Allen, J - Coping With Catch-22s of Depression, (2002) 66 Bulletin Menninger Clinic 103

Catch-22s of depression
Allen
Coping with the catch-22s of

depression: A guide for educating
patients
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 from
depression 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 a
handout 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 disabling disease worldwide in 1990 and anticipated to rank second only
to heart disease by 2020 (Murray & Lopez, 1996). And these may be
underestimates (stn, 2001). The increasing prevalence and stubborn
persistence of depression are only part of the problem. Depressed persons 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 be
properly diagnosed; if they are properly diagnosed, they may be
undertreated; if they are adequately treated, they may not fully respond;
and if they do recover, they are likely to suffer recurrence. Imagine what
the 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 stemming the tide. Given the scenario sketched above, by the time we have a
This article is based on a presentation at the 24th Annual Winter Psychiatry

Conference, held March 3-8, 2001, at Park City, Utah.
Dr. Allen is senior staff psychologist and Hirschberg Professor in the Child and
Family 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: allenjg@menninger.edu. (Copyright 2002 The
Menninger 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 to
giving up on treatment prematurely at a point where residual symptoms
remain, putting them at extremely high risk for relapse (Dawson,
Lavori, Coryell, Endicott, & Keller, 1998). Patient education is essential to the therapeutic collaboration needed to sustain treatment (Rush,
2001). Communicating to patients that we understand their
plightand helping them to fully understand their plightmay enable
them to stay engaged in this arduous endeavor.
This article describes a patient education program implemented in
The Menninger Clinic. Befitting the patient population in a tertiary care
setting, the program focuses on relatively chronic, treatment-resistant
depression. A description of the evolution of the program is followed by
the written material that is given as a handout to the patients participating in the program. Finally, an appendix provides a schematic guide to
the scholarly literature supporting the educational material. One of the
greatest challenges in educating patients about depression is educating
oneself. Given the vastness of this literature, developing even a modicum of expertise is a monumental task. The literature review is intended
to provide the reader with an inroad.
Evolution of the patient education program
My colleagues and I developed the educational approach to coping
with persistent depression in the course of educating patients about
psychological 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 traumatized patients were typically admitted for the treatment of severe
depression. As this educational work evolved, we developed an approach to helping patients appreciate the challenges of coping with
posttraumatic depression (Allen, 2001). In the process of educating
patients who had struggled with trauma-related depression for many
years despite extensive treatment, we gradually learned that solutions are elusive. As we presented various strategies required to recover from trauma, patients explained all the problems with these
strategies. In the course of these discussions, we learned that we
could be most useful to patients by helping them understand why recovery is so difficult, perhaps alleviating their depression somewhat
by encouraging them to ease up on themselves regarding the persistence of their problems. We gradually pulled together this understanding in formulating the problem of the catch-22s of
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Bulletin of the Menninger Clinic
depression, the gist of which is that all the things one must do to recover from depression are made difficult by the symptoms of depression. A glaring example: Hope sustains recovery, and depression
brings hopelessness.
Starting out in a relatively long-term specialized inpatient program
(Allen, Coyne, & Console, 2000), the trauma education program was
highly ambitious. The group met twice weekly to cover the full curriculum in an academic year. Even with long-term treatment, patients were
exposed only to a portion of the material in the group meetings. Thus it
became necessary to have written material that would cover the full
course, which ultimately became a book-length manuscript (Allen,
1995). When we subsequently implemented the trauma education program on an acute inpatient unit, we devoted even greater emphasis to
depression, given that patients were typically admitted for acute exacerbations. As we explained it to patients, severe depression becomes a top
priority in treatment because it is potentially fatal if associated with suicidal states, and at least partial recovery from depression is necessary to
work productively on the problems that precipitated the depression. In
the context of educating patients in acute treatment, we developed videotapes on trauma and depression to provide patients with a quick
overview. A simple stress pileup model (Allen, 2001) served to provide a quick, yet comprehensive, overview of the multiple pathways to
depression.
Having refined the depression component of the trauma education
program, we then added this psychoeducational intervention to the
Professionals in Crisis Program, an inpatient program where patients
typically remain for a few weeks. The group meets once weekly, and the
curriculum spans several weeks. Thus the written handout provides the
full course content for patients who attend only a portion of the sessions. The process is similar to that in the trauma education groups (Allen, 2001) inasmuch as the leader presents some core concepts and
patients are encouraged to discuss how these concepts relate to their
personal experience. Plainly, given their extensive experience, the patients are the experts. At their best, these group meetings become rather
discursive brainstorming sessions in which we pool our expertise to
deepen our conjoint understanding of the challenges in recovering from
depression. As we continue to expand our knowledge, I endeavor to
pass on whatever I learn.
What follows is the text that we have developed as a handout for patients participating in a psychoeducational group on depression in the
Professionals in Crisis program at The Menninger Clinic. Citations and
the professional formulations behind that text are detailed in an accompanying appendix.
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Coping with the catch-22s of depression
The plight of the depressed person is not fully appreciatedeven by
many persons who are depressed. Depression is often seen as an acute
illness: something bad happens, you get depressed, then you recover
fairly quickly. True, depression can be a relatively time-limited response to stressful events, and some persons respond relatively quickly
and 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 things you need
to do to recover from depression are made difficult by the symptoms of
depression! For example, if youre depressed, its likely that youve been
severely stressed and feel exhausted. Therefore you must rest. But consider one of the most common symptoms of depression: insomnia. A
catch-22. There are many others: You should eat well, but depression
decreases your appetite. You should be active, but depression robs you
of energy. Above all, you should remain hopeful, but depression may
bring hopelessness.
Heres another big problem. You may have become depressed because you encountered one or more major stressful events. Chances are,
you were facing many hard life problems. Then, on top of these hard
problems, you became severely depressed. Now not only do you have
all the hard problems that triggered depression, but you also have another extremely hard problem: depression. Moreover, the consequences of depression often lead to additional life problems, such as
increased marital conflicts, more difficulty at work, and financial burdens. But once youve become severely depressed, the depression becomes the highest priority problem, for at least two reasons. First, when
youre depressed, its extremely hard to cope with the problems that
brought on the depression. Second, depression is potentially life threatening, if youve become suicidal. So you may need to recover from depression, at least to some degree, before you can tackle the problems
that triggered the depression.
Contemplating the catch-22s of depression is risky. It might lead you
further into depression. Keep in mind that it is not impossible to recover
from depression, despite the catch-22s. We know this, because the vast
majority of depressed persons recover. Recovery is difficult, but not impossible. Making the distinction between difficult and impossible is
crucial to recovery. Recognizing the difficulty may be discouraging, but
failing to recognize it can be even more demoralizing. Minimizing the
seriousness of depression leads to unrealistic expectations, enormous
frustration, self-criticism, and hopelessnessall of which add further
fuel to depression.
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I believe that understanding depression and accepting the seriousness of the condition puts you in the best position to cope with it. Understanding depression and what it takes to cope with it can provide
a more hopeful view, based on more realistic expectations. You
might need to set your sights on small steps, goals that you can
achieve. Ideally, you might see depression as a challenge, a hard
fight, or a struggle. But this is not an easy stance to take when youre
depressed.
This article reviews the illness of depression and explains how you
may need to work on many fronts to recover. Each of these fronts entails catch-22s. Yet within each of these catch-22 areas you have some
leverage over depression. The leverage is not greatyou cant just
snap 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 (perhaps dark gray to black). You need to be motivated to recover. You
need energy to be motivated. If youre depressed, you may have little energy. But youre likely to have some energy and some motivation. Its
these shades of grayhowever darkthat make the catch-22 problems
very difficult rather than utterly impossible. You have a little leverage in
many areas.
There are many different treatment approaches to depression: behavior therapy, cognitive therapy, interpersonal therapy, and somatic
therapies (e.g., medication and electroconvulsive therapy). All are effective, 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 might find
it hard to take in a lot of information when youre depressed. You may
have problems with concentration and memory that make it difficult to
read. This manuscript is packed with a lot of information, and it may
not be easy to digest. Ive broken it down into short sections so that you
can tackle it a bit at a time. And you can skip to the last part on the
catch-22s if you just want to focus on treatment.
The illness of depression
Depression is a common problem, especially among women. A representative study showed that 12.7% of men and 21.3% of women have
major depression in their lifetime. In a given month, 3.8% of men and
5.9% of women experience major depression. Moreover, the prevalence of depression is increasing in the United States, and most alarming
is its increase among adolescents. Depression is common, and the seriousness of depression is all too frequently minimized. But facing up to
the reality of depression poses a dilemma.
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Between a rock and a hard place
The rock: Its not that seriousif youd just . . . [do x], youd snap out of
it. The hard place: Depression is a serious, persistent, mental-physical
illness. Lets first consider the rock. Many persons who have struggled
for a long time to overcome depression have been urged by others, If
youd just . . . [eat right, go out and exercise, have more fun, stop isolating, quit wallowing, etc.] . . . youd feel better. Ive come to think of
just as a fighting wordits inflammatory to persons who have lived
with depression and have tried to fight their way out of it with limited
success. Theres no single, simple solution to persistent depression. You
must work on several fronts. It can be a long haul, even if youre able to
put a lot of effort into it.
I vote for the hard place, because its realistic. Depression is a serious
illness, recovery may take a lot of time, and you remain vulnerable to relapse. This is a hard place, indeed, but sitting on the rock is potentially
crazy-making: you should be able to snap out of it, but you cannot.
Therefore you conclude that you are crazy, lazy, or some other depressing idea.
To say that depression is a persistent illness does not mean that you
are destined to be severely depressed continuously. You may spend
quite a lot of time, however, at different levels of depression, ranging
from mild to more severe. I use the term persistent to emphasize the
fact that you remain vulnerable to relapse, particularly in the face of significant stress. In this respect, depression is much like other chronic
physical illnesses, such as hypertension or diabetes. The main implication of persistent is this: You must take care of yourself over the long
run. Another catch-22 here is that you may feel like youre not worth
caring for if youre depressed.
Choosing to stay depressed?
Some depressed persons are told that they are choosing to stay depressed, that they just want to be depressed, or they are wallowing
in depression or self-pity. In part, such criticisms reflect the frustration
and sense of helplessness of others who find your depression distressing. If depression is a mental state, you should be able to do something
in your mind to change it. Or you should change your depressed behavior. This can put you back on the rock. You should snap out of it or
somehow will yourself out of it. But how?
Is there any reason to want to stay depressed? Yes. You can take advantage of depression, just as you can take advantage of any other illness. Illness is a biological condition but it also involves a social role
with certain expectations and obligations. A half-century ago, sociologist Talcott Parsons described several aspects of the sick role, all of
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which apply to depression. Illness allows exemption from performance
of certain normal social obligations as well as being exempted from responsibility for your ill state. As Parsons stated, the ill person cannot be
expected to recover by a mere act of will. Yet the ill person is obligated
to seek help, cooperate with treatment, and become well as soon as possible. Plainly, lack of understanding of depression and unrealistic expectations about recovery can create interpersonal conflicts about the
legitimacy of your illness. Those who believe depression is an acute illness from which you can be expected to recover quickly may believe
that youre just not making the proper effort. You also may believe this
if you fail to understand depression.
Depression can be an excruciatingly painful state from which a person would do anything to escapeeven including suicide. But there can
be another side to depression as well. Depression involves a retreat from
problems that have become overwhelming, and persons who have been
depressed for long periods of time often find it familiar, even comfortable and safe in some sense. Being depressed can feel like being in hibernation or being in a cocoon. If youve become accustomed to it, getting
out of depression can be anxiety provoking. Recovering means facing
the world again, plunging back into the unknown. For some persons, as
bad as the depression is, recovery also can be distressing.
I think the idea that you are choosing to be depressed or wallowing in
depression is insulting and minimizes the seriousness of the illness, even
if there is a grain (or even a spoonful) of truth in it. On the other hand,
we must believe that you have some choice and some control over your
depression. Otherwise there would be no point in trying to do anything
about it! You would be totally stuck. The trick is to accept that you have
some degree of choice, control, and responsibility for your state of mind
and behavior without blaming or criticizing yourself for not doing
better. Heres the irony: You have a greater degree of choice and control
when youre less depressed.
You cannot simply choose no longer to be depressed. You cannot
just make up your mind to be well and thats it. But, if youre not profoundly depressed, you can choose to take actions that will take you
slowly along the path of recovery. Recovering from depression involves
a series of hard choices over a long period. It can be a hard choice to get
out of bed, to take a shower, or to get dressed. You cannot choose to recover from depression at one moment, once and for all. Recovering
from depression requires making hard choices continually, one after
another, day after day, month after month. Its like climbing a mountain, with ups and downs, gains and setbacks along the way. The more
depressed 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 have
more strength and ability to climb.
Keep in mind the catch-22s. Its hard to climb a mountain when
youre exhausted. One of the most demoralizing aspects of depression is
its persistence and recurrence. Many persons have worked hard and
successfully over a long period of time to fight depression. They become
demoralized when they become depressed again after all the hard work
theyve done in the past. So often I hear, Im tired of fighting it. I cant
go on fighting. No wonder some depressed persons feel like giving up
entirely. Depression is frustrating. The only way forward is to go slowly
and to take small steps. Frustrating indeed.
A mental-physical illness
There are many reasons to think of depression as a physical illness. Depression can stem partly from genetic (inherited) vulnerability; it is associated with changes in patterns of brain functioning; it is often
accompanied by physical ill health; and it is responsive to medications
and electroconvulsive therapy.
But we should not lose sight of the mental aspects of depression. I
view it this way: Psychological and social stress leads to physiological
stress, which can lead to persistent adverse changes in brain functioning. This may be a hard concept to grasp. The meaning of events in your
life-recent or remote-can produce physiological stress that alters the
way your brain functions.
The sequence is this: Stressful events take on psychological meaning
which 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 in
your brain and the rest of your body. Often the stressful psychological
meanings revolve around two broad themes: loss and failure. For example, you may feel alone, unlovable, inadequate, worthless, and so forth.
Thus low self-esteem plays an important role in translating stressful
events into depression. Also our ability to think (negatively) about
long-range implications plays a significant role in the meaning of stressful events. You may think, for example, Ill never be able to find another job, or Ill never have a good relationship, or Things will
never change.
Fortunately, the mind-brain relationship goes both ways. Positive
psychological and behavioral changes can help reverse the changes in
brain functioning. The interplay of physiology and psychology is the
reason that the best treatment of depression often involves a combination of medication (or electroconvulsive therapy) and psychotherapy.
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Depression impairs functioning
Its obvious to you that depression impairs your functioningyouve
been living through it. You may have difficulty doing your work, taking
care of your household responsibilities, and interacting with your family and friends. At worst, you may not even be able to concentrate on a
TV show, a magazine article, or a book. And, being depressed, you may
feel guilty about being unable to manage your responsibilities. You may
be criticizing yourself for the difficulty youre having, feeling you
should just be able to do better, adding fuel to your depression.
You might be able to adopt a more forgiving attitude toward yourself for the difficulty youre having by appreciating how much impairment is typically associated with depression. This is part of the hard
place of depression, acknowledging that it is a serious illness. The level
of impairment associated with depression is similar to impairment associated with other chronic physical illnesses, such as hypertension, heart
disease, lung disease, and arthritis. Depression is second only to heart
disease in the number of days spent in bed and second only to arthritis in
the extent of physical pain. Obviously, the more severe the depression,
the more severe the impairment is likely to be. Yet even mild depression
is associated with some impairment in role functioning. Thus you
should aim for a full recovery over the long term and stay well to the degree humanly possible.
The seriousness of depression as a public health problem has been
documented by an ambitious World Health Organization study of the
extent of disability associated with a wide range of general medical and
psychiatric conditions. Researchers determined the extent to which various illnesses were associated with mortality and disability (impaired
functioning). They compared diseases in extent of disability measured
in terms of disability-adjusted life years, that is, number of lost years
of healthy life. In 1990, depression ranked fourth worldwide; by 2020,
depression is anticipated to be the second most disabling illnessexceeded 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 should
be able to recover quickly. You may hold a stereotype of others who
take antidepressant medication for a few weeks and then feel well. You
may conclude its your personal failure that accounts for your prolonged depression. Consider this: A large group of individuals who
sought treatment for depression at major medical centersoften after
several months of depressiontypically took a number of months to recover. 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 or
more to recover, and some took 2 or 3 years or more to recover.
I present these statistics to emphasize that recovery from depression
is 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 shown
to increase the length of time to recovery: a large number of previous episodes, long duration of prior episodes, more severe symptoms, presence of general medical conditions and other psychiatric problems (e.g.,
substance abuse), low self-esteem, lack of social support, and ongoing
stress.
But you should also keep in mind that you can influence the time to
recovery. Active and persistent participation in treatment can speed the
process of recovery. Giving up on treatment prematurely can slow the
process of recovery and contribute to relapse.
Course of recovery
The course of an illness refers to its progression over timea fever has a
waxing and waning course when it gets worse, then better, then worse
again. The course of depression can be very complex. And there are
many different subtypes of depression, with major depression being the
prototype. The diagnostic criteria for major depression include five or
more of the following symptoms, most of the day every day, for at least
2 weeks: depressed mood, diminished interest or pleasure, appetite or
weight changes, sleep disturbance, motor agitation or retardation, fatigue or loss of energy, feelings of worthlessness and guilt, problems
with concentration and decisions, and thoughts of death or suicide. Although there are different patterns of symptoms associated with depression, and there are certainly many different developmental pathways to
depression, it is helpful to think of depression as one illness that varies
in 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 normal)
4.Wellness (fully recovered with return to normal; euthymic)
On the path to recovery from a major depressive episode, we distinguish 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 remission)
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 one
person to another. To repeat, about half of the persons admitted to a
major medical center for treatment of major depression achieved recovery (2 months of remission) after 5 months of treatment. Major depression entails 2 weeks of symptoms, and chronic major depression is
defined as symptoms of major depression for 2 years. Dysthymia is distinguished from major depression by both severity (milder) and duration (more persistent). That is, a diagnosis of dysthymia requires at least
2 years of depression at a level milder than major depression. The combination of dysthymia and major depression is sometimes called double depression. A person with dysthymia who becomes more severely
depressed (major depressive episode) may recover to the level of previous 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 continuing state of active illness, that is, some level of ongoing depressioneven if it is mild. Hence ongoing dysthymia and even one or two
subthreshold symptoms entail increased risk for major depression.
This should make intuitive sense: If youre already partway there, it is
easier to return to being extremely depressed.
Another powerful predictor of recurrence is a history of multiple depressive episodes. Other predictors of relapse are similar to those that
predict 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 involves
recurrent problems in interpersonal relationships. Such relationship
problems contribute to depression in part because they are likely to be a
major source of stress. And interpersonal stress is among the most common forms of stress.
The fact that some ongoing depression is the greatest risk factor for
relapse has a clear implication: You should aim for full recovery, restoring your mood back to normal. And the longer you can remain in this
recovered state, the less the risk of recurrence. Also, to the extent that
you can get help early and can work to minimize further episodes, your
chances of staying well increase. Continuing in treatment is one way to
maximize your chances. Unfortunately, an extremely common pattern
is this: A person in a major depressive episode takes medication, feels
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somewhat better (response, not recovery), and then discontinues medication. This common pattern entails a high risk of relapse.
Anxiety and depression
A psychiatrist colleague once told me hed never seen a depressed patient 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 both
feelings. But its helpful to tease apart the differences between depression and anxiety because they often go together and feed into each
other.
Think of depression as the absence of positive emotionyou dont
enjoy anything. You may try to do things that will perk you up, but it
doesnt work. This, too, has a physical aspect. As psychologist Paul
Meehl put it, you may not have enough cerebral joy juice. The neurotransmitter dopamine is one of the juices that activates pleasure and
reward circuits in the brain. This pleasure circuitry is part of an approach system in the brain, and it enables you to seek out pleasurable
activities. If you can, think of the excitement you have felt when you
were about to do something you really enjoyed. The approach-pleasure-reward system was turned on. Of course, too much cerebral joy
juice activity is also a problem. In a manic state, you may get into trouble by approaching too many pleasurable activities. In contrast, when
depressed, you have no interest in anything, and you may just sit in a
chair or stay in bed. The approach-pleasure-reward system is shut
down. Nothing matters, and you cant look forward to anything.
Whereas depression can be seen as an absence of positive mood, anxiety is the presence of negative mood. On this dimension, the low end is
feeling calm, relaxed, and content. The high end is feeling anxious and
frightened. You want to withdraw. An extremely painful combination
of depression and anxiety is agitated depression, in which you feel restless and cant sit still. Pacing is a common form of agitation. You can be
mentally agitated as well, worrying or ruminating, unable to stop thinking. In my view, anxiety feeds into depression because it wears you out
and saps your energy, not to mention also robbing you of pleasure and
enjoyment. Depression also contributes to anxiety, for example, when
you must face a situation you feel you cannot handle because youre so
depressed.
Think of depression and anxiety as involving two circuits in the brain.
To get out of depression, the positive emotion-approach circuit needs to
be turned up; to get out of anxiety, the negative emotion-withdrawal circuit needs to be turned down. Research has localized these two circuits to
different sides of the brain, both in the frontal areas. The pleasure-ap114
proach circuit is predominant in the left hemisphere, and the anxiety-withdrawal circuit is predominant in the right hemisphere. Thus
persons who are prone to distress show more activity in the right hemisphere and less in the left hemisphere. These individual differences have
been observed as early as infancy, and they have also been observed in
nonhuman primates. These differences in brain functioning also relate to
broad personality characteristics. Extraversionbeing outgoing and sociableis associated with positive emotion, and neuroticismproneness
to distressis associated with negative emotion. Thus researchers are
now linking personality characteristics that relate to depression and anxiety to stable individual differences in brain functioning.
Given the likelihood of having to struggle with both depression and
anxiety, you have two challenges. On the one hand, being depressed,
you need to activate yourselfto develop more energy and interest
in things. On the other hand, being anxious, you need to de-activate
yourselfto feel more calm and relaxed. Controlling depression and
anxiety is quite a balancing act. If you can get yourself absorbed and
engaged in relaxing activities, you might even be able to accomplish
both at the same time. If these relaxing activities involve some contact
with other people, so much the better. But socializing when youre depressed and anxious is no small challenge. Depression and anxiety
present a double-whammy that promotes social disengagement. Being
depressed, you may have little incentive to be with other people, because the pleasure is not there. Being anxious, you may be inclined to
actively withdraw from other people. Engaging in social contacts that
do not demand a great deal of interaction may provide a middle
ground.
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 we
are threatened, we feel angry and fight back or become frightened and
run away. Why did evolution equip us to become depressed in response
to stress? This is not so easy to understand. Here is a simple idea: When
stress is overwhelming, your body shuts down at some point to prevent
itself from completely burning out. The model here is the infant who
cries herself to sleepsleep is a protective shutdown response. This
conservation-withdrawal theory is appealing, but there is a big problem
with it: Depression usually doesnt lead to restful sleep. You may withdraw and retreat, but you cant necessarily rest. You may have insomnia, and you may be agitated. Depression, unfortunately, is not restful.
It is a high-stress state, physically and psychologically, intermingled
with anxiety.
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Heres another idea about an adaptive response gone awry. You become depressed when youve lost somethingan important relationship or a valued goal. When the situation appears hopeless, continuing
to 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 persistence is also a bad thing; it can be futile and wear you out. I think giving up is an underrated coping strategy. The challenge is to know when
to give up. But giving up is emotionally difficult. Depression forces your
hand. It forces you to stop striving and to let go. But it goes too far. You
may lose interest in all goals. The approach-pleasure system shuts
down.
Heres another idea that best fits the relationships between depression and trauma. Think of depression as a response to oppressionfeeling overpowered by someone. Think of the animals in the
traumatic learned helplessness experiments, overpowered by the situation 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 were
traumatizedoppressed and depressed. Fear does you no good when
you are overpowered; you cannot escape the oppression. And when you
are overpowered, fighting back in anger may only get you hurt worse.
Giving up and submitting may be the most self-protective thing you can
do. Depression takes over and forces you to submit. It protects you
from getting into more danger. But it goes too far. You may give up on
everything, and you may remain depressed even when youre no longer
in danger or when youre in a position to do something to overcome the
oppression.
All these theories about the adaptive functions of depression suggest that depression has a purpose, but it is overdone. Depression
could be considered a signal that you are feeling overwhelmed and
overpowered. You cannot reach your goals, and somehow you must
do something differently. But you keep pushing yourself, to no avail.
Depression stops you in your tracks. Viewed as a signal, depression
should be heeded. Being able to tolerate depression is an important
strength. To tolerate it means to allow yourself to feel it and understand where its coming from. Its a signal that your goals and strategies (or your stressful lifestyle) need to be reconsidered.
Unfortunately, depression goes beyond being a signal to being a serious illness that impairs your ability to cope. When you recover from
depression, you can learn to heed the signals of mild depression to prevent yourself from sliding into deeper depression.
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The development of depression
Although it sometimes may seem like it, depression does not come out
of nowhere. Severe and persistent depression often has a long history.
We can usefully think of depression as one illness, but there are many
different developmental pathways into it. I think about the development of depression simply as involving a combination of biological vulnerability and a pileup of stress over the lifetime. I also believe that
attachment relationships play a significant role in the creation of stress
and in coping with stress.
Biological vulnerability
Depression has a genetic basis. What does this mean? Genes carry the
instructions for creating the molecular building blocks of cells, organs,
and bodies. Individual differences stem from a unique combination of
genes in interaction with a unique environment over the course of development. Throughout life, genetic instructions control the production of
molecules that control the functioning of neurons in the brain, including manufacture of neurotransmitters and their receptors. Neurons are
highly social creatures, continually changing their connections and patterns of communication. All this communication turns genes on and
off, altering the production of molecules and the functioning of the
brain. Taking medications alters the biochemical environment of the
neurons, and they respond by changing their behavior, thereby returning patterns of brain functioning to normal.
We do not know just what genes contribute to vulnerability to depression, although the hunt is on. Probably many genes, each with small
effects, are involved. But we do know from family studies that a vulnerability to depression can be inherited. Keep in mind that heredity is not
destiny. Your genetic makeup alone will not lead to depression. But
your genetic makeup can contribute to a higher risk for depression
given exposure to environmental stress.
Genetic vulnerability and stress interact in complex ways to produce
depression. We know that stress is a major culprit in the development of
depression. But not all stress is bad. On the contrary, stress is an inevitable part of living, and early exposure to challenging stress can be beneficial. Effectively coping with stress leads to resilience and hardiness. On
the other hand, repeated overwhelming stress can undermine resilience
and hardiness, leading to vulnerability to depression later on in the face
of stress. We know that stressful life events play a major role in bringing
on depressive episodes. Examples of common stressful events contributing to depression are marital problems, divorce, losing a job, serious
illness, being assaulted, and so forth. But not everyone who experiences
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such stressful events becomes depressed. This is where genetics (and
many 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 other
factors that play a role in depression: exposure to stress and availability of social support. Think of it this way. Genetic factors contribute to
personality characteristics, and personality characteristics contribute
to stress and social support. For example, being a risk taker could lead
a person into more stressful situations. Being sociable could provide
greater opportunities to create a network of social support. Genetic
and environmental factors are always interacting with each other, and
persons with a combination of genetic vulnerability and severe environmental stress with little social support are at highest risk for depression.
Genetic factors are not the only form of biological vulnerability to
depression. Many general medical conditions can contribute to depression. These include endocrine disorders (e.g., thyroid disease), infections (e.g., HIV), degenerative diseases (e.g., Parkinsons disease),
cardiovascular problems (e.g., stroke), and some forms of cancer. Thus
it is essential to obtain a thorough medical evaluation to investigate
such possible causes of depression, even if the depression seems to have
been brought on by a major stressor. It is crucial to rule out or diagnose
and treat such conditions. Another important biological vulnerability
factor is aging. Partly as a result of increasingly accumulated stress with
age, resilience to stress can decline, and vulnerability to depression in
the face of stress can increase.
Although we need to pay most attention to the effects of depression
on the brain, it is also important to keep in mind that depression may
have widespread effects throughout the body. The endocrine system is a
major player in depression, and stress hormones in particular have been
studied extensively. Ordinarily, the secretion of stress hormones is
adaptive by preparing the body to cope actively. Yet these hormonal
stress responses also must be shut down promptly, and these shutoff
mechanisms are not working properly in depression. Again, depression
is a high-stress state with many physical consequences. You may have
trouble eating and sleeping, and your immune function may be compromised. In addition, early stress may affect the functioning of the endocrine system such that later stress is more likely to bring on an episode of
depression.
Attachment and depression
We know that loss, such as the death of a loved one or the breakup of a
close relationship, is a common stressor that triggers depression. The
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role of loss in depression draws attention to the importance of attachment relationships in understanding depression. Put simply, disruptions in attachment relationships can contribute to depression, and the
support of secure attachments can play a role in recovery from depression as well as in preventing recurrence.
The mother-infant bond is the prototype of attachment. Attachment
relationships 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 in
an orphanage. He observed that protest followed by despair was a common reaction to separation. The protest reaction is adaptive because
crying out draws the mothers attention. But with continued separation, continued protest would not be adaptive, and despair sets in. Thus
separation-related despair is the prototype for depression in response to
loss. This response to separation is identifiable in infancy, and it is also
identifiable in other mammals. Loss at any time in life may bring on this
fundamental reaction.
Secure attachment relationships protect us from stress. The essence
of a secure attachment relationship is being confident that your attachment figure will be available and responsive in times of distress. Seeking
contact will bring a feeling of comfort and security. Unfortunately, insecure attachment relationships are a source of stress. Typically, insecurity takes one of two forms. Persons who are avoidant try to manage
their distress without relying on others. Persons who are ambivalent
feel a strong need for contact and comfort but fear being hurt or let
down, and they often feel a great deal of frustration or hostility toward
the attachment figure. Both isolation (avoidance) and stressful contact
(ambivalence) can be depressing. Thus part of the treatment for depression is working on developing more secure and stable attachments.
Maternal depression and attachment
Separation, loss, and conflict in attachment relationships can contribute to depression. But depression in attachment relationships also can
be contagious, even in infancy. Tiffany Field and her colleagues intensively studied the interactions of depressed mothers with their infants.
She found that depressed mothers are relatively unresponsive to their
infants, and depressed infants interact less positively with their mother.
Normal mother-infant interactions involve a kind of dance of mutual
responsiveness that involves coordination of gaze, vocalizations, and
body movements. In depressed mother-infant interactions, there is less
mutual responsiveness, although depressed mothers and their infants
are often locked in closely matched states of negative emotions. Thus infants as well as their mother show depressed behavior.
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The effects of maternal depression on infant behavior can be widespread, affecting behavior and physiology. Notably, interacting with a
depressed mother can be even more stressful to an infant than physical
separation. If the mother remains depressed for more than 6 months,
negative effects can persist over the years to come. Yet infants who
show depressed behavior with their depressed mothers can perk up
when they interact with familiar adults who are not depressed, such as
their father or a nursery school teacher. Thus nondepressed adults can
have a buffering effect.
Research on maternal depression shows that depression can be
learned early in life. And the research shows that depression can be
catching, as we all know from adult relationships. But this research also
shows that interactions with other persons who are responsive are a
pathway out of depression, both earlier and later in life.
Attachment trauma
Many persons who struggle with severe and persistent depression have
a history of extreme stresstrauma. A landmark study on the social origins of depression in women conducted in London by George Brown
and colleagues showed that those who experienced major depression
typically had experienced either a severe life event (e.g., death of a loved
one, divorce, loss of a job) or an ongoing difficulty (e.g., marital conflict, caring for a very difficult child) before the onset of depression. Yet
many women who encountered such stressors did not suffer a major depression. What made the difference? Later research discovered that
many of those with less resilience had a history of childhood
traumaabuse and neglect. Could it be that those who had a history of
childhood trauma were more vulnerable to later stress? Yes, for both
psychological and physiological reasons.
The essence of trauma is feeling extremely frightened and alone,
without support. There are many sorts of trauma, ranging from tornadoes to assaults, and trauma can involve either a single event or repeated events. Trauma can befall a person in childhood or adulthood or
both. In my view, trauma in attachment relationships (e.g., abuse and
neglect by caregivers or romantic partners) is especially likely to have
severe consequences, depression among them. Attention has rightly focused on abuse (sexual, physical, and emotional), but it is also important to recognize the impact of isolation and neglect, both of which are
associated with depression. Trauma in attachment relationships in
childhood is especially worrisome because it affects the development of
the child. For example, childhood trauma can contribute to developing
depression early in life, often in adolescence. Childhood depression can
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interfere with social relationships and schoolwork, and it can lay a
foundation for depression later in life.
Many persons who have a history of severe trauma suffer from
posttraumatic stress disorder along with depression. Posttraumatic
stress disorder involves reliving the trauma, for example, in the form
of flashbacks and nightmares. Combining these two disorders mixes
anxiety and depression. Darwin wisely said that fear is the most depressing of the emotions. Many traumatized persons would agree.
Thus treatment for trauma must be combined with treatment for depression. Fortunately, one class of frequently used antidepressants, selective serotonin reuptake inhibitors (SSRIs), can be helpful for
posttraumatic stress disorder (and other anxiety disorders) as well as
depression.
Stress pileup and sensitization
Although genetic factors will influence your response to stress, enough
stress is liable to plunge almost anyone into depression. The simplest
way 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 may
become better at coping. If the stress is overwhelming, your coping may
be increasingly undermined. Everyone has a mixture of ability to cope
with 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 we
are 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 number of times, you feel less distressed about it. Unfortunately, repeated
exposure to extreme stress can have the opposite effect. The more you
encounter the stressful situation, the more upset you become. At
worst, exposure to a series of stressful events can make you more
rather than less reactive. You might get to the point of being so sensitized that even relatively minor stressful events can lead to a severe reaction. This is a physical process; your nervous system can become
more reactive.
As you well know, depression itself is a major stressoron top of the
other stressors that led up to it. You may become sensitized to depression, such that an episode is set off by increasingly minor stressors. Or
you might have more frequent episodes. Psychiatrist Robert Post has
cautioned that episodes beget episodes. It is important to be aware of
sensitization for two reasons. First, you should not blame yourself for
it. Second, it underscores the importance of doing everything you can to
stay well and to minimize additional episodes of depression.
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Sensitization has been conceived of as a physiological process. Stress
pileup captures the psychological perspective. Many persons who seek
inpatient treatment for depression can readily identify a pileup of stress
in the days, weeks, or months before hospitalization. But, with the concept of sensitization in mind, we can also think of stress pileup over the
life span. Stress in childhood and adolescence can be followed by stress
in adulthood. Sometimes the stress in adulthood that precedes depression 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 lifestyle
makes to stress pileup. This might include anything from being a workaholic to frantic caregiving in relationships. Such a lifestyle may be
characterized 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 a
stressful lifestyle. Eventually, such stress may lead you to crash or hit
the wall. From this perspective, depression entails being worn out and
giving up. Keep in mind that depression is physical. You may want to
keep going, but your body quits cooperating. As you begin to slide into
depression, 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 internal
experience also can be a major part of the stress pileup. That is, if you
continually berate yourself or feel guilty, you are subjecting yourself to
relentless psychological stress. Other examples would include being
perfectionistic, constantly worrying, or being stuck in ruminating
about problems or your failings or inadequacies. Thus finding ways to
let up on the internal pressure is another important part of the treatment of depression.
The depressed brain
The discovery of antidepressant medications has drawn widespread attention to the idea that depression results from a chemical imbalance.
This is a helpful idea in one respect: It promotes the idea that depression
is a physical illness. But the idea of a chemical imbalance is not particularly informative. Its relatively mindless, in the sense that the physical
problem (chemical imbalance) doesnt obviously relate to mental functioning.
Neuroimaging technology now allows researchers to study the brain
in action, for example, by measuring changes in blood flow and glucose
utilization in different parts of the brain. To illustrate, we know that for
most persons language tends to be localized in the left cerebral hemisphere. Neuroimaging shows that brain activity increases in the left
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hemisphere when individuals are engaged in language tasks. These
neuroimaging techniques are now being used to study patterns of brain
activation associated with depression. Beware that this is a relatively
new area of research, and we are a long way from conclusive findings.
Also, many different areas of the brain participate in emotional feelings
and behavior, and there is no reason to think that depression would be
associated with a specific change in any single area. On the contrary, research has shown changes in brain activity (increases and decreases) in
many areas in conjunction with depression.
But I want to highlight two areas of the brain that show altered functioning in depression: the amygdala and the prefrontal cortex. The
amygdala is an evolutionarily older part of the brain, deep in the temporal lobe. The amygdala senses danger and plays an active role in our
learning to avoid objects, situations, or persons who are hurtful. The
amygdala is sensitive to facial expressionsespecially threatening
ones. Some neuroimaging research shows that there is a greater amount
of amygdala activity in persons with depression. This activity is consistent with a strong association between depression and anxiety, as well
as the experience of depression as a high-stress state.
Changes in the prefrontal cortex also have been observed in depression. In general, the front part of the brain controls action, and the back
part of the brain specializes in perception. The front-most part of the
brain, 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. You
must keep track of them all, decide what youre going to do when, and
figure 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 with
several peopleor even one person. This is what keeps your prefrontal
cortex busy.
Neuroimaging studies have found decreased activity in prefrontal
cortex in conjunction with depression (although some studies have
found increased activity, which was interpreted as a propensity to ruminate). One particularly noteworthy study examined depressed and
nondepressed persons while they were engaged in a complex problem-solving task. Previous research had shown this task to be sensitive
to cognitive impairments in depression and also had shown what brain
areas are normally activated by the task. The task involved a combination of relatively easy and relatively difficult problems. Depressed persons showed distinctly less prefrontal activation when performing the
difficult problems. They were unable to persist in the mental effort to
see the problems through to solution. Thus such research is beginning
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to show a direct link between brain functioning (decreased prefrontal
activation) and mental functioning (decreased problem-solving ability).
Thus we might start to think beyond the idea of a chemical imbalance to thinking about what it feels like when parts of your brain that
normally 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 required, your mind might just shut downyou cant think. You might
be more easily overloaded in a situation where there is a lot of stimulation and you have to sort it all out. Keep in mind, though, that research
shows somewhat decreased activity in certain brain areas; the brain
does not shut down entirely. This is not an all-or-none situation. But we
can now begin to understand why it is harder to think when youre depressed. I believe that this research may also shed light on why your
thought patterns are more likely to get stuck when you are depressed;
your capacity for flexible thinking normally supported by the
prefrontal cortex is lessened. This is one reason why you are likely to
need the help of other people to get unstuck.
The depressed mind
There is no one mental state associated with depression. Depression can
be exquisitely painful. You may feel so agitated and distressed you want
to crawl out of your skin. You may feel extremely guilty. Or you may
feel empty, numb, incapable of feeling much of anything. Feelings of
low self-worth are extremely common in depressionfeeling worthless, useless, or even bad or evil. Some researchers believe that low
self-esteem is an important pathway from stress into depression.
Regardless of the form it takes, depression is a state of mind that is
learnedalthough not deliberately! It is a state of mind that can become habitual, easily triggered when something goes wrong. In that
sense, depression is like a black hole that has a strong gravitational
pull in the mind-brain. It is easy to get sucked into it if you get near the
edge. Staying out of depression requires resisting its pull, not giving in
to it.
The habit of depression can be learned early, for example, in the context of maternal depression or childhood trauma. And we know that
the more often you have been in a depressed state of mind, the more
likely that you will enter into this state in the future. Part of your stress
pileup may include a pileup of experiences of depression over your lifetime. Its not uncommon for patients to report being depressedon and
off, or at some levelsince childhood or as long as they can remember.
Depression in adolescence is increasingly common and increases the
risk of further depression in adulthood.
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We know that habits, by their very nature, are hard to change. Depression is being stuck, going in circles, spinning your wheels, or just
shutting down. Its hard to pull out of depression, and its hard to stay
out of depression. But, as much trouble as it causes when its not functioning up to par, we should be grateful for our prefrontal cortex. We
are always capable of new learning.
Coping with the Catch-22s
Assuming you are struggling with severe depression, you will need to
work on many fronts. There is no simple solution. And each front involves catch-22s. This section breaks down these catch-22s into several
domains: biological, behavioral, cognitive, and interpersonalall of
which capture different treatment approaches to depression.
In general, the only way I can think of to cope with the catch-22s is to
set modest goals and to try to remain content with small steps of progress. Of course, this will be difficult. Depression is a painful state; it
causes all manner of difficulty in your life; and you want to get out of it
as soon as possible. But you cannot do it quickly. Setting your goals too
high leads to disillusionment and more self-criticism. Heres another
catch-22: Slow progress toward goals is depressing. So the challenge is
to set your sights on modest short-term goals, keeping long-term goals
in the background. Small successes are one way out.
Physical health
You may not be able to work on all fronts at the same time. I think the
best place to start is with physical health. Certainly, you should have a
thorough physical evaluation not only to investigate general medical
conditions that might contribute to depression (e.g., thyroid disease)
but also to treat any general medical condition that may be undermining your health and strength in other ways. A simple example: How are
you going to cope with depression when you have the flu?
Sleeping and eating well should be at the top of the list. For many persons, a key part of the treatment for depression is medication, which is
intended to help with your physical condition (sleep, appetite, energy
level) as well as your mental condition. But any actions you can take to
improve your mood and decrease your anxiety will also help your physical health. Sleep should be a very high priority, and antidepressants as
well as sleeping medications may be helpful in that regard. Good sleep
hygiene is also important (e.g., not using stimulants late in the day,
making an effort to settle down before going to bed, adhering to a regular sleep schedule).
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Activity level
A good next step after attending to your physical health is to work on
your activity level. Again, a catch-22: If youre depressed, you dont
have the energy or motivation to do much of anything. Small steps
here. We know that exercise (e.g., aerobic exercise) is a good antidepressant. Its also a good antianxiety activity. But its not likely youll
have the energy to do vigorous exercise if youre severely depressed.
Getting out of bed and getting bathed and dressed can feel like climbing a mountain. Once you can get yourself going, holding to a regular
schedule or structurea plan for activity throughout the daywill
be important. When youre getting well, you might consider exercise.
Youll need to work up to it. Mind you, were not talking about enjoying activity here. Rather, the goal is just trying to get yourself going.
Seeking pleasure
After activity, Id focus on attempting to experience more pleasure. You
can force yourself to take action to a certain degree, but you cannot
force yourself to feel pleasure. You can only provide yourself with the
opportunity to feel pleasure. Because anxiety interferes with pleasure,
learning and practicing relaxation techniques can be of some help in
this regard. Imagery, meditation, biofeedback, and deep breathing are
examples.
One aspect of behavior therapy for depression entails listing all activities that have provided pleasure for you in the past and making a plan
for doing them in a regular, systematic way. This is a good idea, and its
worth putting time and effort into it. But remember that the core of depression is low positive emotion. The pleasure circuits arent working
properly. They need to be jump-started. I think you can jump-start them
with activity. All you can do is put yourself in situations where you
might experience some pleasure.
At first, youre more likely to feel a spark of interest, involvement, or
absorption in something rather than outright excitement, pleasure, or
playful joy. Thus you might start by just trying to get yourself engaged
in something that will take your mind off your suffering for a bit. You
might try to be more aware of moments of interest or slight glimmers of
pleasure. They wont lastyoure depressed. But they might increase in
frequency and duration over time. Some persons whove been depressed hit on something they enjoy. Then, understandably, they do it
in an addictive way. They overdose on the activity, it becomes stressful,
and the pleasure wears out. Go slowly with pleasure; its best not to try
to force it.
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Thinking flexibly
After pleasure Id tackle thinking. This is getting into the complicated
territory of cognitive therapy. Cognitive therapy is proven to be effective in treating depression. Yet some patients are put off by cognitive
therapy because of a misunderstanding. Aaron Beck, who developed
cognitive therapy for depression, cautioned that cognitive therapy
should not be confused with the power of positive thinking. He emphasized that cognitive therapy does not mean thinking positively but
rather thinking realistically. I would also emphasize that changing your
pattern of thinking is difficult. Its hard work, and it takes a long time. If
you think its supposed to be easy, you will feel like a failure at cognitive
therapy, and youll only feel more depressed. This is not how cognitive
therapy 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 youre
not depressed, you cannot stop thinking negatively! Everyone has negative thoughts and, if youre depressed, you have tons of them. Theyre
automatic, like reflexesthought reflexes. You cannot stop your reflexes. And, in my view, many of the negative thoughts in depression are
not unrealistic or distorted. Bad things have happened, and they have
bad implications. Thats one reason why youre depressed! These automatic reactions lower your mood, and then you have negative thoughts.
The challenge is to avoid getting stuck in these negative thoughts, ruminating about them, and then going down further into the pit of severe
depression.
What you can do, if youre not extremely depressed, is get a grip on
your negative thinking and create more flexibility in your mind. The
most important step you can take is to learn to question your negative
thinking. You reflexively have the negative thought (I really screwed
up), but then you can be aware of it and question it, taking another
point of view on it (To err is human). Theres nothing wrong with
having negative thoughts, but it is important to focus your negative
thinking. The problem is not negative thinking per se but rather global
negative thinking (Im a completely worthless human being, always
have been, and always will be). After thinking Im a total screw-up,
you might think, I screwed up this one thing today, not everything today. Then you might even offset this by thinking about something else
you did well. The goal is not to switch from focusing on the half-empty
to the half-full view of the glass, but rather to be able to see that the glass
can be both half-empty and half-full. You fail, and you succeed. Better
focused negative thinking also can lead to problem solving. If you fail a
test and think, Im a total loser, you are stuck. If you think instead, I
should have studied harder, you have a direction.
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Thus you can be bummed out, think negative thoughts, and yet pull
yourself out of the spiral rather than getting stuck in rumination. Easier
said than done, especially when youre depressed. This is extremely
hard work. I think its very hard to control your thinking, and most patients I talk with agree. Its easier when youre feeling calm, and its
harder when youre feeling upset or depressed. Controlling your thinking is a difficult skill that can only be increased in increments across the
lifetime. The catch-22: You could be better at it if you werent depressed. In keeping with this idea, a recent approach begins cognitive
therapy after recovery from depression with the goal of preventing relapse and recurrence.
Mentalization and mindfulness
Its a misapplication of cognitive therapy to believe that you must ram
negative thoughts out of your mind with positive thoughts. We should
shift our focus off the specific content of our thoughts (i.e., bad
thoughts like Im a rotten person versus good thoughts like Im a
great person). Instead, we might focus more on the process of thinking. Thats why I emphasize increasing the flexibility of thinking, rather
than thinking one kind of thought instead of another. The challenge is
to see the same things from more than one point of view, rather than remaining stuck ruminating in a depressive rut. Again, this is not easy to
do, especially when youre depressed.
The concept of mentalization is helpful in understanding flexible
thinking. To mentalize means to interpret human behavioryour
own and others behavior-in terms of mental states. We do this all the
time, often without being aware of it. You sense that your friend is upset, and you show concern on your face. When interactions with others
do not go smoothly, you may mentalize more consciously, wondering,
Why did she do that? What could he have been thinking? Likewise, you can be puzzled by your own behavior and wonder, Why did I
do that? Thus we mentalize a lot, yet perhaps not enough.
Again, to mentalize means to be aware of mental states. Consider
some common failures of mentalization. You can be insensitive or tactless, unaware of the impact of your behavior on another persons state
of mind. Generally, when we are aware of others mental states, we behave in a more compassionate way. You can also be insensitive to
your own states of mindbeating yourself up in your mind with endless self-criticism, driving yourself deeper into the pit of depression, not
mindful of how youre treating yourself, providing little room for compassion toward yourself.
But I want to emphasize a different kind of failure to
mentalizeconfusing mental states with reality or truth. The best
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example is dreaming, which is a nightly failure to mentalize. We dont
realize (except in lucid dreaming) that the dream is a mental state. It
feels utterly real. If we have nightmares, we might awaken in a state of
terror, feeling in danger, until we realize (mentalizing), It was just a
dream. Here is another example: Persons who have gone through
traumatic events (e.g., being assaulted) are liable to develop flashbacks.
A flashback is a memory of being in a traumatic situation that is so vivid
it feels as if you are back in the situation, reliving it. It is a failure to
mentalize. The person is not aware that it is a memory (mental state) but
rather feels as if the traumatic event is really happening again (present
reality).
Another example of failure to mentalize is getting into a paranoid
state. Have you ever started to worry about being disliked or thought
that people are talking about you critically? Or, when alone in the dark,
have you ever started to imagine being harmed or attacked? Many of us
have such thoughts and fantasies. But we fail to mentalize when we lose
sight of the fact that these are our thoughts and fantasies and we actually become angry or frightened, as if our thoughts and fantasies are a
direct reaction to a current reality. We confuse worrying with being in
danger, 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 person
who makes a mistake and then thinks, Im a worthless human being
who doesnt deserve to live, then slips into a feeling of self-hatred and,
at worst, becomes suicidal. These reactions to making a mistake are
mental states, but they are easily confused with reality or absolute truth.
The self-hatred is like a dream that feels realit is a mental creation. To
mentalize means to be able to develop some detachment from such mental states and to be aware of them as such. There are many other possible mental states one could get into after making a mistake (e.g.,
momentary irritation, self-justification, blaming someone else, dismissing it as insignificant). And mental states are temporary, although depression can be highly persistent. Ideally, such mental states can pass
quickly from one to another. Self-criticism can be a quickly passing
mental state, which you can take for what it isa mental state, not an
absolute truth or reality. Mentalization can be the pathway from low
mood and negative thinking back to a nondepressed state, an alternative 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 an
off-putting response. It may seem to dismiss the seriousness of your feeling 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 stand
back and reflect, to consider that there are other points of view, to let
the state pass. On the contrary, depression has a way of locking you into
a rut. Keep in mind that changes in brain functioning (in the prefrontal
cortex) may make this difficult. Heres another catch-22. Its helpful to
think flexibly and to be aware of your mental states, but the depression
is interfering with your brains capacity to do this. You tend to get stuck
in the same pattern of thinking rather than being able easily to shift out
of it. Its difficult, but not impossible.
There is an ancient practice, called mindfulness meditation, that involves becoming more aware of your mental states. Its like training for
mentalization. There are many aspects to mindfulness. For example,
mindfulness involves being more aware of the present rather than lost in
the past or worrying about the future. You may learn to calm yourself by
focusing your attention on one object, for example, your breathing. But
another facet of mindfulness training involves taking a somewhat detached perspective on your own mind, observing your mental states with
interest and curiosity, rather than becoming swept up in one or another
train of thought. You can learn to observe your mind without judging,
being more neutral and accepting. When you are able to do this, you become aware of how changeable your mental states areor can beand
how it is possible to have an infinite number of states of mind in the same
situation. You can learn to take your states of mind less seriously. They
are fleeting. They are real; yet theyre not realityeach mental state is
one among many possible perspectives on reality.
Is this mindful attitude easy to adopt? On the contrary, it is extremely difficult for anyone. A Buddhist monk may spend a lifetime cultivating mindfulness. And it will be most difficult when you are
depressed. I think learning to control your own mind-brain is one of the
most difficult things you might aspire to do. But there are ways of practicing this skill, becoming better at it with practice, and using it to prevent yourself from getting stuck in depressive ruminations that can take
you from the normal state of feeling bummed out when something goes
wrong to feeling utterly mired in depression. Some recent research indicates that mindfulness practice along with cognitive therapy can help
prevent relapse into depression.
The greatest challenge with mentalizing is to be able to do it in the
heat of the momentto be able to feel intensely, be aware of your feelings, and think about what youre feeling, all at the same time. Consider
what it takes to sustain hope while feeling hopeless. This requires no
small amount of mental flexibility. Practicing mindfulness when youre
not in the heat of the moment might better prepare you to be able to
mentalize when the heat is turned up. Think of this as a skill, like play130
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. Youd
not want to be out of shape when the bear is charging. Few of us are
concert pianists or Olympic runners. But long practice can lead to some
degree of skill, which can be employed when the going gets tough.
Relationships
Ive saved the most complex for last. There is a thicket of catch-22s in
the interpersonal domain of depression. If its difficult to control your
own mind, how difficult must it be to keep your relationships in balance? Theres a big catch-22 here: Often problems in relationshipsconflicts, losses, and breakupsplay a major role in triggering
depression. Often enough, a history of traumatic relationshipsabuse
and neglectplays a role in the history of depression. Thus relationship
problems are often major contributing causes to depression. The catch
is this: Supportive, caring relationships are an important aspect of healing from depressionand preventing relapse into depression. We have
a problem when the cause of depression is also the remedy.
If youre depressed, youve doubtlessly been encouraged to seek support. You may have heard, perhaps countless times, Dont isolate
yourself from others. If youve been hurt by others, you are likely to
want to withdraw. Even without a history of being hurt by others, depression prompts you to withdraw. Recall the idea of pleasure circuits
in the brain, which are somewhat shut down in depression. Commonly,
pleasure is associated with contact with others. Those who are more
cheerful tend to be more sociable; theyre extraverts. Contact with
other persons is a major source of pleasure for many persons. When
youre depressed, you dont find activities interesting and pleasurable,
and this includes socializing with others. You might want to crawl into
bed and turn your face to the wall.
Also, when youre depressed, contact with others can be very stressful. Depression tends to be contagious, and you have a sense that others
dont want to be exposed to it. They withdraw from you. In addition,
when youre depressed, you are inactive. You may not talk much, make
much eye contact, smile, or show much facial expression. You may not
show an interest in others, but rather you may be quite self-preoccupied. You dont make a very good conversational partner. Or you have
to force yourself, and it wears you out to do so. Thus others may not
find it easy to interact with you, and you may encounter either subtle or
blatant rejection. Rejection fuels your wish to withdraw as well as your
feelings of inadequacy and negative thinking.
Heres yet another problem. Youre encouraged to reach out for support 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 not
forthcoming. Often, the feeling of being let down is the last straw that
takes a person from distress to despair. When you reach out for support, you are taking a risk, and it can go badly and make your depression worse. No wonder persons who are depressed tend to withdraw.
Finding social support is difficult but not impossible. As with all the
other catch-22s, the best way to work with them is to set modest goals
and go slowly. Trying to cheer yourself up by going to a lively party, as
others might encourage you to do, can backfire. You can wind up feeling even more alienated and alone. Quiet, low key social situations that
dont demand so much responsiveness are more manageable. Going to
a movie is a good exampleyou dont have to keep up a conversation.
The challenge will be to make contact with others who have some tolerance for depression. Those who have poor tolerance for depression are
liable to try to cheer you up, talk you out of it, or even be critical. Heres
an even greater challenge: One study found that those who received
most support had conveyed that they are coping OK and have other
sources of support. The supportive person presumably was able to offer
more support because he or she did not feel unduly burdened, totally responsible for the distressed persons welfare.
The helpers tightrope
Seeking social support when youre depressed can be a bit of a minefield. Part of the challenge of mentalizing is being aware of not only
your own mental states but also the mental states of others. Its a lot to
ask that you do both, but awareness of your potential support figures
mental 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 be
of help to a depressed person. I think of the helper as being on a tightrope in the sense that its easy to fall off in one direction or the other.
Staying on the tightrope entails providing steadfast, gentle encouragement. Providing support doesnt necessarily require doing anything,
much less fixing anything. Rather, what is most helpful is an accepting
attitude and a willingness to be there so that the depressed person at
least does not feel so totally alone.
Yet, quite often, helpers feel they need to do something to pull you
out of depression. And they may have a strong urge to do so because
your depression is depressing, distressing, or frustrating to them. If you
are suicidal, the helper is likely to feel downright frightened. Short of
being suicidal, when you dont recover quickly despite the helpers efforts, 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 helper
will become.
When the helpers support fails to be effective, there are two ways the
helper can go wrong. I think the natural inclination is to push harder
and to become critical (at worst, If youd just get up off your...). After
criticism also fails, the helper may be inclined to give up and withdraw.
This leaves the depressed person being alternately criticized and abandoned, 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 you
will need to coach your helpers, letting them know whats more helpful
and whats less helpful. This is not easy for you to do, and it may not be
easy for the helper to hear. To feel criticized for not helping in just the
right way also can be very discouraging and frustrating. But often helpers need reinforcementthey need to hear that they are being helpful.
And they may need to learn that just being there, without doing anything or fixing anything, is whats most helpful. Mainly, you will benefit from understanding and a compassionate attitudeprecisely the
attitude that is important to try to cultivate in your own mind, toward
yourself.
Tackling the stress pileup
My focus here has been on depression as a primary problemin effect,
how to manage it and recover from it. But depression is typically a response to other problems, the resolution of which is critical to full recovery and prevention of recurrence. In some ways, recovering from
depression is only the first stepit can give you back the energy and
wits to cope with the problems that brought on the depression.
Thus recovery can help return you to a more effective problem-solving mode. Tackling and resolving problems can decrease stress. This approach is likely to require that you assert yourself and make changes in
your lifestyle such that you are not so overwhelmed and oppressed. Another catch-22: Lifestyle changes can entail significant losses, which can
also be depressing. Yet, having become depressed, you must be mindful
of your vulnerability to stress.
Given the risk of recurrence of depressive episodes over the lifetime
for a person with a history of major depression, I think it is best to take
the hard place view that implies lifelong self-care. At some point,
self-care may become routine and may take relatively little effort. Particularly in the face of many life stressors, however, self-care periodically will take a major effort. A lifelong issue will be learning to
minimize and manage stress to the extent possible. In principle, some
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stress is avoidable (e.g., stress associated with problematic personality
and relationship patterns or with a lifestyle of running). Unavoidable
stress, however, is like a wild cardyou cant prevent it, and it could
occur 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 facilitate
coping.
Integrated treatment
Several forms of treatmentmedication, electroconvulsive therapy, behavior therapy, cognitive therapy, and interpersonal therapyhave
been demonstrated to be effective in promoting recovery from depression as well as in relapse prevention. Collectively, all these treatments
address all the domains of catch-22s discussed here.
Antidepressant medication is often employed as a first-line treatment
of depression, although psychotherapy also can be a viable alternative
to medication. Many research studies show that combining psychotherapy and medication is the optimal approach. Psychotherapy can be employed to facilitate recovery when medication is only partially effective,
and psychotherapy can be employed along with medication to decrease
the risk of relapse or recurrence. Keep in mind that one of the most common problems in treating depression is giving up on treatment prematurely. Continuing on medication well after recovery and taking great
care in collaboration with your doctor about discontinuing medication
is essential to preventing recurrence. You may not need to remain in
psychotherapy continuously, but you might find it helpful to return to
therapy periodically for support during times of extra stress. Getting
the level of care you need when you need it is just what you would do
with other physical illnesses.
Appendix
Guide to pertinent literature
The following overview of the patient education material includes key
literature 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 illness
Following 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, especially among young persons (Hammen, 1997). In the context of
whether a person chooses to remain depressed, we discuss the characteristics of the sick role (Parsons, 1951) and its complications in
the case of depression. The World Health Organization data on disability are shocking (Murray & Lopez, 1996). Extensive research on morbidity is consistent with the WHO findings (Wells, Sturm, Sherbourne,
& Meredith, 1996). Notably, even subsyndromal levels of depression
are associated with significant disability (Judd et al., 2000).
It is simplest, and consistent with much research evidence (Judd et
al., 1998b), to present unipolar depression as one illness that varies in
severity and duration. This view allows for the crucial distinction between major depression and dysthymia, as well as the concept of double depression (McCullough et al., 2000). When discussing the course
of depression, it is helpful to distinguish among response, remission,
relapse, recovery, and recurrencealthough these terms are not always used consistently (Frank et al., 1991). The five-site Collaborative 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 an
acute illnessas Solomon (2001) and Styron (1990) have done so eloquently. Notably, the median time to recovery from an episode of major depression, 5 months, is comparable to Kraepelins (1921) earlier
estimate of the time to recover from simple attacks of affective illness (i.e., 6-8 months). A wide range of variables predict duration of
episodes, and it is important for patients to know that active participation 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 single
most 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 recurrence
have been thoroughly investigated (Ilardi, Craighead, & Evans, 1997;
Keller, 1999; Mueller et al., 1999). Considerable evidence supports the
role of maintenance medication treatment in preventing relapse and recurrence (Dawson, Lavori, Coryell, Endicott, & Keller, 1998), although 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 relationship between them. Specifically, depression is best viewed as low
positive emotionality and anxiety as high negative emotionality (Watson, 2000). Meehls (1975) prescient view of depression as reflecting a
lack of cerebral joy juice (p. 299) has found confirmation in recent
neurobiological research, although we should focus on activation of
brain circuits as well as levels of neurotransmitters (Panksepp, 1998).
Davidsons (2000) programmatic research linking positive and negative affect to approach and withdrawal and localizing these to the left
and right cerebral hemispheres, respectively, helps concretize the distinction, although the evidence for cerebral lateralization is by no
means entirely consistent (Schore, 2001).
Although depression is a serious illness, a number of clinicians and
researchers have sought to understand its potential adaptive value
(Neese, 2000). Useful theories include conservation-withdrawal
(Dubovsky, 1997), incentive disengagement (Klinger, 1993), and involuntary submission in the face of being overpowered (Gilbert, 1992). We
would hope that depression could become a signal that could be used to
head off an illness, which argues for the importance of depression tolerance (Zetzel, 1965).
Development of depression
Depression is best understood from a developmental perspective
(Hammen, 1992) that provides a balanced view of neurobiological
and psychosocial contributions. The evidence for a genetic contribution is well established (Hyman & Moldin, 2001), although the route
from genes to behavior is far more tortuous than is typically appreciated (Elman et al., 1996). Patients can be educated about the
diathesis-stress model in which genetic vulnerability increases risk
for depression in response to stressful life events (Kendler, Thornton,
& Gardner, 2001). Notably, genetic factors (e.g., by influencing
temperament and personality) also contribute to risk for exposure to
stressful life events that precipitate depression (Kendler, Karkowski,
& Prescott, 1999) as well as to level of social support that serves a
protective function (Kendler, 1997). A wide range of general medical
conditions are also significant in the etiology of depression (American Psychiatric Association, 2000). And depression itself can be
viewed as a dysregulated high-stress state associated with widespread adverse physiological effects (Dubovsky, 1997; Sapolsky,
1994).
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Given that separation and loss are common precipitants of depression, attachment theory (Bowlby, 1973, 1982) is a critical part of the
foundation of a developmental model of depression (Blatt & Homann,
1992), and research on nonhuman primates has solidified our understanding of the role of attachment in depression (Suomi, 1991). Not
only separation and loss but also lack of responsiveness can play a significant role in depression, as strikingly indicated by research on maternal depression and infant depression (Field, 1995). In addition, as
ample research now demonstrates, childhood maltreatment is a major
risk factor for depression, in part by virtue of impairing psychosocial
development (Allen, 2001; Bifulco & Moran, 1998). In addition, a host
of early stressors likely contribute to vulnerability for depression later
in life, in part owing to a neurophysiological process of sensitization
(Dunman, Heninger, & Nestler, 1997). In addition, posttraumatic
stress disorder itself is a risk factor for depression (Breslau, Davis,
Adreski, Federman, & Anthony, 1998), consistent with Darwins
(1872/1965) view that fear is the most depressing of emotions. Also
consistent with a traumatic etiological pathway to depression is
Seligmans (1975) learned helplessness model of depression, in which
he explicitly referred to his experimental intervention (inescapable
shock) as a trauma.
In the stress pileup view of posttraumatic depression (Allen, 2001),
early trauma may compound the effects of later stressful life events and
difficulties, which themselves have been amply demonstrated to play a
role in precipitating depressive episodes (Brown & Harris, 1978). Such
stress is compounded further by internal pressure associated with such
personality characteristics as perfectionism (Hewitt & Flett, 2002) and
proneness to rumination (Nolen-Hoeksema, 2000). Finally, depressive
episodes themselves are extremely stressful and hence contribute to the
process of sensitization to further episodes (Post, 1992). At worst, depressive episodes can become self-perpetuating over time, with diminishing contributions of external stress.
As our understanding of the neurobiology of the chemical imbalance becomes dauntingly complex (Dunman, Malberg, & Thome,
1999), we might better help patients understand the brain-based aspects of depression by focusing on neuroimaging research, which affords the potential to link neurobiology and mental functioning more
directly. Unsurprisingly, in this relatively new area of research, the findings are often confusing and contradictory; yet some broad consistencies are emerging (Dougherty & Rauch, 1997). Two domains of
findings can be tied to patients experience. Excessive amygdala activity
(Drevets et al., 1992) is consistent with depression as a high-stress state,
and abnormal prefrontal activity (Mayberg, 1997) is consistent with diVol. 66, No. 2 (Spring 2002)
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minished executive functioning and lack of flexibility in thinking
(Goldberg, 2001). Particularly instructive is Elliott and colleagues
(1997) study demonstrating a direct link between diminished
prefrontal functioning and impaired complex problem solving in depression.
Coping with the catch-22s
The catch-22s pertain to the full range of treatments, from somatic to
psychotherapeutic, and all have demonstrable effectiveness (Weissman,
2001). With respect to physical health, sleep merits emphasis inasmuch
as it is a precondition for general well-being (Dement, 1999). Activity
scheduling in general, and participating in pleasurable activities in particular, are important facets of cognitive-behavioral therapy (Beck,
Rush, Shaw, & Emery, 1979; Lewinsohn, 1974). Exercise also can be
an antidepressant (Dunn & Dishman, 1991; Watson, 2000). Of course,
all these are difficult prescriptions to follow because of the symptoms of
depression (i.e., insomnia, lack of energy, diminished interest and pleasure).
Cognitive therapy will be a cornerstone of any patient education program, and Beck and colleagues (1979) classic work remains an invaluable guide to the treatment of depression. A great deal of subsequent
research has been devoted to teasing out the complex relations between
thinking and mood (Brown & Beck, 2002; Ingram, Miranda, & Segal,
1998), which turns out to be a kind of chicken and egg problem.
However the cycle may start, lowered mood and negative thinking enter into a vicious circle that deepens depression. Yet, as Beck and colleagues argued (1979), the rigidity of thinking in depression can be
construed as the primary problem. With the advent of neuroimaging research, we are now beginning to appreciate the biological basis of the
cognitive catch-22s: The depressed person must maintain flexibility in
thinking, but prefrontal functioning that sustains such thinking is compromised. Hence a particularly promising treatment approach entails
implementing cognitive therapy after recovery as a form of relapse prevention (Segal, Williams, & Teasdale, 2002; Teasdale et al., 2001).
Borrowing from the developmental psychopathology literature and
attachment theory, we are finding the concept of mentalization
(Frith, Morton, & Leslie, 1991) useful in helping patients understand
the need for flexible thinking in depression (Allen & Fonagy, 2002).
Mentalizing entails interpreting the behavior of oneself and others as
intentional, that is, mediated by mental states and processes. Like many
other cognitive capacities (e.g., perception and language), we take
mentalizing for granted, with the glaring exception of autism
(Baron-Cohen, 1995). Yet consider some common failures to
138
mentalize, in which mental states are equated with external reality:
dreams, hallucinations, and posttraumatic flashbacks. Absolutistic
thinking in depression also can be construed as a failure to mentalize, in
which the capacity to adopt multiple perspectives and to reflect on
thinking is lost, and beliefs are equated with absolute truth. Hence it is
noteworty that mindfulness training (Goldstein & Kornfield, 1987),
which enhances awareness of mental states as such, is being incorporated into cognitive therapy for depression (Segal et al., 2002).
The interpersonal challenges associated with depression are most directly addressed in interpersonal therapy (Klerman et al., 1984), but
this is a vast territory of theory and research. A glaring catch-22 is that
attachment relationships can be at once a major contribution to depression and a primary route to healing from depression (Allen, 2001). The
benefits of social support are legion (Monroe & Steiner, 1986). Yet
seeking support in the context of depression is fraught with pitfalls, not
least of which is the prospect of feeling let down and even more depressed (Brown, 1992; Harris, 1992). Hence, rather than blindly encouraging patients to reach out for support, it is best to acknowledge
the many challenges in doing so. Social engagement (and mentalizing)
entails complex problem solving of the highest order and places serious
demands on the cerebral structures we now know to be compromised in
depression (Brothers, 1997; Goldberg, 2001). Moreover, like other
emotions, depression is contagious (Hatfield, Cacioppo, & Rapson,
1994). Depressed persons lack of engagement and unresponsiveness
are also aversive to others (Segrin & Abramson, 1994). With all these
challenges, depressed persons not only find socializing difficult but also
encounter social rejection, be it covert or overt. Hence patients often express frustration with the limited helpfulness of others, and it is helpful
to encourage them to be mindful of the challenges other persons face in
being helpful (i.e., what I call the helpers tightrope). Often persons
who can be most helpful are those who have a relatively high tolerance
for depression.
The upshot of the catch-22 approach is that the depressed person
will need to work on many fronts, and the wide array of treatments that
have been developed address these various fronts (Weissman, 2001).
The inpatients we treat invariably require a combination of
psychopharmacological and psychotherapeutic treatment, and there is
good evidence for the effectiveness of this integrated approach
(Gabbard & Kay, 2001). The challenge for those who aspire to educate
patients about depression is to respect fully the challenges in recovery
while holding firm to the conviction that persistence in adequate treatment over the long haul offers the best hope of wellness.
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Catch-22s of depression

Coping with the catch-22s of

This article is based on a presentation at the 24th Annual Winter Psychiatry

Vol. 66, No. 2 (Spring 2002)

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Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

Vol. 66, No. 2 (Spring 2002)

Bulletin of the Menninger Clinic

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