"You need to be able to own the reality that depression is a physical illness like heart disease, diabetes, and cancer. You cant get over it by 'trying harder' or adjusting your attitude."(DR. RICHARD H. RASKIN)
Richard Raskin, PhD, is a private-practice psychologist in New York City and Litchfield, Conn., who specializes in stress management.
Q: How can I tell whether my condition is the result of stress and anxiety in my daily life, or a serious clinical depression?
A: Everybody feels anxious and blue sometimes. What differentiates those feelings from depression is how long they last; if they persist for two weeks or more, you should consult a mental health professional. And there is a list of symptoms to watch for: persistent anger, irritability, a loss of interest in pleasurable things, lack of interactivity with family and friends, feelings of guilt, sleeping problems, eating too little or too much. These can come in any number of combinations. Still, the first thing I look for is the duration of the symptoms.
Q: When I am depressed, should I strive to maintain a "normal" life at home and at work or cut myself some slack?
A: The answer is both. Depression impacts your judgment about what you ought to be doing, at work and socially: How much is enough? What is OK and not OK? How do others perceive me? A lot of this impaired judgment can make you hypercritical of yourself, especially at work. Combine that with feeling as though you are slogging through a swamp, and your perceptions may not be very trustworthy.
Lets say you are correct in assuming that your work abilities are diminished. Chances are, you can still accomplish some meaningful tasks, however difficult the effort might be. Maybe you cant work at 100% capacity; maybe you can work at only 75% capacity. Still, thats an accomplishment, and it provides genuine feedback about your condition. Patients have told me that, looking back on their darkest days, their work didnt seem so bad after all. Its sort of like the elephant walking on its hind legs: It may not be performed with grace, but its laudable if its performed at all.
It is the same in your home life. Try to maintain your regular schedule, from brushing your teeth to picking up the mail; get out of the house and stay active. So maybe you dont enjoy everything youre doing, but its still better than staying home and focusing on your illness. Then again, if you really cant function, you have to be compassionate with yourself. You deserve a break; take a sick day, whatever you need. Remember that you have a serious illness. This is not your fault and there is no reason to feel guilty.
Q: When I am depressed I become extremely anxious, at times feeling as if Im having a heart attack. Is there anything I can do about this?
A: Depression and anxiety often go hand in hand. Anxiety can cause changes in your breathing pattern. Rather than taking lung-filling breaths, you may shift to very shallow upper-chest breathing, which can make you feel as though you are suffocating or that you might stop breathing altogether. Sometimes taking deep, slow breaths can help. Hold a deep breath to the count of six, then exhale slowly to a six count; repeat this for four to five minutes. Increasing the level of oxygen in your body will often reduce symptoms of anxiety and panic. Sit and talk to yourself: This anxiety is not a dangerous event. You are not having a heart attack. It probably was triggered by some unconscious thought or fear. This is a normal body reaction that typically will pass in a few minutes.
Be mindful of what youre feeling, and accept that feeling in the moment; sometimes thats enough to help it pass. Bad things happen (they happen whether people are depressed or not) and we cant always control outcomes. This is where support groups come in, helping you understand that you are not the only one in this predicament. And remember that you always have choices, even if you cant see them in the moment.
Q: When I am feeling down, making a decision, however minor, is extremely stressful. How can I cope with this?
A: Its very common for a depressed person to be frightened about any little thing: a random negative thought, a glance from someone, something you read or see on TV, an intonation from someone you are speaking with.
You may not be consciously aware that anything has happened to trigger these feelings. Often the fears make you want to be alone, even isolated from the world around you. Its very important that you learn to recognize when these feelings are coming, and have a strategy for managing them and staying connected. This can be as simple as having someone to reach out to when danger strikes.
And you may be feeling a lot of anxiety—anxiety and depression often occur in tandem. When this occurs, you should step back and say to yourself, "What is the worst thing that could happen to me?" Its usually not as bad as you had feared.
[ pagebreak ] Q: Friends and family often maintain that I am merely experiencing "the blues" and consequently should be strong and persevere until it blows over. How do I convey that my situation is far more serious than that?
A: Theres no single best way. Its a good idea to raise the subject with your therapist and come up with a working strategy for informing friends and family and bringing them into your support group.
For most people its a hard message to hear, and they may not accept it, or not want to accept it. You have to spend some time with the trusted people around you and confide in them when it seems appropriate—and this is best done, if possible, when you are not depressed, when you are not suffering. You can discuss the subject with more clarity and choose your words more carefully; you dont want to appear to be exaggerating, and at the same time, you dont want to be so emotional and imprecise that your vital message is clouded.
Q: I dont believe that anyone who has not experienced depression can truly comprehend what I am going through. So how can they possibly be of help?
A: Yes, not everybody is going to understand and be supportive—you know that. If you have a broken arm, or back pain, or a headache, everybody can relate to those, for everyone has experienced them. Not so with mental illness. Some people are more perceptive than others, and they can read your pain and imagine what you must be going through even though they have never been there. This is the best you can hope for. Even better might be someone who has suffered depression and survived. Both can be tremendously helpful as sounding boards, guardians, counsels, lifelines. Suggest that you stay in touch regularly, like the buddy system.
For those who dont get it, you can expose them to literature, websites, even documentaries on the topic. Its hard not to be moved by this. Again, once they comprehend your pain, if even just a little bit, they can be of help.
Q: How do I sort out all of the depression help sites on the Internet?
A: Beware if you see promises of a quick cure or if they promise you some kind of shortcut. Find out if these are just gripe sessions and not helpful discussions by people with similar problems. And beware of sites that charge fees, or those that advocate getting off medicine.
The good news is that you can find support groups just about everywhere for depression and bipolar depression. The Depression and Bipolar Support Alliance, the National Alliance on Mental Illness, and the Mayo Clinic are all good places to start.
Q: When depression comes on for the first time, should I seek drug therapy first, then talk therapy, or the other way around?
A: Talk to your primary physician as soon as possible; doctors are well trained in these matters, are familiar with the medications, and know what to do. Tell them everything that has been going on. They can get a drug treatment going and, if necessary, refer you to a mental health professional. Its better to engage in therapy when the acute pain is under control.
[ pagebreak ] Q: When Im depressed, should I postpone making important decisions, such as taking on a new job or ending (or starting) a personal relationship?
A: One of the symptoms of depression is having a negative outlook on many things going on in your life. This alters your judgment on almost everything, and you might not be aware of it. So to the extent possible, important decisions should be delayed.
If a difficult decision cant be delayed, get the best input you can from those closest to you. Dont make a decision simply to get it over with. Consult your support network—therapist, clergy, family, and friends—and make the best decision youre able to. Its really all any of us can do at times.
Q: When depressed, I dont even want to speak on the telephone, no less build a support network of friends and family. How should I deal with this?
A: Its important that you dont let yourself become isolated. To the degree you can reach out, you reach out. Just get the process going with somebody, and then you may be able to add one or more people. Yes, its difficult to do this when you are depressed, so its best to set up this network during a time when you are feeling well. Typically, you will have periods when the depression lifts, or is not as acute. Also, this is when you should explore support groups.
And being alone does not necessarily mean isolation. Self-care is an important principle that we need to include in our lives—and that can include time to lick our wounds, rest, seek solace in quietude. Prayer, meditation, and spiritual retreats all can be useful and meaningful.
But when we close ourselves off from others and are alone in our own ruminations, anxieties, and fearful thoughts, depression can take control, and this can be destructive. Its important to recognize when this is happening and have a strategy for reaching out. You need to be able to own the reality that depression is a physical illness like heart disease, diabetes, and cancer. You cant get over it by "trying harder" or adjusting your attitude. It requires acceptance that you have a physical illness that requires attention, and that it makes no sense to blame yourself for it.
Q: From what I have read about psychotherapy, it takes years and years to "cure" depression. Is that true?
A: It does not take years to treat; usually the therapy, accompanied by drug treatment, takes a matter of weeks or months. At the beginning, therapy helps you make sense of whats going on, and helps you function better and cope with the symptoms until they go away. Of course, some people have major issues in their lives that they need to resolve, and this could take more time.
Q: How do I differentiate between "normal" suicidal thoughts and "dangerous" suicidal thoughts?
A: Its not your job to differentiate between what is serious and what is not. If you are having suicidal thoughts or start thinking about how to do it, you should contact a mental health professional, clinic, or emergency room.
[ pagebreak ] Q: Unlike other life-threatening illnesses, depression can carry the stigma of culpability: You brought it on yourself, so you can make it go away. This is so cruel. How do I answer it?
A: Sometimes people who have very little knowledge about depression have a difficult time understanding it. Frequently there are no obvious symptoms—its not like a broken leg or the flu—so they are not convinced that depression is an actual illness. They choose to believe that it is simply the blues or unhappiness, and that you may have done something to bring it on. If that is the case, they reason, you should have the ability to work through it and get on with your life.
Again, depression is a very hard thing for families to accept. They dont want to acknowledge that this is real and serious, so they go into denial. They also fear the stigma they could experience if others learn about the depression. What is more, they may be afraid because they feel that if a daughter or son has fallen prey to depression, they might too.
Q: I have never been one for joining groups of any kind. Why should I participate in group therapy or support groups?
A: Of course such groups are not for everyone, but they are definitely worth exploring. Following is a note from a former patient who initially was reluctant to participate in a group but eventually found it immensely beneficial.
"At first I wondered, Are these support groups merely misery-loves-company get-togethers, or something more substantial? Almost from the outset, I found my first group to be very rewarding, in part for that very reason: Misery does love company. We introduced ourselves—there were six or seven of us—and immediately I recognized that, for the first time in more than a decade, I was in a room with people who not only sympathized with me, but in many ways were me. At the risk of sounding overdramatic, I found the experience almost spiritual, because here I was interacting with individuals who needed no education about depression and its many causes, who needed no elucidation about symptoms and pain, who were experiencing the same issues at work and with family, and who certainly needed no more sermons about bucking up and moving on. With these stricken strangers, I could be totally honest. I suppose it was like gathering the 10 smartest physicists in the world in a classroom. You can skip the bullshit and get down to what really matters.
"Moreover, there existed a real generosity of spirit among the participants—every success story was everyone elses success story. There is no substitute for this."
Q: I have read that creating a daily routine can help me get through the week. What does that entail?
A: It's really important to have a regular routine of some sort and remain committed to it to the best of your ability. Whatever activities you decide to engage in, try to do them at the same time every day. You need to stay connected to the world, and self-discipline is a good way to achieve this. A routine—anything from jogging and shopping to doing the dishes—helps you avoid the stay-in-the-house-in-your-pajamas syndrome, which can make things worse; and a routine demonstrates to you and to others that if you are capable of getting through the day, you are capable of recovery. Naturally, when you are engaged during the day, you tend not to be as fixated on the depression.