Undoing Depression

Also by Richard O'Connor, PhD

Happy At Last: The Thinking Person's Guide to Finding Joy

Undoing Perpetual Stress: The Missing Connection
Between Depression, Anxiety, and 21st-Century Illness

Active Treatment of Depression

Preface to the Second Edition

AS I WRITE in 2009, I find myself alternately pleased and dismayed to find that so much of Undoing Depression remains quite relevant eleven years after it was first written. Pleased that I can pat myself on the back for giving useful advice that has stood the test of time; dismayed because there has been so little progress in achieving deeper understanding or developing more effective treatment for this devastating condition. Indeed, it seems sometimes that progress has only been backward. Medications are now understood to be considerably less effective than we'd hoped for. The assumption that depression is caused by a deficiency in serotonin in the brain has proved false. And depression keeps growing in epidemic proportions. The World Bank and World Health Organization estimate that depression soon will be the single most costly disease there is — more costly than AIDS, cancer, or TB.

Yet there is hopeful news for this new edition. Previously, I was out on a scientific limb in arguing that the "skills of depression" — the habits that make it so hard for us to recover — are essentially neural pathways that can be replaced by more effective ways of living. Now the new neuroscience has confirmed that is indeed what happens in the brain; old pathways wither when we stop our habits, to be replaced by new connections that are learned through changes in our behavior. We can change our own brains through focused attention and practice. At the same time, new developments in psychology and behavioral medicine have given us much more specific, proven methods to help us escape the habits of depression and learn new ways out of our misery. Thus it's even more imperative that people with depression be encouraged and enabled to take effective action for themselves — which is the goal of this book.

Introduction

THE ESSENTIAL QUESTION that patients and therapists ask themselves over and over is: why is it so hard to get better? Once we understand the hidden meanings and motives behind our behavior, and see how we keep repeating behaviors that prevent us from feeling good about ourselves and getting to where we want in life, why don't we just stop? Once we have the right medication to prevent us from sinking back into the blackest depths, once we can start feeling a little more optimistic about the future and ourselves, why do we remain shy, passive, and withdrawn? Why do people persist in self-destructive behavior when they can see that it does them no good? Freud had to invent theories as elaborate and arcane as the death instinct to answer this question — the idea that as a counterpart to a desire to create, enjoy, and live we have an equally strong desire to destroy, suffer, and die. All my experience tells me that there is a much simpler answer. People persist in self-destructive behavior because they don't know how to do anything else; in fact, all these depressed behavior patterns become written into the brain itself. How do we undo that?

I'm convinced that the major reason why people with depression stay depressed despite therapy, medication, and support from loved ones is that we are simply unable to imagine an alternative. We know how to "do" depression. We are experts at it. Our feelings about ourselves and the way we see the world have forced us over the years to develop a very special set of skills. We become like those who are blind from birth. They become very attuned to sounds, smells, and other senses that sighted persons take for granted. They can read Braille as well as anyone else can read printed matter. They get very good at memorization. But asking them to imagine a sunset, or a flower, or a Van Gogh is pointless — they have no reference; it's beyond their experience. Expecting us to stop being depressed is like expecting a blind person to suddenly see the light of day, with one important difference: eventually, we can do it. There are also unconscious forces at work, primarily fear, that oppose change. We develop defense mechanisms that distort reality so that we can put up with being depressed, or sustain the unconscious belief that we don't deserve to feel better. People learn and grow through experience, but the depressed person, out of fear, avoids the curative experience. I think that by practicing, by taking big challenges in small steps, by learning gradually that fears can't kill you and impulses don't overwhelm you, the depressed person learns alternatives to depressed behavior, and enough nondepressed behavior means you're not depressed anymore.

Depression becomes for us a set of habits, behaviors, thought processes, assumptions, and feelings that seems very much like our core self; you can't give those up without something to replace them and without expecting some anxiety along the way. Recovery from depression is like recovery from heart disease or alcoholism. The good heart patient knows that medication isn't enough; lifelong habits of diet and exercise, how one deals with stress, must change. The recovering alcoholic knows that abstinence is not enough; ways of thinking, relating to others, and dealing with emotions have to change. We depressives become shaped by our disease as well; the skills that we develop with depression in a vain effort to save ourselves pain — skills like swallowing our anger, isolating ourselves, putting others first, being overresponsible — prevent our recovery. We have to give up the depressed habits that keep us down and make us vulnerable to relapse.

In the ten-plus years since the first edition of this book came out, there have been some startling developments in what we know about depression, thanks to the new technology that allows scientists to see into the brain as it's working. First the bad news: Depression causes brain damage. Then the good news: We can undo that damage with focused practice and attention. In fact, we may be able to move beyond what was normal for us and feel better than we ever have. Science knows now that our brain does not simply store our experiences. Each experience changes the brain, structurally, electrically, chemically. The brain becomes the experience. If we are careful about the experiences we give our brains, we can change the brain itself.

One thing we can take away from all the new brain science: Practice is essential to change. We can spend years in therapy so that we have a pretty good understanding of what led us to this dark place, but if we don't get out of bed in the morning, we're still going to feel depressed. Medications, when they work, do so partly by giving us enough energy to get out of bed. But it's practice that leads to change in the brain. Practice in anything new develops networks between brain cells that previously weren't connected to each other. The networks in your brain that support depressed behavior are so well-used, they're like the interstate highway system. You have to get off the highway and explore some new paths, but with enough practice, going down these new roads becomes automatic to you as new connections develop in your brain.

Overcoming depression requires a new set of skills from us. But now we are recognizing that happiness is a skill, willpower is a skill, health is a skill, successful relationships require skills, emotional intelligence is a skill. We know this because practice not only leads to improvement but also to changes in the brain. This is a much more empowering and adaptive way of understanding life than assuming that these qualities are doled out from birth in fixed quantities and that there's nothing we can do to change our fate. The skills required to undo depression will permeate your entire life, and if you keep practicing, you can go far beyond mere recovery.

My goal is to present a "program" for depression. People in AA know from experience that not drinking is not enough; they have to "live the program." Like alcoholism, depression is a lifelong condition that can be cured only by a deliberate effort to change our selves. Later chapters explain how in key elements of our personality — feelings, thoughts, behavior, relationships, how we treat our bodies, and how we handle stress — depression has taught us certain habits that have come to feel natural, a part of who we are. But we don't realize that those habits just reinforce depression. We have to unlearn those habits and replace them with new skills — which I'll explain in detail — for real recovery to take place. Practicing the exercises described later can be a way for people with depression to "live the program" — and live a vital, rich existence again.

I believe very strongly that people can recover from depression but that medication and conventional psychotherapy don't go far enough — and now the research bears me out. The terrible irony of depression is that we come to blame ourselves for our own illness; I hope to show that this belief is a symptom of the disease, not a matter of fact. People need new tools, and practice in using them, in order to make a full recovery. In putting these techniques together, I've had the benefit of being able to draw on a great deal of research and clinical experience developed over the last thirty years, which have suggested new ways of thinking, acting, relating, and feeling to replace the old ways of being that have never worked and often made things worse. I've also had the benefit of working in clinics in the real world to help me understand how these methods can be applied in everyday life. Further, my own experience with depression and recovery has helped me learn firsthand what's helpful and what's not.

When I was fifteen I came home from school one day to find that my mother had committed suicide in the basement. She had bolted the doors and taped a note to the window saying she was out shopping and I should wait at a neighbor's. I knew something was wrong and was climbing in a window when my father came driving in after work. We discovered her body together.

She had put a plastic bag over her head and sat down at the table where I played with my chemistry set. She ran the gas line from my Bunsen burner into the plastic bag and turned on the gas. Later we learned that she had also taken a lethal dose of a sleeping pill that my father sold in his job as a pharmaceutical representative. Her body was cold, so she must have started to set things up soon after we had left the house in the morning. This was no cry for help; she went to a great deal of trouble to make sure she would end her life.

Until two years before, my mother had seemed happy, confident, and outgoing. I remember her joy getting ready to go out to a party, or singing forties songs with my father on evening car rides. When I look back at the course of my life, I realize now how much it has been shaped by my need to understand what happened to her.

To understand also what was happening to me, because I've had my own depression to contend with. I didn't recognize it for a long time, though I'm a reasonably well-trained and experienced psychotherapist. I've been a patient myself several times, but I never put a label on my problems; I always told myself I sought help for personal growth. This was despite the fact that there were long periods in my life when I drank too much, when I alienated everyone close to me, when I could just barely get to work, when I would wake up each morning hating the thought of facing the day and my life. There were many times I thought of suicide, but if I couldn't forgive my mother, I couldn't forgive myself, either. And I have children and family, patients, and colleagues I couldn't bear to do that to. But for many long periods life seemed so miserable, hopeless, and joyless that I wished for a way out. Everyone who has ever been depressed knows it's impossible to be sure, but I think those days are finally behind me now. I don't hit the deepest depths, but I live with the aftereffects. I still struggle with the emotional habits of depression. But accepting the fact that it's going to be a long struggle has made me more able to deal with the short-term ups and downs. And I see progress.

I've worked in mental health for thirty years, as a therapist, supervisor, and agency director. I've studied psychoanalytic, family systems, biochemical, cognitive, mindfulness-based, you name it, ways of understanding people. I've worked with some wonderful teachers and had some wonderful patients. I won't pretend to have all the answers on depression, but you won't find many people with more experience, both personal and professional.

I believe now that depression can never be fully grasped by mental health professionals who have not experienced it. I've repeatedly seen "comprehensive" theories of depression develop, flourish, and dominate the field for a time, only to be rejected because new, contradictory evidence is found. Many psychologists and psychiatrists seem to prefer theory-building — making their observations fit with some preexisting theory or developing a new theory that will explain it all — rather than trying to figure out practical ways to help their patients. They get too far away from experience. I realize now that no simple, single-factor theory of depression will ever work. Depression is partly in our genes, partly in our childhood experience, partly in our way of thinking, partly in our brains, partly in our ways of handling emotions. It affects our whole being.

Imagine if our medical knowledge was such that we could reliably diagnose heart disease but knew nothing about the effects of exercise, cholesterol, salt and fat, stress, and fatigue. Patients who were diagnosed would be grasping at all kinds of straws that might help them recover. Some would stop all exercise, some would exercise furiously. Some would withdraw from stressful situations. Some would take medication to reduce blood pressure without knowing that their unhealthy diet undoes any beneficial effect of medication. Many would die prematurely; some would get better accidentally; without good, controlled scientific studies, doctors would not learn what was causing some to die, some to recover.

This is where we are with depression. We get all kinds of advice, some of it helpful, some of it not, most of it unproven. Some of it simply designed to sell a product. The depressed patient is in the dark about what exactly he or she needs to do to help recovery. But in fact a great deal is known about how people recover from depression. It doesn't all fit into a neat theoretical package, so it's hard to pull together, but the knowledge is there to be used.

Depression is a complex condition that blurs our Western boundaries between mind and body, nature and nurture, self and others. Many people with depression seem to have been primed for it by trauma, deprivation, or loss in childhood. Most people with depression describe difficulties in their childhood or later in life that have contributed to low self-esteem and a sensitivity to rejection, an uncertainty about the self and an inability to enjoy life. But these observations are not true for everyone with depression: some people who have no history of stress, who appear very stable and well integrated, develop it suddenly, unexpectedly, in response to a life change. There is clearly a biochemical component to depression, and medication can be helpful for many people, but medication alone is not sufficient treatment for most. The truth is that whether the roots of depression are in the past in childhood, or in the present in the brain, recovery can only come about through a continuous act of will, a self-discipline applied to emotions, behavior, and relationships in the here and now. This is a hard truth, because no one deserves to feel this way, and it doesn't seem fair that the blameless have to work so hard to help themselves. Besides, the depressed are always being told to snap out of it, pull yourself together, don't give in to weakness, and it's the cruelest, most unfeeling advice they can be given. What I want to do here is to give guidance and support, along with advice, to help the depressive find the resources he or she needs for recovery.

People who are depressed are in over their heads and don't know how to swim. They work very hard at living, at trying to solve their problems, but their efforts are futile because they lack the skills necessary to support themselves in deep water. The real battle of depression is between parts of the self. Depressed people are pulled under by shadows, ghosts, pieces of themselves that they can't integrate and can't let go. The harder they work, the more they do what they know how to do, the worse things get. When their loved ones try to help in the usual ways, the commonsense ways that only seem natural expressions of caring and concern, they get rejected. The depressed person then feels more guilty and out of control.

People with depression have to learn new ways of living with themselves and others — new emotional skills. These skills take practice, coordination, and flexibility. Instead of flailing at the water in panic, they have to learn emotional habits that are much more like swimming: smooth, rhythmic, learning to float, learning to be comfortable in the water. Depressed people are great strugglers, but to struggle is to drown. Better to learn how to let the water hold you up.

Obviously this is an intensely personal book for me. I want to keep would-be suicides alive, I want to spare people the useless pain of depression. There is a great deal more that can be done now than was available for my mother or for myself when I was younger. Psychotherapy and medication offer hope to everyone. Learning techniques of self-control, skills of communication and self-expression, and challenging one's assumptions about the self and the world, can give people who literally don't know anything other than depression the chance for a rewarding life.

Something that touched me deeply when I worked at our community mental health clinic was the great number of people who didn't know they were depressed. People are usually prompted to call for help not because they simply feel rotten, but because something is going wrong in their lives: their children won't listen, there is a marital problem, they are having trouble at work. But it often doesn't take much digging to find that the caller has been depressed for some time; the family conflict, the job problem, is a manifestation, not a cause, of the depression. If we had been able to help them sooner, their lives wouldn't be the train wrecks they are now. These are people who now feel almost no joy in life, who have no hope, no ambition, who feel stuck, powerless, and perennially sad — and who think this is the normal way to feel. It's not.

Part 1

What We Know About Depression

1

Understanding Depression

WE ARE LIVING in an epidemic of depression. Every indication suggests that more people are depressed, more of the time, more severely, and starting earlier in their lives, than ever before. Depression is not going to go away no matter how much we ignore it, scorn it, or neglect it. We need to attend to it as a major public health problem. But that's difficult to do because the idea of depression frightens us all — we think of a descent into madness — and thus we avoid the subject. We have a natural wish to forget about depression, to hope that we are immune. Can you make yourself remember the sensation of pain? Most people react to the question with a cringe but really can't describe pain or evoke the sensation in their memory. We repress it, push it away, so that most of the time we don't think about it and we can get on with life. But when we hear the dentist's drill, we suddenly remember exactly what it's going to feel like. We do the same mental trick with depression. We've all felt it, but we believe we have to shut out the memory. We want to think of depression as something that happens to somebody else.

But it strikes closer to home now, because the incidence is increasing. For each generation born since 1900, the age of onset of depression is younger and younger, and the lifetime risk has increased.¹ According to the most official, conservative estimates, approximately 6.7 percent of Americans will experience an episode of major depression in their lifetimes.² When you add in the so-called milder forms of depression, I believe the rate goes up well past 25 percent. Every fourth person you meet is likely to have a serious encounter with depression at some point in their lives. And every fifth person is depressed right now: researchers estimate that almost 20 percent of the population meet the criteria for some form of depression at any given time — and that does not mean people who are temporarily feeling the blues and will be better next week, but people who are having real difficulty functioning in life.³

This epidemic is not merely a result of growing awareness of depression, but a true growth in hard numbers.⁴ Nor is it only a phenomenon of American, or even Western, culture. A recent study comparing incidence of depression in Taiwan, Puerto Rico, and Lebanon, among other countries, found that for each successive generation, depression was likely to begin at earlier ages, and that over the course of a lifetime, the risk of depression kept increasing.⁵ Of all people with major depression, 15 percent will end their lives by suicide.

Clinical depression is a serious, often fatal illness that is so common it's hard to recognize. But health economists consider it just as disabling as blindness or paraplegia.⁶ In terms of overall economic burden to our society, depression is the second most costly disease there is. This surprising news comes from the World Bank and World Health Organization, which measured the lost years of healthy life due to disease.⁷ The cost, in terms of direct treatment, unnecessary medical care, lost productivity, and shortened life span, was estimated at $83 billion dollars a year in the United States alone for the year 2000.⁸ Depression is second only to cancer in terms of economic impact, and approximately the same as the cost of heart disease and AIDS. The number of deaths from suicide in the United States each year (33,000) is approximately twice the number of deaths from AIDS,⁹ and shows no sign of declining. And the impact will only get worse: if current trends continue, children today will develop depression at the average age of twenty, instead of the thirty-plus we are used to.¹⁰ Yet only a third of people with long-term depression have ever been tried on antidepressants, and only a small number of them have ever had adequate treatment.¹¹

If this is all true, if depression is as dangerous and prevalent as I'm saying, you may well ask: Where's the big national foundation leading the battle against depression? Where's the Jerry Lewis Telethon and the Annual Run for Depression? Little black ribbons for everyone to wear?^* The obvious answer is the stigma associated with the disease. Too much of the public still views depression as a weakness or character flaw, and thinks we should pull ourselves up by our own bootstraps. And all the hype about new antidepressant medications has only made things worse by suggesting that recovery is simply a matter of taking a pill. Too many people with depression take the same attitude; we are ashamed of and embarrassed by having depression. This is the cruelest part of the disease: we blame ourselves for being weak or lacking character instead of accepting that we have an illness, instead of realizing that our self-blame is a symptom of the disease. And feeling that way, we don't step forward and challenge unthinking people who reinforce those negative stereotypes. So we stay hidden away, feeling miserable and blaming ourselves for our own misery.

This is a dirty little secret of mental health economics: if you're depressed, you don't think you're worth the cost of treatment. You feel guilty enough about being unproductive and unreliable; most likely your family members have been telling you to snap out of it, and you believe you should. You're not likely to shell out a hundred dollars an hour to see a therapist, and if your insurance won't pay, you're not likely to put up a fight. Yet your therapist needs his fee, and insurance carriers often require you to be very determined before they will pay their share. They will play on your own guilt about your condition to make it difficult for you to get anything more than the absolute minimum treatment. They count on discouraging you from pursuing your claims in order to save themselves money; and, in doing so, they reinforce your depression. There are hopeful signs about "parity" for mental health services, but until the laws are changed and new regulations published, managed care plans still will find ways of drastically restricting coverage for outpatient care.

The decade between 1987 and 1997 brought extraordinary changes in how depression was treated in the United States, trends that have very likely continued since. The percentage of people being treated for depression tripled in that time, from less than one percent to 2¹ ³ percent (while the percentage of people receiving healthcare treatment of any kind actually declined slightly). But all that growth was due to the appearance of new drugs on the market. In 1987, 37 percent of people being treated for depression were taking an antidepressant; in 1997, it was 75 percent. Meanwhile, the proportion receiving psychotherapy declined from 70 to 60 percent, and the average number of therapy sessions declined as well.¹²