The Complete Guide to Self-Management of Depression: Practical and Proven Methods

By Harpreet S. Duggal MD FAPA

Depression is a complex illness that presents in a myriad of ways and affects more than 350 million people worldwide. While medications and conventional cognitive-behavioral approaches to the treatment of depression have success, for many people these kinds of one-size-fits-all treatments are not enough to alleviate the symptoms of depression or help them find a long-term path toward wellness.

In The Complete Guide to Self-Management of Depression: Practical and Proven Methods, Dr. Harpreet S. Duggal offers several evidence-based treatments for depression and presents them in a practical, easy-to-use format that can be incorporated into day-to-day self-management of depression. Self-management is increasingly becoming the standard of care in people with long-standing medical conditions, and it broadens the narrow perspective of self-help beyond the traditional treatment of symptoms to include behavioral methods, positive psychology interventions, mindfulness, and complementary and alternative medicine approaches for treating depression. Finally, besides a focus on treating symptoms, it also addresses lifestyle changes, social relationships, communication, problem-solving, and elements of wellness and recovery.

In contrast to the traditional one-size-fits-all approach of self-help books on depression, The Complete Guide to Self-Management of Depression offers a menu of options for self-management of depression and provides guidance on whenand when notto use or combine particular strategies. Placing those who suffer from depression in the drivers seat of self-management can help them build confidence and prepare for the journey of managing depression.

• Language: English
• Publisher: Archway Publishing
• Release date: Jun 9, 2016
• ISBN: 9781480829527

Harpreet S. Duggal MD FAPA

Harpreet S. Duggal is a board-certified psychiatrist in the San Francisco Bay Area. An international expert on self-management of depression, he has practiced psychotherapy and psychopharmacology for more than 20 years. He has written over one hundred professional articles and is author of the most comprehensive evidence-based self-help book on depression, The Complete Guide to Self-Management of Depression. Visit his blog at selfmanagedepression.blogspot.com.

Book preview

Copyright © 2016 Harpreet S. Duggal, MD, FAPA.

All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

Archway Publishing

1663 Liberty Drive

Bloomington, IN 47403

www.archwaypublishing.com

1 [phone]

Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

Any people depicted in stock imagery provided by Thinkstock are models, and such images are being used for illustrative purposes only.

Certain stock imagery © Thinkstock.

ISBN: 978-1-4808-2951-0 (sc)

ISBN: 978-1-4808-2953-4 (hc)

ISBN: 978-1-4808-2952-7 (e)

Library of Congress Control Number: 2016906181

Archway Publishing rev. date: 6/8/2016

CONTENTS

Introduction

1 UNDERSTANDING DEPRESSION

What is Depression?

Types of Depression

Conditions That Mimic Depression

Risk Factors for Depression

Prognosis in Depression

Suicide and Depression

Some Myths and Facts about Depression

2 SELF-ASSESSMENT OF DEPRESSION

Why Self-Assessment is Important?

What are the Available Tools for Self-Assessment?

Monitor Your Depression Using the 5 Rs

3 SELF-MANAGEMENT AND DEPRESSION

What is Self-Management?

Empower Yourself with Self-Management

Bibliotherapy as a Self-Management Tool

How to Put This Book to its Best Use?

When to Seek Professional Help?

4 ROLE OF IRRATIONAL THOUGHTS (BELIEFS) IN DEPRESSION

Types of Negative or Irrational Thoughts

The ABC Framework: Change the B for a More Desirable C"

Identify Irrational Thoughts

Challenge Your Irrational Thoughts

Substitute Irrational Thoughts with Rational Thoughts

Identify Negative Core Beliefs Underlying the Irrational Thoughts

Problem-Solve for Genuine Problems

5 HELPLESSNESS, LOW MOTIVATION, PROCRASTINATION AND LOSS OF PLEASURE

Feelings of Helplessness during Depression

Break the Amotivation Cycle to Beat Procrastination

Learn to Reward Yourself

Recognize Your Flow Moments

Keep a Daily Activity Log

Analyze Your Daily Activity Log and Make Changes

Challenge the Irrational Thoughts That Prevent Change

Are Perfectionistic Tendencies Sucking the Pleasure Out of Your Life?

Get Out of the Trap and Back on "Trac(k) Using Opposite Action

Overcome Rumination with Mindful Distraction

Use a 2 x 2 Decision Matrix to Deal with Indecisiveness

The DARN Approach to Enhance Motivation

Moving to Commitment: The Importance Ruler and the Confidence Ruler

Overcome Analysis Paralysis with an Action Plan

6 WORTHLESSNESS AND LOW SELF-ESTEEM

Worthlessness and Low Self-Esteem in Depression

What Defines Your Self-Worth? It is self-RESPECT

Circle-of-Worth Technique

Don’t Rely on Emotions Alone to Define Your Self-Worth

Practice Unconditional Self-Acceptance

Stay Clear of the Approval Trap

Handle Criticism with Tact

Beware of the Social Comparisons

Stop Being a Victim of the Self-Imposed If-Then rules

Watch Out for the Negative Self-Fulfilling Prophecies

Know and Use Your Strengths

Tap into Your Self-Confidence

Create a Success or an Achievement Chart

Learn from Your Mistakes and Practice Self-Forgiveness

Try the SWOT Analysis

Identify and Interact with Positive People in Your Life

Express Gratitude More Often

Create and Practice Self-Affirmations

Create Your Own Coping Cards

Practice Positive Imagery

7 GUILT AND SHAME

Guilt and Shame in Depression

Types of Guilt

Is it Really Guilt?

Modify Your Behavior or Modify Your Rules/Values

Assess the Gravity of Your Guilt-Inducing Actions

Is Rescue Fantasy Driving Your Guilt?

Stay Clear of the Guilt Trap

Beware of the Guilt-Inducers

Know the Limits of Your Responsibility

Try the Percentage of Truth Technique to Reassign Responsibility

Why and When to say No without Guilt

How to Say No without Guilt

Practice Acceptance and Make Amends

Consider Self-Forgiveness

Use the Two-Chair Technique to Deal with Shame

Rescript Your Self-Blame Story with a Compassionate Letter to Self

8 HOPELESSNESS AND SUICIDAL THOUGHTS/BEHAVIOR

Hopelessness and Suicidality in Depression

Seek Professional Help if You Are Feeling Hopeless or Suicidal

My Family Will be Better Off without Me: You Are Wrong!

Debunk the Irrational Thoughts Underlying Hopelessness

Build Hope by Identifying Strengths and Reasons to Live

Choose Clear and Workable Goals and Stay on Them

Ask Yourself These Questions to Make Hope Visible

What Is Your Hope Story?

Build Your Resilience to Buffer Against Suicidality

What Is Your Meaning in Life?

Develop a Safety Plan

9 ANGER, IRRITABILITY AND FRUSTRATION

Anger, Irritability and Frustration in Depression

Don’t Justify Your Anger with These Common Misconceptions

Identify Triggers for Your Anger

Recognize Early Warning Signs of Anger and Get Away from It

Are You Overestimating the Anger-Provoking Situation?

Find the Should Behind Your Anger

Don’t Defend Your Vulnerabilities with Anger

Turn Your Frustration and Anger into Assertiveness

Learn to Forgive and Let Go of Hurts

Use Mindfulness Skills to Calm That Anger

Inject Some Humor into Your Life

Expect Setbacks and Disappointments from Time to Time

10 EMPTINESS, LONELINESS AND BOREDOM

Feelings of Emptiness and Its Variants in Depression

Is it Existential Crisis or Depression?

Is Your Pursuit of Love Making You Depressed and Lonely?

Are You Suffering from Loneliness?

Overcome Loneliness Using the Traditional Approaches

Enhance Your Emotional Intelligence to Overcome Loneliness

Explore Interpersonal Psychotherapy for Loneliness

Do Something about Chronic Boredom

Practice Mindfulness as an Antidote to Emptiness, Loneliness and Boredom

11 INSOMNIA

Insomnia in Depression

Cognitive/Behavioral Model of Insomnia

Keep a Sleep Diary

Follow a Healthy Sleep Hygiene

Change Your Faulty Beliefs and Attitudes about Sleep

Stop Trying to Sleep

Try These Techniques to Quieten Your Mind

Role of Supplements and Herbs in Treating Insomnia

Role of Sleep Aids and Medications in Treating Insomnia

12 COGNITIVE SYMPTOMS IN DEPRESSION

What is Cognitive Functioning?

Cognitive Symptoms in Depression

Is Depression or Something Else Causing Your Cognitive Symptoms?

Use Problem Adaptation Therapy to Address Cognitive Symptoms

Keep Your Brain Active with Cognitive Remediation

Practice Sahaj Yoga

Role of Medications in Treating Cognitive Symptoms

13 ANXIETY, FEAR AND PANIC

Anxiety and its Co-occurrence with Depression

Anxiety, Fear, Phobias and Panic

Assess Your Type and Severity of Anxiety

Identify Your Worrisome Irrational Thoughts – the Ifs and What Ifs

Don’t Misinterpret Physical Sensations as a Sign of Anxiety

Ask Yourself These Five Questions to Change Your Anxious Thoughts

Set Up an Experiment to Challenge Your Anxious Thoughts

Use the Catastrophe Scale to Put Things in Perspective

Assign Yourself a Daily Worry Time

Keep a Worry/Outcome Diary

Use Thought Stopping Techniques and Positive Imagery

Retrain Your Breathing

Distract Yourself from Worry

Overcome Avoidance and Fear with Graded Exposure

Use Coping Self-Statements

Bring on the Panic Sensations and Learn to Tolerate Them

Practice the Body Scan

Add Yoga to Your Daily Routine

Role of Herbs in Treating Anxiety

Role of Prescribed Medications in Treating Anxiety

14 GRIEF, COMPLICATED GRIEF AND BEREAVEMENT-RELATED DEPRESSION

Bereavement, Grief and Mourning

Grief and Depression

Complicated Grief

When to Seek Help

Don’t Isolate – Talk to Others

Don’t Postpone Grief with Short-Term Distractions

Change Your Irrational Thoughts about Loss

Finish the Unfinished Business

Reestablish Your Life after the Loss

Role of Medications

15 EXERCISE AS AN ANTIDOTE TO DEPRESSION

Role of Physical Exercise in Treating Depression

How Does Exercise Lead to Mood Improvement?

Other Benefits of Exercise

Are You Physically Healthy for Exercise?

Identify Barriers to Starting an Exercise Program

Determine the Type, Intensity, Duration and Frequency of Exercise

Gradually Work Toward Your Target

Monitor Your Progress

Make Exercise Fun and Not a Chore

16 ROLE OF HAVING A STRONG SUPPORT SYSTEM

Why Do You Need a Support System?

Identify Barriers to Seeking a Support System

Educate Family and Friends about Depression

Join a Peer Support Group

Do Volunteer Work

17 MARITAL/INTIMATE PARTNER PROBLEMS AND DEPRESSION

The Relationship between Marital Problems and Depression

Who May Benefit from Couple/Marital Therapy?

Educate Your Partner about Depression

Increase Caring Behaviors and Gestures toward Your Partner

Increase Your Shared Pleasurable or Meaningful Activities

Improve Your Communication Skills

Don’t Do the ABCDE Behaviors during Communication

Approach Problem-Solving Jointly with Your Partner

Know Your and Your Partner’s Personality Type

Are Rigid Standards and Faulty Assumptions Derailing Your Relationship?

Buffer Your Relationship from Stress

Learn to Accept and Change

Use the STOP and START Techniques to Handle Arguments

18 BRIGHT LIGHT THERAPY FOR DEPRESSION

What Is Bright Light Therapy?

Seasonal Depression and Bright Light Therapy

How Does Bright Light Therapy Work?

Who Can Benefit from Bright Light Therapy?

The Practical Aspects of Bright Light Therapy

Precautions and Side Effects

What to Look for in a Bright Light Device?

Other Treatments for Seasonal Depression

19 OTHER COMPLEMENTARY AND ALTERNATIVE TREATMENTS FOR DEPRESSION

What Is Complementary and Alternative Medicine?

St. John’s Wort

S-Adenosylmethionine

Folate (Folic Acid)

Omega-3 Fatty Acids

Other Complementary and Alternative Approaches for Depression

20 PRESCRIPTION MEDICATIONS FOR TREATING DEPRESSION

What are the Main Classes of Antidepressants?

Are Antidepressant Medications Addictive?

When do Antidepressants Help?

What Decides the Choice of an Antidepressant?

How Long Does it Take for the Antidepressants to Work?

What about the Placebo Response?

Are All Antidepressants the Same in Terms of Efficacy?

How do Antidepressants Differ in Their Side Effect Profile?

What are Some Strategies to Manage Antidepressant Side Effects?

Can Antidepressants Lead to Suicidality?

How is Response to Antidepressants Assessed?

What are the Causes of an Inadequate Antidepressant Response?

How is Inadequate Antidepressant Response Managed?

How Long do You Have to Take Antidepressants?

Who is More Prone for Recurrence of Depressive Episodes?

When to and How to Stop Antidepressants?

What is the Role of Combining Psychotherapy with Antidepressants?

21 TREATMENT-RESISTANT DEPRESSION

What is Treatment-Resistant Depression?

What is Pseudo-Resistance?

What are the Risk Factors for Treatment-Resistant Depression?

What Strategies Work for Treatment-Resistant Depression?

22 WHEN DEPRESSION BECOMES CHRONIC

What is Chronic Depression?

Thinking and Emotional Patterns in Chronic Depression

Tackle Maladaptive Social Patterns with Situational Analysis

Use Mindfulness-Based Skills to Prevent Relapse of Depression

Other Psychotherapies that Prevent Recurrence of Depression

Role of Medications in Chronic Depression

23 ALCOHOL/SUBSTANCE USE AND DEPRESSION

Alcohol and Substance Use with Depression

Do You Have a Substance Use Disorder?

Where are You in Your Readiness to Change?

List Pros and Cons for Substance Use

Have an Action Plan for Making a Change

Identify Your Triggers for Relapse

Recognize the Early Warning Signs of Relapse

Are Irrational Thoughts Impeding Your Recovery?

Develop a Relapse Prevention Plan

Role of Contingency Management in Treating Substance Use Disorders

Role of Antidepressants in Depression Co-occurring with Substance Use Disorders

24 SEEKING PROFESSIONAL HELP

When do You Need to seek Professional Help?

What Kind of Help do You Need?

How to Find the Right Kind of Mental Health Professional?

What are You Looking for in Your Mental Health Provider?

Improve Your Communication with Your Mental Health Provider

Try These Tips to Navigate the Healthcare System

Personalize Your Care: The Role of Measurement-Based Care

Develop a Personalized Treatment Plan

Internet-Based Psychological Treatments of Depression

25 PROMOTING SELF-MANAGEMENT THROUGH WELLNESS AND RECOVERY

What is Wellness?

What is Recovery?

What are the Key Ingredients of Wellness and Recovery?

References

My Recovery Toolbox

To Ira and Aiden, for believing in me and always being there for me,

To those with lived experience with depression who have inspired me with their stories of hope and resilience,

And

To my teachers at Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania and Central Institute of Psychiatry, Ranchi, India, who taught me the art and science of healing the mind.

The author has worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards. In view of ongoing research, equipment modification, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipments, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in instructions or indication of usage and for added warnings or precautions. Moreover, specific situations may require a specific therapeutic intervention not included in this book. The material contained in this book is not a substitute for professional psychiatric or medical advice. The contents of this work are not intended and not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians or therapists for any particular patient or condition. For these reasons, the reader, where appropriate, should follow the advice of mental health providers or physicians directly involved in their care or the care of a member of their family. No warranty may be created or extended by any promotional statements for this work. The author or the publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The fact that an organization or Website is referred to in this work does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Neither the author nor the publisher shall be liable for direct or consequential damages resulting from the use of material contained in this book.

INTRODUCTION

Depression is a complex illness, which presents in a myriad of ways and affects more than 350 million people worldwide. It is now accepted that genes and environmental interplay leads to depression. While there are several ways to treat depression, the most popular being antidepressants, almost 60-70% people treated with antidepressants fail to achieve a symptom-free state when first treated with these medications. Needless to say, antidepressants are not the be-all and end-all of depression treatment. In addition, about 80% of people with depression will experience a recurrence and approximately 15% will have a long-standing course. Self-management is increasingly becoming the standard of care in people with long-standing medical conditions. Self-management puts one in the driver’s seat with regards to making choices to treat depression. People with diabetes, heart disease, emphysema, asthma, and other long-standing medical conditions have successfully used self-management to live a healthy life. However, treatment of depression has lagged behind in incorporating the concept of self-management with most popular self-help books on depression focusing mostly on cognitive-behavioral approaches. Other self-help books on depression do talk about positive life style changes, but don’t elaborate on medications, psychotherapy, or other alternative approaches such as light therapy or supplements. This book, a product of thorough research with over 600 references, attempts to fill this void by consolidating evidence-based approaches for treatment of depression and presenting this information in a practical and easy-to-use format that can be incorporated into day-to-day self-management of depression.

The beginning few chapters of the book focus on identifying depression, recognizing the various presentations of depression, assessing its severity using self-assessment tools, understanding the course of depression, familiarizing oneself with the concept of self- management, introducing the cognitive model of depression, and using behavioral strategies to treat depression. The middle section of the book deals with the common symptoms of depression and the therapeutic techniques used to address these symptoms. The last few chapters discuss other approaches to treat depression such as exercise, bright light therapy, role of social support, medication treatment, and other positive life style changes. In contrast to the traditional paternalistic model of healthcare, consumer-defined wellness and recovery are now becoming the norm of healthcare delivery in mental health settings. The book ends with a discussion on the role of wellness and recovery in self-management of depression.

Some features unique to this book include:

• Strategies to manage anxiety and substance use, which commonly co-occur with depression.

• Discussion of overlap between grief and depression and strategies to deal with grief.

• Evidence-based discussion on the usefulness of medications in treating depression.

• Evidence-based discussion on alternative and complementary approaches in treating depression.

• Strategies for treatment-resistant and chronic depression, which are often overlooked in self-help books.

• Recognition and treatment of cognitive symptoms as research now suggests that these influence functional outcomes in depression.

• Discussion of internet-based psychological treatments of depression that are supported by research.

• Elaborate discussion on seeking professional help, improving communication with mental health professionals, and the concept of measurement-based care.

This book is not limited to one type of psychotherapeutic technique or school of thought for treating depression. It broadens the narrow perspective of self-help beyond the traditional treatment of symptoms to self-management of depression. Self-management, besides a focus on treating symptoms, also addresses life style changes, social relationships, communication, problem-solving, and also includes elements of wellness and recovery. Being trained in and having practiced psychopharmacology, cognitive-behavioral therapy, interpersonal psychotherapy, motivational interviewing, rational emotive behavior therapy, and integrated dual diagnosis treatment (for co-occurring psychiatric and substance use disorders), this is my humble attempt to synthesize evidence-based approaches for depression and present them under the rubric of a self-management model. The strategies in this book are derived from the following evidence-based approaches used for treating depression and other co-occurring conditions:

• Cognitive-Behavioral Therapy (CBT).

• Other cognitive therapy approaches such as Rational Emotive Behavior Therapy (REBT)

• Interpersonal Psychotherapy (IPT).

• Behavioral Activation (BA).

• Problem-Solving Therapy.

• Cognitive Behavioral Analysis System of Psychotherapy (CBASP).

• Positive Psychology Interventions (PPI) such as gratitude and use of signature strengths.

• Mindfulness-Based Cognitive Therapy (MBCT).

• Couple Therapy.

• Motivational Enhancement Therapy.

• Integrated Dual Diagnosis Treatment.

• Cognitive Remediation.

• Graded Exposure.

• Dialectical Behavior Therapy (DBT).

While the highlight of this book is to make you aware of the proven strategies that work for depression based on research, where applicable, caveats or situations when a particular strategy may not work are also discussed. This approach differs from the traditional self-help books on depression that sometimes tend to convey the one-size-fits-all paradigm. However, depression is a very heterogeneous condition and its treatment cannot be pigeon-holed into one or two kinds of treatment modalities. This book, in contrast, offers you a menu of options for self-management of depression.

Managing depression can sometimes be a long journey and this book will help you prepare yourself as an effective self-manager who is capable and confident of dealing with any bumps on this journey. While this book serves as a guide for self-management for depression, it is in no way a substitute for the professional opinion or treatment that you may be getting from your mental health professional.

Harpreet S. Duggal, MD, FAPA

CHAPTER 1

UNDERSTANDING DEPRESSION

WHAT IS DEPRESSION?

Depression affects more than 350 million people worldwide. The World Health Organization (WHO) estimates depression to be the fourth leading cause of disability (Murray & Lopez, 1997). Depression is common and in a survey conducted in 17 countries, about 1 in 20 people reported having an episode of depression in last one year (Source: WHO).

The Diagnostic and Statistical Manual of Mental Disorders – fifth edition (DSM-5) defines major depressive disorder as having the following nine symptoms (American Psychiatric Association, 2013):

1. Depressed mood or sadness or feelings of hopelessness. Some people with depression may not experience either sadness or depression, but may feel irritable, frustrated, or discouraged. They may also use expressions such as, feeling blah, down in the dumps, or I have no feelings to describe their low mood.

2. Loss of interest or sense of pleasure in things, which were previously enjoyable. Individuals with depression may describe this as not being interested in hobbies or pleasurable activities any more or not having the drive or motivation to engage in such activities. Expressions such as, I don’t care anymore may indicate this symptom.

3. Increase or decrease in appetite accompanied by either weight loss or weight gain.

4. Sleep problems – either insomnia or excessive sleep.

5. Agitation (pacing, restlessness, inability to sit still, hand wringing) or slowing down of movements, thoughts, and speech. These symptoms have to be prominent enough to be observed by others

6. Loss of energy or fatigue. Small tasks may take a lot of effort to complete.

7. Feeling worthless or having excessive or inappropriate guilt.

8. Difficulty concentrating and making decisions.

9. Thoughts of death, suicidal thoughts, and suicidal behavior.

The diagnosis of depression requires either depressed mood or loss of interest (criterion 1 and 2) along with four of the other depressive symptoms to be present on most days for at least two weeks. Since symptoms such as low energy, fatigue, sleep, and appetite problems can manifest with other medical conditions, the latter have to be ruled out. Moreover, if the depressive symptoms occur exclusively when one is using alcohol or other illicit drugs, then the diagnosis is related to that substance instead of being a major depressive disorder. Also, bipolar disorder has to be excluded before a diagnosis of major depressive disorder is made and this is discussed later. Finally, the depressive symptoms have to lead to distress or impairment in one’s functioning either at home or work or social life or school or other important areas of functioning. Throughout this book, the word depression refers to major depressive disorder as defined by the DSM-5 unless otherwise specified.

TYPES OF DEPRESSION

Besides major depressive disorder, as described above, there are other presentations of depressive symptoms. These are:

Dysthymia: Also called persistent depressive disorder (American Psychiatric Association, 2013), this condition is characterized by chronic low grade depressive symptoms such as depressed mood, appetite changes, sleep disturbance, low self-esteem, difficulty concentrating, and feelings of hopelessness. These symptoms persist for at least two years; any interval free of symptoms doesn’t exceed two months. A person may have dysthymia superimposed on major depression, also known as double depression.

Substance/medication-induced depressive disorder: The criteria for this condition is the same as for major depressive disorder (needing at least 5 out of 9 symptoms). However, these symptoms are related to recent use of a substance or medication. A person may have history of depression and ongoing substance use may worsen it, which sometimes makes it difficult to tease out these entities. If depressive symptoms persist more than a month after stopping a substance or medication, then the diagnosis is most likely a true depression (American Psychiatric Association, 2013).

Depressive disorder due to medical conditions: Depression can be an early manifestation of certain medical conditions (Cosci et al., 2015). These include: Parkinson’s disease, stroke, traumatic brain injury, hypothyroidism, Cushing’s disease, primary hyperparathyroidism, multiple sclerosis, pancreatic cancer, lung cancer, myocardial infarction, Wilson’s disease, and Acquired Immune Deficiency Syndrome (AIDS). Excluding medical conditions that either cause or present with depression is important to fully treat depressive symptoms. This is because these symptoms may respond to treatment of the underlying medical condition, thus obviating the need for an antidepressant (Fava, 2014).

Mixed anxiety and depression: Symptoms of anxiety can occur along with depression. The DSM-5 diagnosis for this condition is called major depressive disorder with anxious distress. This includes depressive symptoms co-occurring with anxiety symptoms such as feeling tense, restless, difficulty concentrating due to worry, fear of something awful happening, and fear that one may lose control of oneself. Depression and anxiety go hand in hand; about 85% of people with depression experience significant symptoms of anxiety and around 90% of people with anxiety have co-occurring depression (Gorman, 1996-1997). In addition, depression becomes difficult to treat when anxiety symptoms are also present (Katon et al., 2010).

Bipolar depression: A depressive episode can present in context of bipolar disorder. When diagnosing depression, it is imperative to first exclude an underlying bipolar disorder. This is because the medication treatment for bipolar depression differs from that for unipolar depression. People with bipolar disorder have manic or hypomanic episodes. These are periods of persistently elevated or irritable mood along with feelings of grandiosity, decreased need for sleep, talkativeness, racing thoughts, increase in sexual drive, increased goal-directed activity, or excessive involvement in foolish or impulsive activities.

Bipolar depression deserves a little more attention. Individuals with bipolar disorder spend around 40% of the symptomatic time being depressed (Judd et al., 2002). Moreover, people with bipolar disorder are more likely to seek help when they are depressed. Therefore, it is not uncommon for bipolar depression to be misdiagnosed as unipolar depression or major depressive disorder. The consequences of such a misdiagnosis may result in treatment with antidepressants, some of which can cause mood episodes to occur more frequently in people with bipolar disorder (Hirschfeld, 2014). Pointers that suggest a possibility of bipolar disorder are as below (Goodwin & Jamison, 2007; Hirschfeld, 2014):

• Family history of bipolar disorder.

• Earlier onset of illness (early 20’s).

• Multiple past episodes and psychiatric hospitalizations.

• Seasonal mood episodes.

• Switching into mania or hypomania on antidepressants.

• Depressive episodes characterized by increased sleep, increased appetite, and weight gain.

• Depressive episodes mixed with hypomanic or manic symptoms.

• Depressive episodes with psychotic symptoms such as delusions or hallucinations.

If you notice one or more of the above features, complete the Mood Disorder Questionnaire (MDQ), which is available on the Depression and Bipolar Support Alliance website (http://www.dbsalliance.org). The MDQ can correctly identify almost 75% of people with bipolar disorder and also correctly screen out 90% of people who don’t have bipolar disorder (Hirschfeld et al., 2000). Consult your mental health or primary care provider for a more comprehensive assessment if you screen positive for bipolar disorder on the MDQ.

Depression with mixed features: Sometimes people with depression may experience some manic/hypomanic symptoms, but never a clinical manic or hypomanic episode. In such cases, the most likely diagnosis is major depressive disorder with mixed features (American Psychiatric Association, 2013). Recognizing mixed symptoms in context of depression is important as they are a risk factor for future bipolar disorder and make depression less responsive to antidepressants (Hu et al., 2014).

Atypical depression: The word atypical means that the symptoms of depression are different from the usual presentation of depression. The mood in people with atypical depression brightens in response to a happy event in contrast to melancholic depression (the traditional concept of depression) where the mood remains sad despite such events. In addition, atypical depression may manifest with increased appetite, weight gain, oversleeping, sensation of heaviness in arms and legs, and a heightened sensitivity to rejection in social situations (American Psychiatric Association, 2013). Seasonal depression or winter depression may also have some atypical symptoms of depression. Bupropion (Wellbutrin), one of the more activating antidepressants, is widely used in depression with atypical features (Thase, 2009).

Seasonal or winter depression: This is discussed in detail in the chapter on Bright Light Therapy for Depression (Chapter 18).

Depression with psychotic features: This is a more serious kind of depression wherein a person may experience delusions or hallucinations. Delusions are fixed false beliefs; these may be related to depressive themes of guilt or be unrelated such as paranoid thoughts. Antipsychotic medications along with antidepressants are needed in this condition.

Peripartum and postpartum depression: Depression occurring during the pregnancy is peripartum depression and that occurring within four weeks after delivery is postpartum depression. In contrast to postpartum depression, postpartum blues are more common; they last from 7 to 10 days, and usually require no treatment. However, depression during pregnancy or after delivery with psychotic symptoms requires urgent attention.

Other varieties of depression: Sometimes individuals with depressive symptoms may not either have all the symptoms required for diagnosis of depression or if the symptoms are present, they don’t last up to at least two weeks. These conditions are subsumed under the category of other specified depressive disorder in the DSM-5.

CONDITIONS THAT MIMIC DEPRESSION

Sadness: Depression is more than the normal pangs of sadness one gets when experiencing a stressful situation. Depression is a more pervasive and persistent change in your mood along with changes in your physiological functions such as sleep, appetite, and energy level. Although stress can trigger a depressive episode, not everyone faced with stress becomes depressed. And, sometimes depression can occur without any specific triggers and may not respond to changes in environment (the so-called endogenous depression), which differentiates it from sadness. Moreover, while sadness can disrupt your day-to-day functioning, the effect of depression is more significant, though some researchers believe that this criterion is not clinically meaningful to distinguish sadness from depression (Wakefield et al., 2010). In contrast to sadness, depression is associated with a pattern of negative or distorted thinking which perpetuates the symptoms (Burns, 1999).

Bereavement: Bereavement and depression have a complex relationship. The Diagnostic and Statistical Manual of Mental Disorders – fourth edition, text revision (DSM-IV TR) excluded depressive symptoms occurring up to a couple of months after a loss as being a sign of a major depressive episode (American Psychiatric Association, 2000). However, depression arising after a loss of a loved one is no different compared to that arising due to a job loss or recent divorce or out of the blue (Pies, 2014). Moreover, not diagnosing depression during grief can potentially divest such people from getting timely help; professionals may defer treatment until symptoms persist or become more severe. In tandem with these observations, the DSM-5 doesn’t consider bereavement as an exclusion for diagnosing depression.

Certain symptoms may help one distinguish when bereavement may have transformed into depression (American Psychiatric Association, 2013). These include persistently sad mood that doesn’t improve with changes in environment, lack of pleasure, feelings of worthlessness, pessimistic or self-critical ruminations, and suicidal thoughts related to negative feelings about self.

Complicated grief: Another condition called complicated grief or as the DSM-5 calls it, the persistent complex bereavement disorder, also mimics depression. In short, this is characterized by preoccupation with the deceased or the circumstances related to death, feelings of disbelief or numbness, excessive avoidance of reminders of the loss, a desire to die in order to be with the deceased, social withdrawal, and persistence of other intense and impairing symptoms of acute grief beyond the socially and culturally accepted norms (American Psychiatric Association, 2013; Shear, 2015). Complicated grief differs from depression as it an extension of the normal grieving process and usually lasts more than a year while depression is a clinically diagnosable entity. Approximately, 7% of grieving individuals develop complicated grief. Women and those with preexisting mental illness, substance use, trauma history, limited social support, and multiple recent losses are more at risk of complicated grief (Simon, 2013). Screening tools such as the Inventory of Complicated Grief can help people with prolonged grief arrive at a proper diagnosis (Prigerson et al., 1995). Although, antidepressants have been used to treat complicated grief, it is best treated with focused psychotherapy.

Adjustment disorder with depressed mood: Stressors – breakups, job loss, marital conflict, natural disasters, or life changes such as school, illness, marriage, divorce, retirement, etc. – can cause a heightened emotional or behavioral reaction in some people. If you experience low mood, tearfulness or feelings of hopelessness within three months of a stressful situation and these symptoms subside after the stressor is over, the diagnosis is more likely to be adjustment disorder with depressed mood (American Psychiatric Association, 2013). Compared to depression, adjustment disorder always has a clear precipitating event, is time limited, and never meets the full criteria for depression. Psychotherapy is the mainstay of treatment for adjustment disorder with depressed mood.

Premenstrual syndrome and premenstrual dysphoric disorder: Premenstrual symptoms, starting a week before the onset of menstrual cycle, range from mild physical or behavioral symptoms in premenstrual syndrome to marked mood changes – irritability, crying spells, depression, and anxiety – in premenstrual dysphoric disorder. The latter is also characterized by changes in sleep, appetite, lack of interest, difficulty concentrating, increased sensitivity to rejection, and physical symptoms such as feeling of bloating, breast tenderness or swelling, or joint/muscle pain. The symptoms in premenstrual dysphoric disorder are severe enough to interfere with normal functioning. However, unlike depression, the symptoms subside after the onset of menses and don’t represent an amplification of pre-existing depressive symptoms (American Psychiatric Association, 2013).

RISK FACTORS FOR DEPRESSION

The exact cause of what causes depression – genes, environment, or personality – is unclear; depression is best conceptualized in terms of risk factors. Depression does run in families and first-degree relatives of people with depression have two to three times greater risk of developing depression (Sullivan et al., 2000). Women are at greater risk of getting familial depression and depression which is severe, recurrent, and has an early onset lends itself to greater inheritability (Flint & Kendler, 2014). Interestingly, having a strong family history of depression not only increases risk of one’s chance of depression, but may also increase ones’ sensitivity to environmental stressors, thus increasing the vulnerability for depression (Caspi et al., 2003). Therefore, if you have a family history of depression in either your parents, siblings, or children, then you may have an increased risk of developing depression in the face of stressful events. While stressful events cannot be predicted, being aware of this genetic susceptibility may prepare you for these adversities.

Besides family history, other factors that increase the risk of depression are stressful events, certain chronic medical conditions, having temperamental traits like low self-esteem, and a negative view of the world (Yeung et al., 2010). Notably, people in mid-life may be more vulnerable to develop depression when faced with a life event (Stegenga et al., 2012a).

PROGNOSIS IN DEPRESSION

Good prognostic indicators in depression include the following (American Psychiatric Association, 2013; Sadock et al., 2015):

• Mild symptoms.

• Absence of psychotic symptoms.

• Absence of other psychiatric conditions such as anxiety disorder.

• Absence of co-occurring personality disorder.

• Absence of chronic medical conditions.

• Stable family functioning.

• History of solid friendships during adolescence.

• No more than one previous hospitalization for depression.

• Advance age of onset.

• Absence of alcohol or other substance use.

You may not be able to change some of the prognostic factors like age of onset of illness or having co-occurring psychiatric conditions. However, having stable social support and staying away from alcohol and other substances can improve the course of depression.

SUICIDE AND DEPRESSION

Around 15% of individuals with depression attempt suicide at least once and the lifetime risk of death by suicide in depression is 6% (Bentley et al., 2014). According to the American Psychiatric Association, risk factors for suicide in depression include previous history of suicide attempts or threats, male gender, being single or living alone, having marked feelings of hopelessness, and presence of borderline personality disorder. Centers for Disease Control and Prevention (CDC) lists suicide as the tenth leading cause of death in the United States with firearms, suffocation, and poisoning being the three most common ways of committing suicide.

SOME MYTHS AND FACTS ABOUT DEPRESSION

Myth: Depression is a character flaw and is a sign of weakness.

Fact: Depression has nothing to do with strength of one’s character. It happens due to a complex interplay of biological and environmental risk factors and is a treatable condition like any other physical illness. With all the attached stigma, seeking help for depression is a sign of courage and not weakness.

Myth: Depression is just having the blues.

Fact: As mentioned earlier, depression is more just feeling sad or down in the dumps. The sadness is more persistent and pervades your day-to-day life and it, along with other symptoms of depression, makes it harder for you to function at your normal levels.

Myth: You can just snap out of depression.

Fact: Telling people with depression to just snap out of it never helps as depression, like other physical illnesses, takes time to heal. While treated episodes of depression lasts about three months, untreated depression may last from 6 to 13 months (Sadock et al., 2015).

Myth: Depression affects only women.

Fact: Although women are 1.5 to 3 times more likely to get depressed compared to men, men are not immune from it. According to the National Institute of Mental Health (NIMH), men may experience depression differently than women. While feelings of sadness, worthlessness, and excessive guilt are more common in women, men usually show signs and symptoms of extreme tiredness, irritability, lack of interest in once-pleasurable activities, and difficulty sleeping. In addition, men with depression are more prone for alcohol or drug use. Men may also avoid talking about their depression with relatives or friends and may turn to work as an escape, but ultimately becoming more frustrated, discouraged, and angry. Although suicide attempts are more common in women, more men than women actually die due to this reason in the United States.

Myth: Depression only affects adults.

Fact: Depression does affect children and teenagers. The National Comorbidity Study found that 11.7% of the 10,123 surveyed adolescents aged 13-18 met diagnosis of either major depression or dysthymia (Merikangas et al., 2010). Of note, the rate of depressive disorders doubled in the 17-18 year age group compared to 13-14 age group. In contrast to adults, children and adolescents, when depressed, may experience irritability rather than sadness. While not all teenagers who are moody should be investigated for depression, but if the mood symptoms are persistent and exist with other symptoms suggestive of depression, then it may prudent to rule out depression.

Myth: If you have depression in your family, you will also develop depression.

Fact: Depression, like diabetes and high blood pressure, is a heritable illness. However, genes alone account for about 37% of causality in depression and the rest is non-genetic, including environmental and physical factors (Flint & Kendler, 2014).

Myth: Depression is only for losers or those who feel sorry for themselves.

Fact: Depression is an equal opportunity illness and cuts across nationalities, education level, social status, occupation, race, and culture. Celebrities, politicians, scientists, artists, and other professionals who have been successful in their respective fields have dealt with depression.

Myth: Depression is a life-long illness.

Fact: Most individuals with depression do eventually improve. Recovery begins within three months for about 40% of people with depression and within one year for about 80% (Bentley et al., 2014). In one study, only 17% of people with depression had symptoms of depression when followed up at 39 months (Stegenga et al., 2012b). While majority improve, some also tend to get recurrent episodes of depression.

Myth: Depression can be diagnosed by a medical test.

Fact: Unfortunately, there is no medical test to diagnose depression like there are for diabetes or other medical conditions. Whereas you can try to self-diagnose depression using some internet-based rating scales, a formal diagnosis should best be left to a professional. This is important because a professional can rule out other psychological or medical conditions that can mimic depression.

Myth: Depression only responds to medications.

Fact: Over the last few decades, the trend in print media has been to present depression as a bio-medical disorder rather than an entity caused by a variety of reasons (Clarke & Gawley, 2009). This in turn has perpetuated a belief that the antidepressants may be the only effective way of treating depression. While antidepressants alone may be more effective in more severe forms of depression, both cognitive-behavioral therapy and interpersonal psychotherapy are effective by themselves in mild or moderate depression (American Psychiatric Association, 2010). In addition, mindfulness-based cognitive therapy helps prevent future episodes of depression in people with multiple depressive episodes (Kuyken et al., 2012). A caveat when choosing therapy as a treatment modality for depression is to seek an expert trained in depression-focused therapy as there a lot of other therapies that are not helpful for depression.

CHAPTER 2

SELF-ASSESSMENT OF DEPRESSION

WHY SELF-ASSESSMENT IS IMPORTANT?

Unlike other fields of medicine where illnesses can be diagnosed using laboratory tests or imaging techniques, psychiatry heavily relies on an individual’s account of their current and past symptoms. This is also true for depression. Recounting one’s depressive symptoms without using an objective self-assessment tool is fraught with inaccuracies. People overemphasize symptoms that need urgent attention and miss some, especially if they are ignorant about the full spectrum of depressive symptoms. In this realm, self-assessment tools offer the following advantages:

• Self-assessment tools provide you with an objective measure on whether or not you have depression.

• Once diagnosed with depression, periodic self-assessments help you monitor your progress with treatment and change course if needed.

• Sharing information from the self-assessment tools with your provider ensures that you don’t forget to report any important symptoms.

• Repeated self-assessments broaden your understanding of depression and help you recognize early symptoms in case of a relapse or recurrence.

• Self-assessments, if tracked along with interventions, will help you figure out the kind of interventions that have worked for particular symptoms and to put them to use if these symptoms return.

WHAT ARE THE AVAILABLE TOOLS FOR SELF-ASSESSMENT?

The following self-assessment tools can be downloaded for no charge from the internet:

Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16): This is a 16-item self-rating scale used for screening depression or assessing its severity (Lamoureux et al., 2010; Rush et al., 2003). The scale comprises of domains of depression as covered in DSM-IV and has been validated for use in trials on depression. QIDS-SR16, along with its scoring instruction, is available online (www.ids-qids.org/).The total score ranges from 0-27 and if you score above 13 or 14, the chances of you being correctly identified as having depression is above 80% (Lamoureux et al., 2010). If you have been diagnosed with depression, then you can assess the severity of depression using the following guidelines: 0-5 (no depression), 6-10 (mild depression), 11-15 (moderate depression), 16-20 (severe depression), and ≥21 (very severe depression).

The Center for Epidemiological Studies Depression Scale (CES-D): This is a 20-item self-rating scale, which has been used for screening depression in the general population (Radloff, 1977). The scale can be accessed online (http://www.chcr.brown.edu/pcoc/cesdscale.pdf). The total score ranges from 0-60 and a score of >21 correlates with a high possibility of having depression (Yeung et al., 2010).

The Patient Health Questionniare-9 (PHQ-9): The PHQ-9 is a self-reporting scale, which is extensively used in primary care and other medical settings for screening depression. It has nine items which parallel the DSM-IV criteria for major depressive disorder with a total score ranging from 0-27 (Kroenke al., 2001). A copy of the scale can be downloaded from a website (http://www.phqscreeners.com/). On this scale, the cut-off scores of 5, 10, and 15 represent mild, moderate, and severe depressive symptoms, respectively (Kroenke et al., 2010). If you score 10 or higher on PHQ-9, then you have an above 82% chance of being correctly identified as having clinical depression (Haddad et al., 2013).

If you screen above the cut-off score for depression in one of the above rating scales, it is prudent to consult your primary care provider. They will either assess you in depth for depression or refer you to a mental health provider to do the same. Once diagnosed with depression, you can use these self-assessment tools to monitor the progress of your symptoms and also the impact of treatment as described next.

MONITOR YOUR DEPRESSION USING THE 5 RS

You can track the course of your depression using the 5 Rs, which are defined as below (Frank et al., 1991; Riso et al., 1997).

Response: Response is defined as a significant level of improvement in depression following a treatment. This improvement is big enough to separate an individual who is a responder from a non-responder. The concept of response is applied to first 4-8 weeks of starting a new treatment for depression. Typically, in studies of depression, response denotes a 50% reduction in depression scores in one of the rating scales for depression. For example, if your initial score on PHQ-9 was 22 and it dropped to 11 after six weeks of starting an intervention, then you will be considered as having a positive response to treatment.

Remission: Remission is defined as clinical improvement, which is greater than response with few signs of depression still remaining and a lower likelihood of subsequent exacerbations. Remission can be partial if an individual still has more than minimal symptoms of depression, but not enough to meet the clinical criteria for depression. On the other hand, in full remission, an individual has no more than minimal symptoms of depression. For example, if your score on the PHQ-9 drops to 5 or less than 5 and is sustained at that level for at least a few weeks, then your depression is in full remission.

Relapse: Relapse is defined as re-emergence of depressive symptoms after response to treatment, but before reaching recovery. For example, if your PHQ-9 score initially decreased from 16 to 4 after starting a treatment, but again rose to 16 and stayed the same for at least two weeks, then your depression has relapsed.

Recovery: Recovery means achieving full remission for at least six months. In terms of self-assessment, it would be having a score below the cut-off for depression on one of the rating scales for at least 6 months. But recovery is more than just a number. It signifies an individual’s return to their previous healthy level of functioning accompanied with a general sense of well-being. People in recovery may not be entirely free from depressive symptoms. They may still have good and bad days, but their sense of optimism and hope helps them have a sustained recovery, especially if they are using the tools to self-manage depression.

Recurrence: Recurrence is return of depressive symptoms, which meet criteria for a new episode of depression after at least six months of recovery. A score higher than the cut-off for depression on one of the self-assessment tools signals a recurrence.

The 5Rs have long been used in clinical research in depression, but seldom used as a self-management tool by people with depression. Knowing these definitions empowers you to track the course of your depression by using the self-assessment tools described before. It also prepares you to have a meaningful dialogue with your healthcare provider, which ensures that you get optimal and effective treatment. The gold standard for treating depression doesn’t stop at response, but is full remission leading to recovery. Failure to achieve full remission is associated with higher risk of relapse of depressive symptoms, increased functional impairment, and a greater burden of other medical and psychiatric conditions (McIntyre & O’Donovan, 2004). Make full remission leading to recovery your goal in your journey of overcoming depression.

CHAPTER 3

SELF-MANAGEMENT AND DEPRESSION

WHAT IS SELF-MANAGEMENT?

You probably have heard the term self-help and may have also read a few books on self-help. Most self-help books on depression focus on acute treatment of depression based on a particular model of therapy, usually the Cognitive-Behavioral Therapy (CBT). While the self-help approach tries to address a condition using a focused treatment modality over a short period of time, self-management is learning new ways to manage an illness over a longer period of time. In other words, self-management is using the resources and learning the skills to positively manage an illness (Lorig et al., 2006). Lorig and colleagues (2006) further elaborate on self-management; it is a management style wherein you are a positive self-manager who not only uses the best treatments provided by healthcare professionals, but also approach your illness in a proactive manner on a daily basis, leading to a more healthy life. For example, good self-managers of diabetes, besides taking medications, educate themselves about diabetes, learn to recognize symptoms of low or high blood sugar, monitor their blood sugar levels regularly, eat healthy and avoid foods that may destabilize their diabetes, exercise to maintain their weight, and seek professional help if their blood sugar levels are staying above or below their normal range. The same strategies can be used to self-mange depression and this book will guide you through this. The key components of self-management include the following (Barlow et al., 2002):

1. Information:

• Educating self and family members/friends about depression.

2. Medication management:

• Taking medications as recommended by your provider.

• Overcoming barriers to adherence to medications.

3. Symptom management:

• Using various strategies (e.g., cognitive, behavioral, mindfulness, etc.) to manage symptoms of depression.

• Self-monitoring of symptoms.

• Managing concurrent symptoms of anxiety and/or substance use.

• Using techniques to deal with frustration, fatigue, pain, and isolation.

• Managing sleep.

• Managing symptoms of medical conditions that may be associated with depression.

• Relaxation.

• Using strategies for preventing relapse of depressive symptoms.

4. Life style:

• Exercise.

• Overcoming barriers to exercise adherence.

• Holidays.

• Leisure activities.

• Nutrition and diet.

5. Social support:

• Family support.

• Relationships with peers and friends.

6. Communication:

• Assertiveness.

• Communication strategies (e.g., with mental health professionals).

7. Other:

• Accessing support services.

• Creating action plans.

• Decision making.

• Goal setting.

• Problem solving.

• Career planning.

• Spirituality.

EMPOWER YOURSELF WITH SELF-MANAGEMENT

Healthcare is moving toward a model of client-centered care. In this model, clients are partners in decisions related to their healthcare and collaborate with their healthcare providers to prioritize and set goals and choose interventions for their illness. In this context, self-management strategies prepare you to be an active player in your own treatment rather than being a passive recipient. With self-management, you assume the primary responsibility of your treatment, though with support from your provider and your social network. A growing body of evidence shows that compared to no-intervention (i.e., standard care), self-management approaches can provide benefit to you in terms of knowledge, performance of self-management behaviors, self-efficacy (defined below), and health status (Barlow et al., 2002). Research demonstrates that individuals with chronic medical conditions with higher depression scores show a decrease in depression after participating in chronic disease self-management programs (Ritter et al., 2014).

Self-management techniques in this book will enhance your confidence and give you a sense of control in dealing with depression. Depression can make you doubt your capability for dealing with stress or sometimes even mundane day-to-day stuff. Learning self-management skills is an antidote to these negative feelings and enhances your self-efficacy. Self-efficacy is your belief that you are capable of making changes to your