Treatment of Depression:
Suggestions for Helping Yourself
- Depression often co-exists with anxiety disorders. Most recent
research suggests that when both disorders are present, depression
is usually a secondary complication of the primary anxiety
- Depression is a health problem that touches every part of a
person's life. All of us know what it is like to be stuck in a
depressed mood that is temporary. However, as many as 1 in 4 women
and 1 in 8 men will at some point in their lives experience a much
more severe and persistent episode of depression.
- Symptoms of depression include:
1. Ongoing sadness or irritability
2. Loss of interest or enjoyment in daily activities, including
3. Decrease or increase in appetite and weight
4. Poor sleep or sleeping too much
5. Feeling restless, anxious or worried
6. Feeling tired or like you have no energy
7. Feeling hopeless, helpless, worthless or guilty
8. Trouble concentrating or making decisions
9. Physical symptoms that don't respond to treatment
10. Thoughts about death, maybe including thoughts about
- If your physician or your psychotherapist believes you are
significantly depressed, this does not mean that you are "crazy,"
or "weak," or that you have failed somehow.
- Some people seem to be more likely to get depressed because it
runs in their family, even when they don't seem to have a
compelling reason to be unhappy. Other people seem to be more prone
to depression because of poor self-esteem, perfectionism or a
persistently pessimistic outlook about life. Still others become
depressed in the midst of dealing with an ongoing stressful
situation, a traumatic incident or a significant loss which may be
either the literal loss of a loved one or a more figurative
- Even if your depression clearly began after some very upsetting
life event, certain physical changes take place within you that
exert a powerful effect on your body, mood and thoughts. The
thinking patterns you have when depressed tend to keep you in a
"rut" that becomes self-perpetuating and that makes it hard to cope
- Although depression can be devastating to both individuals and
their families, the good news is that depression does tend to
respond to treatment. There is impressive literature to support the
effectiveness of both cognitive-behavioral psychotherapy (see
below) and antidepressant medications.
- Psychotherapy is most likely to be effective if it focuses on
changing distorted thinking, behavioral habits, ineffective
problem-solving, emotionally-skewed beliefs, or relationship
conflicts that contribute to or help to perpetuate an individual's
depression. Evidence suggests that a successful course of such
treatment cuts the risk of a recurrence of depression compared to
treatment with medication only. Treatment of depression with
psychotherapy may not provide relief as quickly as medication, but
the results may be more durable.
- There are at least 15 commonly used medications that seem to
have significant antidepressant effects. Your doctor and your
therapist can provide you with more specific information if
medication is recommended for you. In general, no single
antidepressant is more effective than any other antidepressant in
most grouped data. However, for a given individual, there may be
marked differences in effectiveness across drugs. After several
medication trials, results may range from partial improvement of
symptoms to truly transforming effectiveness. (No, antidepressants
are not "just a crutch" and, no, you cannot get "addicted" to
- If medicine is part of your treatment, be sure to take it as
your doctor instructs. These medicines are not effective if
you take them only when you are especially upset. You must maintain
a fairly constant blood level of the medicine for it to help
- You may notice some positive changes during the first week of
taking a medicine; however, it is likely that you will have to take
a medicine for at least four weeks at an adequate dose before you
can really judge whether it might help you. Do not despair if the
first choice of medicine does not work well for you. Switching to a
similar drug or switching to a chemically distinct drug often
results in significant improvement after a "failed" first or second
trial of medication. Follow your doctor's instructions and be
- Choices about medications are often driven by side effect
profiles. Most side effects of antidepressants tend to improve with
time as your body adjusts to the drug. However, some people may
experience persistent side effects (e.g., gastrointestinal upset,
activation or sedation, diminished sexual arousal or performance,
headaches, weight gain). Side effects can usually be minimized by
working with your doctor toward finding the best medication for
you, switching medications, adjusting the dose, or taking an
additional medication that either augments your antidepressant
response at a given dose or diminishes the side effects.
- There is some evidence that "natural" supplements like St.
John's Wort or SAMe may be helpful for mild to moderate depression.
Calling these substances "natural" does not mean that they
are somehow better for you, entirely safe, won't have side effects,
and won't interact with other drugs. (For example, note the recent
concerns about liver damage with kava, once thought to be a benign,
natural treatment for anxiety.) Be sure to discuss this decision
with your doctor before starting anything and keep your doctor
informed about what you're taking. At a sufficient dose, such
substances may be nearly as expensive as prescribed
- There is continuing debate about whether psychotherapy and
medication combined is more effective than either approach alone.
There is evidence both supporting and contradicting such a
recommendation based on grouped data. However, some individuals
simply do not respond unless treatment efforts are combined. There
is also some evidence that individuals who don't respond well to
one approach still have a good chance of responding to the other.
All research data notwithstanding, effective treatment for
depression must be tailored to the individual.
- There is considerable evidence that regular exercise has
antidepressant effects that may even be comparable to the effects
of antidepressant medications (see below). Check with your doctor
before starting any rigorous exercise program. Start slow: 15-20
minutes of outdoor walking or walking on a treadmill regularly is a
good starting point.
- Consider keeping a journal as a means of getting your thoughts
and feelings outside your head so that you can see them more
objectively. It may be especially helpful to divide the pages into
three columns and record daily examples of: 1) upsetting situation
or event, 2) resulting thoughts, feelings and meanings, and 3)
challenge the content in the second column by writing more
objective, less distorted, and more rational alternatives in the
third column, even if you don't always believe what you're writing.
This technique sounds simplistic, but depressed individuals who
commit to doing this on a daily basis nearly always report that it
- Be very careful about your use of substances while depressed.
Alcohol and sedatives can bring on depression or make it worse.
Depression may also prompt you to drink more coffee, smoke more
cigarettes or take other drugs that may compound feelings of
agitation, restlessness or irritability that are part of your
- If you are having suicidal thoughts, do not keep this
information from your doctor or a loved one. Keeping such thoughts
secret can be fatal. When depressed, you may well rationalize that
loved ones will be better off without you. Quite the contrary, the
suicide of a loved one usually devastates others in a way from
which they never fully recover. Allow your doctor and your loved
ones to help keep you safe while you recover.
- In addition to psychotherapy, antidepressant medication and/or
exercise, it is important to read about depression and about
practical, self-help methods for treating depression (see
Cognitive Distortions Contribute to Depression:
Depression is often perpetuated by frequent cognitive distortions
(i.e., errors in thinking) that might be apparent to an objective
listener, yet are usually left unquestioned and accepted as "fact"
by the depressed person. Learn about such distortions from the
examples below, begin to identify them in your daily thinking and,
when you do recognize a likely distortion, challenge it: "What's
the evidence for and against this thought?" "What is a more
rational alternative to this distorted thought?" "They are just
thoughts." "I am not my thoughts."
(Shearer & Kaplin-Adams)
Irrational Beliefs Contribute to Distorted Thinking and to
Depression: We often cling to irrational beliefs that distort
our thinking about ourselves and about stressful situations, thus
contributing to depression. Learn to recognize some of your
"favorite" irrational beliefs that can contribute to errors in your
thinking and to a depressed mood.
(Shearer & Kaplin-Adams)
Depression is a Vicious Circle that Effective Treatment Can
Traditional CBT focused on changing
irrational thought content.
Evolving CBT focuses more on mindfully noting
and accepting thought content.
- The former has a 30-year tradition; the latter has a 2500-year
- When CBT was closely examined, the benefit was less a result of
changing toxic thoughts and more a result of a changed
relationship with toxic thoughts. (Segal, Williams, and
- Evidence of a "changed relationship with depressing thoughts"
or "cognitive de-fusion" (Hayes, 2004) might include thoughts
"Yes, this self-critical thought is part of me, but it's not
ALL of me."
"Yes, this really sucks right now. But it
will pass and it won't ALWAYS feel this way."
thoughts are just my thoughts. They're often irrational. They're
not the litmus test of reality."
"Oh, my mind is criticizing me again." "Who's life is this anyway,
mine or my mind's?" "Is this thought really useful right
"This is just a story I tell myself."
- Use of "creative hopelessness" (Hayes):
"I really CAN'T change how I feel right now, but I'll probably
feel differently tomorrow."
Or, like the Yiddish saying, "The situation is hopeless, but not
- Practice acceptance but stay engaged in your day: "This is
what it is. I do not have to make it go away. I do not have to go
to bed because of it. I'll go on with my day and take note of
changes in how this feels."
- Becoming an observer of one's thought process ("Oh, there's
that guilty thought again") repeatedly over time has a very
different emotional impact. Compare this to participating in the
same thought over and over with no intellectual distance until it
seems to be the only reality possible and becomes the primary
driver of your depressed mood.
- "A 'negative thought' mindfully observed will not necessarily
have a negative function" (Hayes, 2004) Eastern writers have long
noted: "If I can take something under awareness, then I am not
- Regular practice of mindfulness-based meditation may have a
role in treating active depression (e.g., Finucane & Mercer,
2006) as well as treatment-resistant depression (Kenny &
Williams, 2006) and quite clearly has a role in preventing
future depression (Ma & Teasdale, 2004), and in overall
stress management (e.g., Grossman, et al., 2004).
- Being truly disciplined about regular mindfulness-based
meditation practice is a challenge for most people. However, any
person can disengage from automatic thinking by watching a breath
for a full inhalation and exhalation, or can become more aware of
inner experience by stopping activity for a few minutes and asking,
"What am I feeling? What is occurring at this moment?"
- Re-directing one's focus and energy to the things that truly
have meaning can allow toxic experiences or thoughts to become the
background rather than the foreground of awareness. Depending on
one's spiritual beliefs or values, there may be many different ways
to implement this. For example, if one's job or health situation
seems inherently depressing, one might refocus on being the kind of
person their loved ones need. For another person, it might mean
pursuit of their spiritual leanings or contributing their time,
effort or money to someone who needs it.
- Antidepressant Effects of
- 10 weeks of supervised exercise followed by 10 weeks of
unsupervised exercise in elderly (mean age =71) with major
depression or dysthymia: Compared to control group that attended
lectures, there was significant improvement in depression scores
that persisted at 26 month follow-up. (Singh, et al., 2001)
- Older (> age 50) patients (n=156) with major depression
received a 16 week trial of aerobic exercise alone, sertraline
(Zoloft) alone or exercise + sertraline combined. Those who
received medication alone responded most quickly, but at 16 weeks,
all groups displayed improvement in depression without any
significant differences among groups.(Blumenthal, et al., 1999)
After 10 months, however, remitted subjects in the exercise group
had significantly lower relapse rates than subjects in the
medication group. Exercising on one's own during the follow-up
period was associated with a reduced probability of depression
diagnosis at the end of that period. (Babyak, et al., 2000)
- Both resistance training and aerobic activity can reduce
symptoms of depression. All levels of exercise intensity can reduce
symptoms of depression. Evidence is mixed as to whether exercise
alone or true fitness is necessary for antidepressant
response.(Dunn, et al., 2001)
- Treadmill x 30 minutes x 10 days in middle-aged patients
resulted in significant subjective and objective improvement in
major depression.(Dimeo, et al., 2001)
- However, this effect has been demonstrated most clearly in
subclinical depression and anxiety.(Salmon, 2001)
- Eight week, placebo-controlled trial of a daily 20 minute brisk
walk outdoors + increase in daily light exposure + vitamin regimen
in women with mild-moderate depression and not on medications:
Significant improvement on five outcome measures and remarkable
adherence.(Brown, et al., 2001)
- After only 30 minutes on a treadmill, urinary concentration of
phenylacetic acid increased by 77%. Might the reflected change in
phenylethylamine levels explain the short-term antidepressant
effects of exercise? (Szabo, et al., 2001)
- Might increased stress resilience explain the long-term effects
An Intriguing Abstract:
Might both antidepressants and exercise treat
by facilitating neurogenesis in the hippocampus?
Ernst, C, et al., Antidepressant effects of
exercise: evidence for an adult-neurogenesis hypothesis?
Journal of Psychiatry and Neuroscience, 2006;
(Neuroscience Program, UBC Hospital, University of British
Columbia, Vancouver, BC)
It has been hypothesized that a decrease in the synthesis of new
neurons in the adult hippocampus might be linked to major
depressive disorder (MDD). This hypothesis arose after it was
discovered that antidepressant medications increased the synthesis
of new neurons in the brain, and it was noted that the therapeutic
effects of antidepressants occurred over a time span that
approximates the time taken for the new neurons to become
functional. Like antidepressants, exercise also increases the
synthesis of new neurons in the adult brain: a 2-3-fold increase in
hippocampal neurogenesis has been observed in rats with regular
access to a running wheel when they are compared with control
animals. We hypothesized, based on the adult-neurogenesis
hypothesis of MDD, that exercise should alleviate the symptoms of
MDD and that potential mechanisms should exist to explain this
therapeutic effect. Accordingly, we evaluated studies that suggest
that exercise is an effective treatment for MDD, and we explored
potential mechanisms that could link adult neurogenesis, exercise
and MDD. We conclude that there is evidence to support the
hypothesis that exercise alleviates MDD and that several mechanisms
exist that could mediate this effect through adult
Light Therapy May Be Just as Effective for
For many years, special full-spectrum light, typically for 30
minutes each morning, has proven effective for treatment of
depression that occurs during the fall and winter months especially
when marked by weight gain and diminished energy level. Recent
systematic reviews suggest that regular light therapy is equally as
effective for non-seasonal depression and that the effect size may
be equal to antidepressant medications.
Golden RN, et al. The efficacy of light therapy in the treatment of
mood disorders: A review and meta-analysis of the evidence.
American Journal of Psychiatry, 2005; 162:656-662.
Tuunainen A, et al., Light therapy for non-seasonal depression.
Cochrane Database of Systematic Reviews, 2004;(2):CD004050
Martiny K. Adjunctive bright light in non-seasonal major
depression. Acta Psychiatr Scand 2004; 110:7-28
Further Reading on
Williams, Teasdale, Segal, & Kabat-Zinn The
Mindful Way through Depression: Freeing Yourself from Chronic
Harris, Russ The Happiness
Trap: How to Stop Struggling and Start Living.
Burns, David The Feeling Good
Burns, David & Beck, Aaron Feeling Good: The New Mood
DePaulo, J. Raymond, et al. Understanding Depression: What We
Know and What You Can Do About It. 1st Edition, 2002.
Solomon, Andrew The Noonday Demon: An Atlas of Depression,
ASDI: Serving the Baltimore Area & Central Maryland