period of time to fight depression. They becomedemoralized when they become depressed again after all the hard worktheyve done in the past. So often I hear, Im tired of fighting it. I cantgo on fighting. No wonder some depressed persons feel like giving upentirely. Depression is frustrating. The only way forward is to go slowlyand to take small steps. Frustrating indeed.

A mental-physical illnessThere are many reasons to think of depression as a physical illness. De-pression can stem partly from genetic (inherited) vulnerability; it is as-sociated with changes in patterns of brain functioning; it is oftenaccompanied by physical ill health; and it is responsive to medicationsand electroconvulsive therapy.

But we should not lose sight of the mental aspects of depression. Iview it this way: Psychological and social stress leads to physiologicalstress, which can lead to persistent adverse changes in brain function-ing. This may bea hard concept to grasp. Themeaning of events in yourlife-recent or remote-can produce physiological stress that alters theway your brain functions.

The sequence is this: Stressful events take on psychological meaningwhich generates brain changes. For example, losing your job (event)may lead you to fear that you can no longer support your children(meaning), which in turn leads to persistent stress-related changes inyour brain and the rest of your body. Often the stressful psychologicalmeanings revolve around two broad themes: loss and failure.Forexam-ple, you may feel alone, unlovable, inadequate, worthless, and so forth.Thus low self-esteem plays an important role in translating stressfulevents into depression. Also our ability to think (negatively) aboutlong-range implications plays a significant role in the meaning of stress-ful events. You may think, for example, Ill never be able to find an-other job, or Ill never have a good relationship, or Things willnever change.

Fortunately, the mind-brain relationship goes both ways. Positivepsychological and behavioral changes can help reverse the changes inbrain functioning. The interplay of physiology and psychology is thereason that the best treatment of depression often involves a combina-tion of medication (or electroconvulsive therapy) and psychotherapy.

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Depression impairs functioning Its obvious to you that depression impairs your functioningyouvebeen living through it. You may have difficulty doing your work, takingcare of your household responsibilities, and interacting with your fam-ily and friends. At worst, you may not even be able to concentrate on aTV show, a magazine article, or a book. And, being depressed, you mayfeel guilty about being unable to manage your responsibilities. You maybe criticizing yourself for the difficulty youre having, feeling youshould just be able to do better, adding fuel to your depression.

You might be able to adopt a more forgiving attitude toward your-self for the difficulty youre having by appreciating how much impair-ment is typically associated with depression. This is part of the hardplace of depression, acknowledging that it is a serious illness. The levelof impairment associated with depression is similar to impairment asso-ciated with other chronic physical illnesses, such as hypertension, heartdisease, lung disease, and arthritis. Depression is second only to heartdiseaseinthenumberofdaysspentinbedandsecondonlytoarthritisinthe extent of physical pain. Obviously, the more severe the depression,the more severe the impairment is likely to be. Yet even mild depressionis associated with some impairment in role functioning. Thus youshould aim for a full recovery over the long term and stay well to the de-gree humanly possible.

The seriousness of depression as a public health problem has beendocumented by an ambitious World Health Organization study of theextent of disability associated with a wide range of general medical andpsychiatric conditions. Researchers determined theextent to which var-ious illnesses were associated with mortality and disability (impairedfunctioning). They compared diseases in extent of disability measuredin terms of disability-adjusted life years, that is, number of lost yearsof healthy life. In 1990, depression ranked fourth worldwide; by 2020,depression is anticipated to be the second most disabling illnessex-ceeded only by heart disease. This is not the rock; its the hard place.

Time to recover Heres more about the rock of depression: You may think you shouldbe able to recover quickly. You may hold a stereotype of others whotake antidepressant medication for a few weeks and then feel well. Youmay conclude its your personal failure that accounts for your pro-longed depression. Consider this: A large group of individuals whosought treatment for depression at major medical centersoften afterseveral months of depressiontypically took a number of months tore-cover. Of course, some recovered sooner, and others recovered later,but 5 months was in the middle range. That is, half of the persons in the


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study had recovered by 5 months. About a third took over a year ormore to recover, and some took 2 or 3 years or more to recover.

I present these statistics to emphasize that recovery from depressionis generally a long process, so that you might be less critical of yourself for taking a long time to recover. A number of factors have been shownto increase the lengthof timeto recovery: a large numberof previousep-isodes, long duration of prior episodes, more severe symptoms, pres-enceof general medical conditions andother psychiatric problems (e.g.,substance abuse), low self-esteem, lack of social support, and ongoingstress.

But you should also keep in mind that you can influence the time torecovery. Active and persistent participation in treatment can speed theprocess of recovery. Giving up on treatment prematurely can slow theprocess of recovery and contribute to relapse.

Course of recoveryThe courseof an illness refers to its progression over timeafever has awaxing and waning course when it gets worse, then better, then worseagain. The course of depression can be very complex. And there aremany different subtypes of depression, with major depression being theprototype. The diagnostic criteria for major depression include five ormore of the following symptoms, most of the day every day, for at least2 weeks: depressed mood, diminished interest or pleasure, appetite orweight changes, sleep disturbance, motor agitation or retardation, fa-tigue or loss of energy, feelings of worthlessness and guilt, problemswith concentration and decisions, and thoughts of death or suicide. Al-though there aredifferentpatterns of symptoms associated with depres-sion, and there are certainly many different developmental pathways todepression, it is helpful to think of depression as one illness that variesin severity and duration. Four levels of severity can be distinguished:

1. Major depression (meet criteria of five symptoms for 2 weeks)2. Minor depression (fewer than five symptoms)3. Subthreshold symptoms (one or five symptoms; not back to nor-

mal)4.Wellness (fully recovered with return to normal; euthymic)

On the path to recovery from a major depressive episode, we distin-guish among the following:

1. Response (improvement after starting treatment)2. Remission (back to normal but not stable)

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3. Relapse (return to more severe symptoms after response or remis-sion)

4. Recovery (stable remission)5. Recurrence (a new episode of depression after stable recovery)

The length of time to response and remission can vary greatly from oneperson to another. To repeat, about half of the persons admitted to amajor medical center for treatment of major depression achieved recov-ery (2 months of remission) after 5 months of treatment. Major depres-sion entails 2 weeks of symptoms, and chronic major depression isdefined as symptoms of major depression for 2 years. Dysthymia is dis-tinguished from major depression by both severity (milder) and dura-tion (more persistent). That is, a diagnosis of dysthymia requires at least2 years of depression at a level milder than major depression. The com-bination of dysthymia and major depression is sometimes called dou-ble depression. A person with dysthymia who becomes more severelydepressed (major depressive episode) may recover to the level of pre-vious dysthymia or, ideally, may fully recover to a state of wellness.

There are many factors that indicate risk for relapse and recurrence.The single most powerful predictor of relapse and recurrence is a con-tinuing state of active illness, that is, some level of ongoing depres-sioneven if it is mild. Hence ongoing dysthymia and even one or twosubthreshold symptoms entail increased risk for major depression.This should make intuitive sense: If youre already partway there, it iseasier to return to being extremely depressed.

Another powerful predictor of recurrence is a history of multiple de-pressive episodes. Other predictors of relapse are similar to those thatpredict a slow time to recovery: ongoing life stress, low social support,and the presence of other psychiatric problems such as substance abuse,anxiety, and personality disturbance. Personality disturbance involvesrecurrent problems in interpersonal relationships. Such relationshipproblems contribute to depression in part because they are likely to be amajor source of stress. And interpersonal stress is among the most com-mon forms of stress.

The fact that some ongoing depression is the greatest risk factor forrelapse hasa clear implication: You should aimfor full recovery, restor-ing your mood back to normal.And the longer you can remain in thisrecovered state, the less the risk of recurrence. Also, to the extent thatyou can get help early and can work to minimize further episodes, yourchances of staying well increase. Continuing in treatment is one way tomaximize your chances. Unfortunately, an extremely common patternis this: A person in a major depressive episode takes medication, feels


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somewhat better (response, not recovery), and then discontinues medi-cation. This common pattern entails a high risk of relapse.

Anxiety and depressionA psychiatrist colleague once told me hed never seen a depressed pa-tient who wasnt anxious or an anxious patient who wasnt depressed.To understand depression fully, we must give anxiety its due. I think of distress (or dysphoria) as a broad category that encompasses bothfeelings. But its helpful to tease apart the differences between depres-sion and anxiety because they often go together and feed into eachother.

Think of depression as the absence of positive emotionyou dontenjoy anything. You may try to do things that will perk you up, but itdoesnt work. This, too, has a physical aspect. As psychologist PaulMeehl put it, you may not have enough cerebral joy juice. The neuro-transmitter dopamine is one of the juices that activates pleasure andreward circuits in the brain. This pleasure circuitry is part of an ap-proach system in the brain, and it enables you to seek out pleasurableactivities. If you can, think of the excitement you have felt when youwere about to do something you really enjoyed. The approach-plea-sure-reward system was turned on. Of course, too much cerebral joyjuice activity is also a problem. In a manic state, you may get into trou-ble by approaching too many pleasurable activities. In contrast, whendepressed, you have no interest in anything, and you may just sit in achair or stay in bed. The approach-pleasure-reward system is shutdown. Nothing matters, and you cant look forward to anything.

Whereas depression can beseen as an absence of positivemood, anx-iety is the presence of negative mood. On this dimension, the low end isfeeling calm, relaxed, and content. The high end is feeling anxious andfrightened. You want to withdraw. An extremely painful combinationof depression and anxiety is agitated depression, in which you feel rest-less and cant sit still. Pacing is a common form of agitation. You can bementally agitated as well, worrying or ruminating, unable to stop think-ing. In my view, anxiety feeds into depression because it wears you outand saps your energy, not to mention also robbing you of pleasure andenjoyment. Depression also contributes to anxiety, for example, whenyou must face a situation you feel you cannot handle because youre sodepressed.

Think of depression and anxiety as involving two circuits in the brain.To get out of depression, the positive emotion-approach circuit needs tobe turned up; to get out of anxiety, the negative emotion-withdrawal cir-cuitneeds to be turned down. Researchhas localized these two circuits todifferent sides of the brain, both in the frontal areas. The pleasure-ap-

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proach circuit is predominant in the left hemisphere, and the anxi -ety-withdrawal circuit is predominant in the right hemisphere. Thuspersons who are prone to distress show more activity in the right hemi-sphere and less in the left hemisphere. These individual differences havebeen observed as early as infancy, and they have also been observed innonhuman primates. These differences in brain functioning also relate tobroad personality characteristics. Extraversionbeing outgoing and so-ciableisassociatedwithpositive emotion, and neuroticismpronenessto distressis associated with negative emotion. Thus researchers arenow linking personality characteristics that relate to depression and anx-iety to stable individual differences in brain functioning.

Given the likelihood of having to struggle with both depression andanxiety, you have two challenges. On the one hand, being depressed,you need to activate yourselfto develop more energy and interestin things. On the other hand, being anxious, you need to de-activateyourselfto feel more calm and relaxed. Controlling depression andanxiety is quite a balancing act. If you can get yourself absorbed andengaged in relaxing activities, you might even be able to accomplishboth at the same time. If these relaxing activities involve some contactwith other people, so much the better. But socializing when youre de-pressed and anxious is no small challenge. Depression and anxietypresent a double-whammy that promotes social disengagement. Beingdepressed, you may have little incentive to be with other people, be-cause the pleasure is not there. Being anxious, you may be inclined toactively withdraw from other people. Engaging in social contacts thatdo not demand a great deal of interaction may provide a middleground.

What good is depression?Its easy to understand why evolution equipped us with anger and fear.They are part of the self-protective fight-or-flight response. When weare threatened, we feel angry and fight back or become frightened andrun away. Why did evolution equip us to become depressed in responseto stress? This is not so easy to understand. Here is a simple idea: Whenstress is overwhelming, your body shuts down at some point to preventitself from completely burning out. The model here is the infant whocries herself to sleepsleep is a protective shutdown response. Thisconservation-withdrawal theory is appealing, but there is a big problemwith it: Depression usually doesnt lead to restful sleep. You may with-draw and retreat, but you cant necessarily rest. You may have insom-nia, and you may be agitated. Depression, unfortunately, is not restful.It is a high-stress state, physically and psychologically, intermingledwith anxiety.


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Heres another idea about an adaptive response gone awry. You be -come depressed when youve lost somethingan important relation-ship or a valued goal. When the situation appears hopeless, continuingto strive toward a goal would be counterproductive. You need to let go.Depression forces you to disengage, to let go of the unattainable goal.We are taught, I think, that giving up is a bad thing. But too much per -sistence is also a bad thing; it can be futile and wear you out. I think giv-ing up is an underrated coping strategy. The challenge is to knowwhento give up. But giving up is emotionally difficult. Depression forces yourhand. It forcesyou to stop striving and to let go. But it goes too far. Youmay lose interest in all goals. The approach-pleasure system shutsdown.

Heres another idea that best fits the relationships between depres-sion and trauma. Think of depression as a response to oppres-sionfeeling overpowered by someone. Think of the animals in thetraumatic learned helplessness experiments, overpowered by the situa-tion set up by the psychologists. When subjected to inescapable shock,many of the animals would just lie down and give up, showing signs of depression. When the experimenter made it possible for them to escape,the animals remained depressed and didnt learn. These animals weretraumatizedoppressed and depressed. Fear does you no good whenyou are overpowered; you cannot escape the oppression. And when youare overpowered, fighting back in anger may only get you hurt worse.Giving up and submitting may be the most self-protective thing you cando. Depression takes over and forces you to submit. It protects youfrom getting into more danger. But it goes too far. You may give up oneverything, and you may remain depressed even when youre no longerin danger or when youre in a position to do something to overcome theoppression.

All these theories about the adaptive functions of depression sug-gest that depression has a purpose, but it is overdone. Depressioncould be considered a signal that you are feeling overwhelmed andoverpowered. You cannot reach your goals, and somehow you mustdo something differently. But you keep pushing yourself, to no avail.Depression stops you in your tracks. Viewed as a signal, depressionshould be heeded. Being able to tolerate depression is an importantstrength. To tolerate it means to allow yourself to feel it and under-stand where its coming from. Its a signal that your goals and strate-gies (or your stressful lifestyle) need to be reconsidered.Unfortunately, depression goes beyond being a signal to being a seri-ous illness that impairs your ability to cope. When you recover fromdepression, you can learn to heed the signals of mild depression to pre-vent yourself from sliding into deeper depression.

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such stressful events becomes depressed. This is where genetics (andmany other factors) come into play.

There is very clear evidence of genetic vulnerability to depression.You may be surprised to learn that genes also contribute to two otherfactors that play a role in depression: exposure to stress and availabil-ity of social support. Think of it this way. Genetic factors contribute topersonality characteristics, and personality characteristics contributeto stress and social support. For example, being a risk taker could leada person into more stressful situations. Being sociable could providegreater opportunities to create a network of social support. Geneticand environmental factors are always interacting with each other, andpersons with a combination of genetic vulnerability and severe envi-ronmental stress with little social support are at highest risk for de-pression.

Genetic factors are not the only form of biological vulnerability todepression. Many general medical conditions can contribute to depres-sion. These include endocrine disorders (e.g., thyroid disease), infec-tions (e.g., HIV), degenerative diseases (e.g., Parkinsons disease),cardiovascular problems (e.g., stroke), and some forms of cancer. Thusit is essential to obtain a thorough medical evaluation to investigatesuch possible causes of depression, even if the depression seems to havebeen brought on by a major stressor. It is crucial to rule out or diagnoseand treat such conditions. Another important biological vulnerabilityfactor is aging. Partly as a result of increasingly accumulated stress withage, resilience to stress can decline, and vulnerability to depression inthe face of stress can increase.

Although we need to pay most attention to the effects of depressionon the brain, it is also important to keep in mind that depression mayhave widespread effects throughout the body.The endocrine system is amajor player in depression, and stress hormones in particular have beenstudied extensively. Ordinarily, the secretion of stress hormones isadaptive by preparing the body to cope actively. Yet these hormonalstress responses also must be shut down promptly, and these shutoff mechanisms are not working properly in depression. Again, depressionis a high-stress state with many physical consequences. You may havetroubleeating and sleeping, andyour immune function may becompro-mised. In addition, early stress may affect the functioning of the endo-crine systemsuch that later stress ismore likely to bring on an episode of depression.

Attachment and depressionWe know that loss, such as the death of a loved one or the breakup of aclose relationship, is a common stressor that triggers depression. The

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role of loss in depression draws attention to the importance of attach -ment relationships in understanding depression. Put simply, disrup-tions in attachment relationships can contribute to depression, and thesupport of secure attachments can play a role in recovery from depres-sion as well as in preventing recurrence.

The mother-infant bond is the prototype of attachment. Attachmentrelationships serve the function of providing protection and security,and secure attachment is important to well-being across the life span.

John Bowlby developed attachment theory in studying infants placed inan orphanage.Heobserved that protest followed by despair was a com-mon reaction to separation. The protest reaction is adaptive becausecrying out draws the mothers attention. But with continued separa-tion, continued protest would not be adaptive, and despair sets in. Thusseparation-related despair is theprototype for depression in response toloss. This response to separation is identifiable in infancy, and it is alsoidentifiable in other mammals. Loss at any time in lifemay bring on thisfundamental reaction.

Secure attachment relationships protect us from stress. The essenceof a secure attachment relationship is being confident that your attach-ment figure will be available and responsive in times of distress. Seekingcontact will bringa feeling of comfort and security. Unfortunately, inse-cure attachment relationships are a source of stress. Typically, insecu-rity takes one of two forms. Persons who are avoidant try to managetheir distress without relying on others. Persons who are ambivalentfeel a strong need for contact and comfort but fear being hurt or letdown, and they often feel a great deal of frustration or hostility towardthe attachment figure. Both isolation (avoidance) and stressful contact(ambivalence) can be depressing. Thus part of the treatment for depres-sion is working on developing more secure and stable attachments.

Maternal depression and attachment Separation, loss, and conflict in attachment relationships can contrib-ute to depression. But depression in attachment relationships also canbe contagious, even in infancy. Tiffany Field and her colleagues inten-sively studied the interactions of depressed mothers with their infants.She found that depressed mothers are relatively unresponsive to theirinfants, and depressed infants interact less positively with their mother.Normal mother-infant interactions involve a kind of dance of mutualresponsiveness that involves coordination of gaze, vocalizations, andbody movements. In depressed mother-infant interactions, there is lessmutual responsiveness, although depressed mothers and their infantsare often locked in closely matched statesof negativeemotions. Thus in-fants as well as their mother show depressed behavior.


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The effects of maternal depression on infant behavior can be wide-spread, affecting behavior and physiology. Notably, interacting with adepressed mother can be even more stressful to an infant than physicalseparation. If the mother remains depressed for more than 6 months,negative effects can persist over the years to come. Yet infants whoshow depressed behavior with their depressed mothers can perk upwhen they interact with familiar adults who are not depressed, such astheir father or a nursery school teacher. Thus nondepressed adults canhave a buffering effect.

Research on maternal depression shows that depression can belearned early in life. And the research shows that depression can becatching, as we all know from adult relationships. But this research alsoshows that interactions with other persons who are responsive are apathway out of depression, both earlier and later in life.

Attachment traumaMany persons who struggle with severe and persistent depression havea history of extreme stresstrauma. A landmark study on the social or-igins of depression in women conducted in London by George Brownand colleagues showed that those who experienced major depressiontypically had experienced either a severe lifeevent (e.g., death of a lovedone, divorce, loss of a job) or an ongoing difficulty (e.g., marital con-flict, caring for a very difficult child) before the onset of depression. Yetmany women who encountered such stressors didnot suffer a major de-pression. What made the difference? Later research discovered thatmany of those with less resilience had a history of childhoodtraumaabuse and neglect. Could it be that those who had a history of childhood trauma were more vulnerable to later stress? Yes, for bothpsychological and physiological reasons.

The essence of trauma is feeling extremely frightened and alone,without support. There are many sorts of trauma, ranging from torna-does to assaults, and trauma can involve either a single event or re-peated events. Trauma can befall a person in childhood or adulthood orboth. In my view, trauma in attachment relationships (e.g., abuse andneglect by caregivers or romantic partners) is especially likely to havesevere consequences, depression among them. Attention has rightly fo-cused on abuse (sexual, physical, and emotional), but it is also impor-tant to recognize the impact of isolation and neglect, both of which areassociated with depression. Trauma in attachment relationships inchildhood is especially worrisome because it affects the development of the child. For example, childhood trauma can contribute to developingdepression early in life, often in adolescence. Childhood depression can

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interfere with social relationships and schoolwork, and it can lay afoundation for depression later in life.

Many persons who have a history of severe trauma suffer fromposttraumatic stress disorder along with depression. Posttraumaticstress disorder involves reliving the trauma, for example, in the formof flashbacks and nightmares. Combining these two disorders mixesanxiety and depression. Darwin wisely said that fear is the most de-pressing of the emotions. Many traumatized persons would agree.Thus treatment for trauma must be combined with treatment for de-pression. Fortunately, one class of frequently used antidepressants, se-lective serotonin reuptake inhibitors (SSRIs), can be helpful forposttraumatic stress disorder (and other anxiety disorders) as well asdepression.

Stress pileup and sensitizationAlthough genetic factors will influence your response to stress, enoughstress is liable to plunge almost anyone into depression. The simplestway to understand the development of depression is to think in terms of a pileup of stress over the lifetime. If the stress is manageable, you maybecome better at coping. If the stress is overwhelming, your coping maybe increasingly undermined. Everyone has a mixture of ability to copewith stress and vulnerability to being overwhelmed by stress.

Ideally, we would like to become desensitized to stress. That is, if we encounter something that is stressful and frightening, the more weare exposed to it, the less upset we become over time. For example,you might have a fear of speaking in public. Yet, after you do it a num-ber of times, you feel less distressed about it. Unfortunately, repeatedexposure to extreme stress can have the opposite effect. The more youencounter the stressful situation, the more upset you become. Atworst, exposure to a series of stressful events can make you morerather than less reactive. You might get to the point of being so sensi-tized that even relatively minor stressful events can lead to a severe re-action. This is a physical process; your nervous system can becomemore reactive.

Asyou well know, depression itself is a major stressoron top of theother stressors that led up to it. You may become sensitized to depres-sion, such that an episode is set off by increasingly minor stressors. Oryou might have more frequent episodes. Psychiatrist Robert Post hascautioned that episodes beget episodes. It is important to be aware of sensitization for two reasons. First, you should not blame yourself forit. Second, it underscores the importance of doing everything you can tostay well and to minimize additional episodes of depression.


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Sensitization has been conceived of as a physiological process. Stresspileup captures the psychological perspective. Many persons who seekinpatient treatment for depression can readily identify a pileup of stressin the days, weeks, or months before hospitalization. But, with the con-cept of sensitization in mind, we can also think of stress pileup over thelife span. Stress in childhood and adolescence can be followed by stressin adulthood. Sometimes the stress in adulthood that precedes depres-sion takes the form of discrete stressful life events (accidents, illnesses,breakups in relationships) or ongoing life difficulties (marital conflict,struggling with a difficult child, caring for an ill parent).

I have also been struck by the contribution that a stressful lifestylemakes to stress pileup. This might include anything from being a work-aholic to frantic caregiving in relationships. Such a lifestyle may becharacterized by a feeling of running, going 90 miles an hour, all day,day after day. Often stressful events and difficulties are piled on top of astressful lifestyle. Eventually, such stress may lead you to crash or hitthe wall. From this perspective, depression entails being worn out andgiving up. Keep in mind that depression is physical. You may want tokeep going, but your body quits cooperating. As you begin to slide intodepression, you may push harder, but your energy keeps declining.Eventually, you reach your limit, and you cant keep going.

Although I have been emphasizing external stressors, your internalexperience also can be a major part of the stress pileup. That is, if youcontinually berate yourself or feel guilty, you are subjecting yourself torelentless psychological stress. Other examples would include beingperfectionistic, constantly worrying, or being stuck in ruminatingabout problems or your failings or inadequacies. Thus finding ways tolet up on the internal pressure is another important part of the treat-ment of depression.

The depressed brainThe discovery of antidepressant medications has drawn widespread at-tention to the idea that depression results from a chemical imbalance.This is a helpful idea in one respect: It promotes the idea that depressionis a physical illness. But the idea of a chemical imbalance is not particu-larly informative. Its relatively mindless, in the sense that the physicalproblem (chemical imbalance) doesnt obviously relate to mental func-tioning.

Neuroimaging technology now allows researchers to study the brainin action, for example, by measuring changes in blood flow and glucoseutilization in different parts of the brain. To illustrate, weknow that formost persons language tends to be localized in the left cerebral hemi-sphere. Neuroimaging shows that brain activity increases in the left

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hemisphere when individuals are engaged in language tasks. Theseneuroimaging techniques are now being used to study patterns of brainactivation associated with depression. Beware that this is a relativelynew area of research, and we are a long way from conclusive findings.Also, many different areas of the brain participate in emotional feelingsand behavior, and there is no reason to think that depression would beassociated with a specificchange in any single area. On the contrary, re-search has shown changes in brain activity (increases and decreases) inmany areas in conjunction with depression.

But I want to highlight two areas of the brain that show altered func-tioning in depression: the amygdala and the prefrontal cortex. Theamygdala is an evolutionarily older partof the brain,deep in the tempo-ral lobe. The amygdala senses danger and plays an active role in ourlearning to avoid objects, situations, or persons who are hurtful. Theamygdala is sensitive to facial expressionsespecially threateningones. Some neuroimaging research shows that there is a greater amountof amygdala activity in persons with depression. This activity is consis-tent with a strong association between depression and anxiety, as wellas the experience of depression as a high-stress state.

Changes in the prefrontal cortex also have been observed in depres-sion. In general, the front part of the brain controls action, and the backpart of the brain specializes in perception. The front-most part of thebrain, the prefrontal cortex, is the most evolutionarily advanced part of the brain. You can think of it as the executive part of the brain.Prefrontal activity is involved with planning and flexible responding.

Just think of being in a situation where you have many things to do. Youmust keep track of them all, decide what youre going to do when, andfigure out how youre going to squeeze them all into a certain period of time. Or think of what it takes to engage in a lively conversation withseveral peopleor even one person. This is what keeps your prefrontalcortex busy.

Neuroimaging studies have found decreased activity in prefrontalcortex in conjunction with depression (although some studies havefound increased activity, which was interpreted as a propensity to rumi-nate). One particularly noteworthy study examined depressed andnondepressed persons while they were engaged in a complex prob-lem-solving task. Previous research had shown this task to be sensitiveto cognitive impairments in depression and also had shown what brainareas are normally activated by the task. The task involved a combina-tion of relatively easy and relatively difficult problems. Depressed per-sons showed distinctly less prefrontal activation when performing thedifficult problems. They were unable to persist in the mental effort tosee the problems through to solution. Thus such research is beginning


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to show a direct link between brain functioning (decreased prefrontalactivation) and mental functioning (decreased problem-solving ability).

Thus we might start to think beyond the idea of a chemical imbal-ance to thinking about what it feels like when parts of your brain thatnormally participate in problem solving are not optimally activated.There is good reason for you to have difficulty with concentration,memory, and problem solving. When a great deal of mental effort is re-quired, your mind might just shut downyou cant think. You mightbe more easily overloaded in a situation where there is a lot of stimula-tion and you have to sort it all out. Keep in mind, though, that researchshows somewhat decreased activity in certain brain areas; the braindoesnot shut down entirely. This is not an all-or-none situation. But wecan now begin to understand why it is harder to think when youre de-pressed. I believe that this research may also shed light on why yourthought patterns are more likely to get stuck when you are depressed;your capacity for flexible thinking normally supported by theprefrontal cortex is lessened. This is one reason why you are likely toneed the help of other people to get unstuck.

The depressed mind There is no one mental state associated with depression.Depression canbe exquisitely painful. You may feel so agitated and distressed you wantto crawl out of your skin. You may feel extremely guilty. Or you mayfeel empty, numb, incapable of feeling much of anything. Feelings of low self-worth are extremely common in depressionfeeling worth-less, useless, or even bad or evil. Some researchers believe that lowself-esteem is an important pathway from stress into depression.

Regardless of the form it takes, depression is a state of mind that islearnedalthough not deliberately! It is a state of mind that can be-come habitual, easily triggered when something goes wrong. In thatsense, depression is like a black hole that has a strong gravitationalpull in the mind-brain. It is easy to get sucked into it if you get near theedge. Staying out of depression requires resisting its pull, not giving into it.

The habit of depression can be learned early, for example, in the con-text of maternal depression or childhood trauma. And we know thatthe more often you have been in a depressed state of mind, the morelikely that you will enter into this state in the future. Part of your stresspileup may include a pileup of experiences of depression over your life-time. Its not uncommon for patients to reportbeing depressedon andoff, or at some levelsince childhood or as long as they can remember.Depression in adolescence is increasingly common and increases therisk of further depression in adulthood.

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Activity level A good next step after attending to your physical health is to work onyour activity level. Again, a catch-22: If youre depressed, you donthave the energy or motivation to do much of anything. Small stepshere. We know that exercise (e.g., aerobic exercise) is a good antide-pressant. Its also a good antianxiety activity. But its not likely youllhave the energy to do vigorous exercise if youre severely depressed.Getting out of bed and getting bathed and dressed can feel like climb-ing a mountain. Once you can get yourself going, holding to a regularschedule or structurea plan for activity throughout the daywillbe important. When youre getting well, you mightconsider exercise.Youll need to work up to it. Mind you, were not talking about en-joying activity here. Rather, the goal is just trying to get yourself go-ing.

Seeking pleasureAfter activity, Id focus on attempting to experiencemore pleasure. Youcan force yourself to take action to a certain degree, but you cannotforce yourself to feel pleasure. You can only provide yourself with theopportunity to feel pleasure. Because anxiety interferes with pleasure,learning and practicing relaxation techniques can be of some help inthis regard. Imagery, meditation, biofeedback, and deep breathing areexamples.

One aspectof behavior therapy for depression entails listing all activ-ities that have provided pleasure for you in the past and making a planfor doing them in a regular, systematic way. This is a good idea, and itsworth putting time and effort into it. But remember that the core of de-pression is low positive emotion. The pleasure circuits arent workingproperly. They need to be jump-started. I think you can jump-start themwith activity. All you can do is put yourself in situations where youmight experience some pleasure.

At first, youre more likely to feel a spark of interest, involvement, orabsorption in something rather than outright excitement, pleasure, orplayful joy. Thus you might start by just trying to get yourself engagedin something that will take your mind off your suffering for a bit. Youmight try to be moreaware of moments of interest or slight glimmers of pleasure. They wont lastyoure depressed. But they might increase infrequency and duration over time. Some persons whove been de-pressed hit on something they enjoy. Then, understandably, they do itin an addictive way. They overdose on the activity, it becomes stressful,and the pleasure wears out. Go slowly with pleasure; its best not to tryto force it.

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Thinking flexiblyAfter pleasure Id tackle thinking. This is getting into the complicatedterritory of cognitive therapy. Cognitive therapy is proven to be effec-tive in treating depression. Yet some patients are put off by cognitivetherapy because of a misunderstanding. Aaron Beck, who developedcognitive therapy for depression, cautioned that cognitive therapyshould not be confused with the power of positive thinking. He empha-sized that cognitive therapy does not mean thinking positively butrather thinking realistically. I would also emphasize that changing yourpattern of thinking isdifficult. Itshard work, and it takes a long time. If you think its supposed to be easy, you will feel like a failure at cognitivetherapy, and youll only feel more depressed. This is not how cognitivetherapy should work!

I look at it this way: Your mood has your thinking by the tail. If youre depressed, you cannot stop thinking negatively. Even if yourenot depressed, you cannot stop thinking negatively! Everyone hasnega-tive thoughts and, if youre depressed, you have tons of them. Theyreautomatic, like reflexesthought reflexes. You cannot stop your re-flexes. And, in my view, many of the negative thoughts in depression arenot unrealistic or distorted. Bad things have happened, and they havebad implications. Thats one reason why youre depressed! These auto-matic reactions lower your mood, and then you have negativethoughts.The challenge is to avoid gettingstuck in these negative thoughts, rumi-nating about them, and then going down further into the pit of severedepression.

What you can do, if youre not extremely depressed, is get a grip onyour negative thinking and create more flexibility in your mind. Themost important step you can take is to learn to question your negativethinking. You reflexively have the negative thought (I really screwedup), but then you can be aware of it and question it, taking anotherpoint of view on it (To err is human). Theres nothing wrong withhaving negative thoughts, but it is important to focus your negativethinking. The problem is not negative thinking per se but rather global negative thinking (Im a completely worthless human being, alwayshave been, and always will be). After thinking Im a total screw-up,you might think, I screwed up this one thing today, not everything to-day. Then you might even offset this by thinking about something elseyou did well. The goal is not to switch from focusing on the half-emptyto the half-full viewof theglass,but rather tobeable tosee that the glasscan be both half-empty and half-full. You fail, and you succeed. Betterfocused negative thinking also can lead to problem solving. If you fail atest and think, Im a total loser, you are stuck. If you think instead, Ishould have studied harder, you have a direction.


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Thus you can be bummed out, think negative thoughts, and yet pullyourself out of the spiral rather than getting stuck in rumination. Easiersaid than done, especially when youre depressed. This is extremelyhard work. I think its very hard to control your thinking, and most pa-tients I talk with agree. Its easier when youre feeling calm, and itsharder when youre feeling upset or depressed. Controlling your think-ing is a difficult skill that can only be increased in increments across thelifetime. The catch-22: You could be better at it if you werent de-pressed. In keeping with this idea, a recent approach begins cognitivetherapy after recovery from depression with the goal of preventing re-lapse and recurrence.

Mentalization and mindfulnessIts a misapplication of cognitive therapy to believe that you must ramnegative thoughts out of your mind with positive thoughts. We shouldshift our focus off the specific content of our thoughts (i.e., badthoughts like Im a rotten person versus good thoughts like Im agreat person). Instead, we might focus more on the process of think-ing. Thats why I emphasize increasing theflexibility of thinking, ratherthan thinking one kind of thought instead of another. The challenge isto see the same things from more than one point of view, rather than re-maining stuck ruminating in a depressive rut. Again, this is not easy todo, especially when youre depressed.

The concept of mentalization is helpful in understanding flexiblethinking. To mentalize means to interpret human behavioryourown and others behavior-in terms of mental states . We do this all thetime, often without being aware of it. You sense that your friend is up-set, and you show concern on your face. When interactions with othersdo not go smoothly, you may mentalize more consciously, wondering,Why did she do that? What could he have been thinking? Like-wise,youcanbepuzzledbyyourownbehaviorandwonder,WhydidIdo that? Thus we mentalize a lot, yet perhaps not enough.

Again, to mentalize means to be aware of mental states. Considersome common failures of mentalization. You can be insensitive or tact-less, unaware of the impact of your behavior on another persons stateof mind. Generally, when we are aware of others mental states, we be-have in a more compassionate way. You can also be insensitive toyour own states of mindbeating yourself up in your mind with end-less self-criticism, driving yourself deeper into the pit of depression, notmindful of how youre treating yourself, providing little room for com-passion toward yourself.

But I want to emphasize a different kind of failure tomentalizeconfusing mental states with reality or truth. The best

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example is dreaming, which is a nightly failure to mentalize. We dontrealize (except in lucid dreaming) that the dream is a mental state. Itfeels utterly real. If we have nightmares, we might awaken in a state of terror, feeling in danger, until we realize (mentalizing), It was just adream. Here is another example: Persons who have gone throughtraumatic events (e.g., being assaulted) are liable to develop flashbacks.A flashback is a memory of being in a traumatic situation that is so vividit feels as if you are back in the situation, reliving it. It is a failure tomentalize.The person isnot aware that it is a memory (mental state)butrather feels as if the traumatic event is really happening again (presentreality).

Another exampleof failure to mentalize is getting into a paranoidstate. Have you ever started to worry about being disliked or thoughtthat peopleare talking about you critically? Or, when alone in the dark,have you ever started to imagine being harmed or attacked? Many of ushave such thoughts and fantasies. But we fail to mentalize when we losesight of the fact that these are our thoughts and fantasies and we actu-ally become angry or frightened, as if our thoughts and fantasies are adirect reaction to a current reality. We confuse worrying with being indanger, a mental state with reality or truth. When we have the thought,My imagination is running wild, we are back to mentalizing.

What does all this have to do with depression? Consider the personwho makes a mistake and then thinks, Im a worthless human beingwho doesnt deserve to live, then slips into a feeling of self-hatred and,at worst, becomes suicidal. These reactions to making a mistake aremental states, but they are easily confused with reality or absolute truth.The self-hatred is likea dream that feels realit is a mental creation. Tomentalize means to beable to develop somedetachment fromsuch men-tal states and to be aware of them as such. There are many other possi-ble mental states one could get into after making a mistake (e.g.,momentary irritation, self-justification, blaming someone else, dismiss-ing it as insignificant). And mental states are temporary, although de-pression can be highly persistent. Ideally, such mental states can passquickly from one to another. Self-criticism can be a quickly passingmental state, which you can take for what it isa mental state, not anabsolute truth or reality. Mentalization can be the pathway from lowmood and negative thinking back to a nondepressed state, an alterna-tive to the ruminating pathway into the pit of depression.

When you express negative thoughts, you might have been told,Thats just your depression talking. Some patients find this to be anoff-putting response. Itmay seem to dismiss the seriousness of your feel-ing or perhaps to imply that you should easily shake off these thoughts.


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Its not easy to mentalize in the middle of a depressed state, to standback and reflect, to consider that there are other points of view, to letthe state pass. On the contrary, depression has a way of locking you intoa rut. Keep in mind that changes in brain functioning (in the prefrontalcortex) may make this difficult. Heres another catch-22. Its helpful tothink flexibly and to be aware of your mental states, but the depressionis interfering with your brains capacity to do this. You tend to get stuckin the same pattern of thinking rather than being able easily to shift outof it. Its difficult, but not impossible.

There is an ancient practice, called mindfulness meditation, that in-volves becoming more aware of your mental states. Its like training formentalization. There are many aspects to mindfulness. For example,mindfulness involves being more aware of the present rather than lost inthe past or worrying about the future. You may learn to calm yourself byfocusing your attention on one object, for example, your breathing. Butanother facet of mindfulness training involves taking a somewhat de-tached perspective on your own mind, observing your mental states withinterest and curiosity, rather than becoming swept up in one or anothertrain of thought. You can learn to observe your mind without judging,being more neutral and accepting. When you are able to do this, you be-come aware of how changeable your mental states areor can beandhow it ispossible to havean infinitenumber of states of mind in thesamesituation. You can learn to take your states of mind less seriously. Theyare fleeting. They are real; yet theyrenot realityeach mental state isone among many possible perspectives on reality.

Is this mindful attitude easy to adopt? On the contrary, it is ex-tremely difficult for anyone. A Buddhist monk may spend a lifetime cul-tivating mindfulness. And it will be most difficult when you aredepressed. I think learning to control your own mind-brain is one of themost difficult things you might aspire to do. But there are ways of prac-ticing this skill, becoming better at it with practice, and using it to pre-vent yourself from getting stuck in depressive ruminations that can takeyou from the normal state of feeling bummed out when something goeswrong to feeling utterly mired in depression. Some recent research indi-cates that mindfulness practice along with cognitive therapy can helpprevent relapse into depression.

The greatest challenge with mentalizing is to be able to do it in theheat of the momentto be able to feel intensely, be aware of your feel-ings, and think about what youre feeling, all at the same time. Considerwhat it takes to sustain hope while feeling hopeless. This requires nosmall amount of mental flexibility. Practicing mindfulness when yourenot in the heat of the moment might better prepare you to be able tomentalize when the heat is turned up. Think of this as a skill, like play-

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ing the piano. Youd not want to be thrown into giving a concert if youd not practiced. Or think about needing to run from danger. Youdnot want to be out of shape when the bear is charging. Few of us areconcert pianists or Olympic runners. But long practice can lead to somedegree of skill, which can be employed when the going gets tough.

RelationshipsIve saved the most complex for last. There is a thicket of catch-22s inthe interpersonal domain of depression. If its difficult to control yourown mind, how difficult must it be to keep your relationships in bal-ance? Theres a big catch-22 here: Often problems in relation-shipsconflicts, losses, and breakupsplay a major role in triggeringdepression. Often enough, a history of traumatic relationshipsabuseand neglectplays a role in the history of depression. Thus relationshipproblems are often major contributing causes to depression. The catchis this: Supportive, caring relationships are an important aspect of heal-ing from depressionand preventing relapse into depression. We havea problem when the cause of depression is also the remedy.

If youre depressed, youve doubtlessly been encouraged to seek sup-port. You may have heard, perhaps countless times, Dont isolateyourself from others. If youve been hurt by others, you are likely towant to withdraw. Even without a history of being hurt by others, de-pression prompts you to withdraw. Recall the idea of pleasure circuitsin the brain, which are somewhat shut down in depression. Commonly,pleasure is associated with contact with others. Those who are morecheerful tend to be more sociable; theyre extraverts. Contact withother persons is a major source of pleasure for many persons. Whenyoure depressed, you dont find activities interesting and pleasurable,and this includes socializing with others. You might want to crawl intobed and turn your face to the wall.

Also, when youre depressed, contact with others can be very stress-ful. Depression tends to be contagious, and you have a sense that othersdont want to be exposed to it. They withdraw from you. In addition,when youre depressed, you are inactive. You may not talk much, makemuch eye contact, smile, or show much facial expression. You may notshow an interest in others, but rather you may be quite self-preoccu-pied. You dont make a very good conversational partner. Or you haveto force yourself, and it wears you out to do so. Thus others may notfind it easy to interact with you, and you may encounter either subtle orblatant rejection. Rejection fuels your wish to withdraw as well as yourfeelings of inadequacy and negative thinking.

Heres yet another problem. Youre encouraged to reach out for sup-port when youre distressed. Its quite likely that youve done so. But


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one very common trigger for depression is a negative consequence of reaching out for support. You can feel let down when the support is notforthcoming. Often, the feeling of being let down is the last straw thattakes a person from distress to despair. When you reach out for sup-port, you are taking a risk, and it can go badly and make your depres-sion worse. No wonder persons who are depressed tend to withdraw.

Finding social support is difficult but not impossible. As with all theother catch-22s, the best way to work with them is to set modest goalsand go slowly. Trying to cheer yourself up by going to a lively party, asothers might encourage you to do, can backfire. You can wind up feel-ing even more alienated and alone. Quiet, low key social situations thatdont demand so much responsiveness are more manageable. Going toa movie is a good exampleyou dont have to keep up a conversation.The challenge will be to make contact with others who have some toler-ance for depression. Those who have poor tolerance for depression areliable to try to cheer you up, talk you out of it, or even becritical. Heresan even greater challenge: One study found that those who receivedmost support had conveyed that they are coping OK and have othersources of support. The supportive person presumably was able to offermoresupport because heor she did not feelunduly burdened, totally re-sponsible for the distressed persons welfare.

The helpers tightropeSeeking social support when youre depressed can be a bit of a mine-field. Part of the challenge of mentalizing is being aware of not onlyyour own mental states but also the mental states of others. Its a lot toask that you do both, but awareness of your potential support figuresmental states may allow you to avoid setting off some of the mines.

I think there is a delicate balance that people need to maintain to beof help to a depressed person. I think of the helper as being on a tight-rope in the sense that its easy to fall off in one direction or the other.Staying on the tightrope entails providing steadfast, gentle encourage-ment. Providing support doesnt necessarily require doing anything,much less fixing anything. Rather, what is most helpful is an acceptingattitude and a willingness to be there so that the depressed person atleast does not feel so totally alone.

Yet, quite often, helpers feel they need to do something to pull youout of depression. And they may have a strong urge to do so becauseyour depression is depressing, distressing, or frustrating to them. If youare suicidal, the helper is likely to feel downright frightened. Short of being suicidal, when you dont recover quickly despite the helpers ef -forts, the helper may feel helpless and inadequate. Ironically, the more

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the helper cares about you, the more frustrated and anxious the helperwill become.

When the helpers support fails to beeffective, there are two ways thehelper can go wrong. I think the natural inclination is to push harderand to becomecritical (at worst, If youd justget up off your...).Aftercriticism also fails, the helper may be inclined to give up and withdraw.This leaves the depressed person being alternately criticized and aban-doned, both of which fuel depression.

At best, those who want to support you are in a difficult situation.They too are at risk for becoming distressed, frustrated, and depressed.It is a lot to ask of you when you are depressed, but it is likely that youwill need to coach your helpers, letting them know whats more helpfuland whats less helpful. This is not easy for you to do, and it may not beeasy for the helper to hear. To feel criticized for not helping in just theright way also can be very discouraging and frustrating. But often help-ers need reinforcementthey need to hear that they are being helpful.And they may need to learn that just being there, without doing any-thing or fixing anything, is whats most helpful. Mainly, you will bene-fit from understanding and a compassionate attitudeprecisely theattitude that is important to try to cultivate in your own mind, towardyourself.

Tackling the stress pileupMy focus here has been on depression as a primary problemin effect,how to manage it and recover from it. But depression is typically a re-sponse to other problems, the resolution of which is critical to full re-covery and prevention of recurrence. In some ways, recovering fromdepression is only the first stepit can give you back the energy andwits to cope with the problems that brought on the depression.

Thus recovery can help return you to a more effective problem-solv-ing mode. Tackling and resolving problems can decrease stress. This ap-proach is likely to require that you assert yourself and make changes inyour lifestyle such that you are not so overwhelmed and oppressed. An-other catch-22:Lifestylechanges can entail significant losses, which canalso be depressing. Yet, having become depressed, you must be mindfulof your vulnerability to stress.

Given the risk of recurrence of depressive episodes over the lifetimefor a person with a history of major depression, I think it is best to takethe hard place view that implies lifelong self-care. At some point,self-care may become routine and may take relatively little effort. Par-ticularly in the face of many life stressors, however, self-care periodi-cally will take a major effort. A lifelong issue will be learning tominimize and manage stress to the extent possible. In principle, some


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stress is avoidable (e.g., stress associated with problematic personalityand relationship patterns or with a lifestyleof running). Unavoidablestress, however, is like a wild cardyou cant prevent it, and it couldoccur at any time. Some unavoidable stress at least can be anticipated(e.g., the death of a loved one who is gravely ill), which might facilitatecoping.

Integrated treatment Several forms of treatmentmedication, electroconvulsive therapy, be-havior therapy, cognitive therapy, and interpersonal therapyhavebeen demonstrated to be effective in promoting recovery from depres-sion as well as in relapse prevention. Collectively, all these treatmentsaddress all the domains of catch-22s discussed here.

Antidepressant medication is often employed as a first-line treatmentof depression, although psychotherapy also can be a viable alternativeto medication. Many research studies show that combining psychother-apy and medication is the optimal approach. Psychotherapy can be em-ployed to facilitate recovery when medication is only partially effective,and psychotherapy can be employed along with medication to decreasethe risk of relapse or recurrence. Keep in mind thatone of the mostcom-mon problems in treating depression is giving up on treatment prema-turely. Continuing on medication well after recovery and taking greatcare in collaboration with your doctor about discontinuing medicationis essential to preventing recurrence. You may not need to remain inpsychotherapy continuously, but you might find it helpful to return totherapy periodically for support during times of extra stress. Gettingthe level of care you need when you need it is just what you would dowith other physical illnesses.

Appendix

Guide to pertinent literature

The following overview of the patient education material includes keyliterature citations that provide documentation for the main points.This literature review parallels the organization of the patient handout,where these points are discussed at greater length.

Depression as illnessFollowing the model of interpersonal psychotherapy (Klerman,Weissman, Rounsaville, & Chevron, 1984), we present depression as a

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serious illness. The National Comorbidity Survey (Blazer, Kessler,McGonagle, & Swartz, 1994) provides solid statistics on prevalence,and data documenting chronicity are all too plentiful (Keller & Hanks,1995). Of great concern is the increasing prevalence of depression, es-pecially among young persons (Hammen, 1997). In the context of whether a person chooses to remain depressed, we discuss the char-acteristics of the sick role (Parsons, 1951) and its complications inthe case of depression. The World Health Organization data on disabil-ity are shocking (Murray & Lopez, 1996). Extensive research on mor-bidity is consistent with the WHO findings (Wells, Sturm, Sherbourne,& Meredith, 1996). Notably, even subsyndromal levels of depressionare associated with significant disability (Judd et al., 2000).

It is simplest, and consistent with much research evidence (Judd etal., 1998b), to present unipolar depression as one illness that varies inseverity and duration. This view allows for the crucial distinction be-tween major depression and dysthymia, as well as the concept of dou-ble depression (McCullough et al., 2000). When discussing the courseof depression, it is helpful to distinguish among response, remission,relapse, recovery, and recurrencealthough these terms are not al-ways used consistently (Frank et al., 1991). The five-site Collabora-tive Depression Study, with its naturalistic prospective design,provides a solid anchor on the course of depression (Keller, 1999;Mueller & Leon, 1996; Solomon et al., 1997). As Michaels (2001)contends, we must continue dispelling the myth that depression is anacute illnessas Solomon (2001) and Styron (1990) have done so elo-quently. Notably, the median time to recovery from an episode of ma-jor depression, 5 months, is comparable to Kraepelins (1921) earlierestimate of the time to recover from simple attacks of affective ill-ness (i.e., 6-8 months). A wide range of variables predict duration of episodes, and it is important for patients to know that active participa-tion in treatment is a significant determinant (Mueller & Leon, 1996;Paykel et al., 1999).

Patients must be cognizant of the high risk of relapse and recurrence(Mueller et al., 1999) and especially mindful of the fact that the singlemost powerful predictor of relapse is any residual level of active illness(Judd et al., 1998a), implying that they should aspire to full recovery(Nierenberg & Wright, 1999). Predictors of relapse and recurrencehave been thoroughly investigated (Ilardi, Craighead, & Evans, 1997;Keller, 1999; Mueller et al., 1999). Considerable evidence supports therole of maintenance medication treatment in preventing relapse and re-currence (Dawson, Lavori, Coryell, Endicott, & Keller, 1998), al-though loss of efficacy is a significant clinical problem (Byrne &Rothschild, 1998). Particularly encouraging is emerging evidence for


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the value of cognitive therapy in preventing recurrence (Fava, Rafanelli,Grandi, Canestrari, & Morphy, 1998; Paykel et al., 1999).

Given the kinship of depression and anxiety as fraternal twins(Solomon, 2001, p. 65), it is helpful to educate patients about the rela-tionship between them. Specifically, depression is best viewed as lowpositive emotionality and anxiety as high negative emotionality (Wat-son, 2000). Meehls (1975) prescient view of depression as reflecting alack of cerebral joy juice (p. 299) has found confirmation in recentneurobi

Documents

Allen, J - Coping With Catch-22s of Depression, (2002)