You will never reach your destination if you stop and throw stones at every dog that barks.
Winston Spencer Churchill.
Sir Winston Churchill, the British wartime Prime Minister, used the childhood expression “Black Dog”, to describe periods of altered, gloomy mood, that plagued him throughout his life.
These dips in mood could be so severe as to render him bed bound, yet they usually recovered over a period of weeks. Despite this, he managed to lead the United Kingdom from almost certain defeat to victory.
The expression, Black Dog, has since become almost synonymous with depression.
The experience of depression is in many ways a little like walking a dog. It roams around out of sight for a bit, and then comes back to check up on you, usually from some unexpected direction, before heading off into the woods again, only to return when it wants to be fed. Like a dog it needs training to keep it in it’s place.
Like some wild dog, depression can also just appear out of the night and bite you on the bum.
The mental state that we have named depression covers a wide range of symptoms, both mental and physical, and the criteria used in making a diagnosis have evolved slowly over time. This can make it difficult to compare older research with more recent work in this field.
Depression covers a wide spectrum, from a relatively mild problem, perhaps triggered by a negative and pessimistic world view (intermittent or persistent dysthymia), all the way to a life threatening, biological brain disorder (melancholia), which can also be accompanied by psychotic symptoms. Some people even say they are depressed because it is monday!
The incidence of the more severe, melancholic depression, has remained relatively stable over the centuries. A similar condition was described in surviving ancient Egyptian papyri, and was more clearly defined by Hippocrates 2500 years ago.
The name melancholia coming from the belief that it was caused by an excess of black bile.
Depression can just appear out of the night and bite you on the bum.
Depressive disorders that are secondary to social and environmental stresses have shown a rapid rise over the last hundred and fifty years. This increase seems to be greater in countries that are more westernised, and where the population has moved from smaller, close-knit communities to larger towns and cities.
In the United States, for example, it has been estimated that the lifetime risk of suffering from some form of depression has increased at least twenty fold since the early 1900s.Usually, it is the interaction between several factors that leads to the onset of a depressive state.
- Genetic risk.
- Adverse environmental situations – especially during early development.
- Life events.
- Psychosocial stressors.
- Relationship difficulties.
- Lack of sleep.
- Low levels of general fitness.
- Personality traits,
All make their own particular contribution to the onset, presentation, and course, of the disorder.
There is an interplay between:
- Predisposing factors. These are elements such as having a family history (particularly relevant for the more severe forms such as Bipolar disorder), having an anxiety state, being male, older, chronic physical illness, pain and smoking. Having a previous episode of depression also increases risk.
- Preventative factors. Having a strong social support network is one of the main preventative factors, but regular exercise, getting enough sleep and being of an optimistic outlook all help.
- Precipitating factors. The various life events that can act as triggers to an individual episode.
- Perpetuating factors. Things that contribute to an episode persisting.
All of these elements interact to bring about the relevant mix of symptoms in any particular person.
It is perhaps not surprising to find that there is no single treatment approach that works for all people with depression. Helpful interventions range from ECT and medication, all the way to various talking therapies and lifestyle changes – such as practicing mindfulness, taking up Yoga, exercising regularly, and getting enough sleep.
The benefits and effectiveness of these differing approaches depends on the severity of the disorder, and the mix of symptoms with which each person presents.
One thing that is clear, is that the more severe the presentation, the more likely it is that a “biological” treatment will contribute to recovery.
For less severe cases, a mix of medication and other interventions seems to work more effectively than either alone. For those with a milder – but often no less problematic – form of depression, the non “biological” treatments would, at present, seem to have the most to offer.
Making changes to our lifestyle can make a significant change to our risks of relapse, or developing a depression in the first place. However, these are often difficult to initiate.
Anyone who has had depression will tell you that lack of interest and motivation, which are core features of the depression syndrome, make it very difficult to engage in the recovery process, and contribute to the prolonged course of depression.
We can psych ourselves out of our own recovery.
Being able to contribute to recovery, and to play an active part in the treatment process, are key indicators for a successful outcome. Full recovery, and a return to the status quo ante takes a great deal of effort.
The hopelessness and helplessness that are often present make it even harder to become actively involved in treatment, and the associated cognitive changes, brought on by, and part of depression, can make it harder still.
Too often, what we see as being needed appears far too hard, if not impossible, to achieve. We can psych ourselves out of our own recovery. We need to find a way to make our recovery seem possible. To do this it helps if we can break our treatment goals into manageable mini or microgoals. An exercise regimen might seem well beyond us, but we can probably manage a walk round our sitting room.
If we start small, with something we know that we can manage, we still get benefits, and this will give us some small foundation of success on which to build, helping us to reach our ultimate goal.
It is for this reason, that the US Marine Corps insists that their members make their beds properly as soon as they get up. In this way every day starts with a succesfully completed task that will influence everything else that happens that day.
Having well-formed goals is a great benefit for recovery. Each one must be something that we wish to achieve and so will buy into. Without our goals being attractive and meaningful we are unlikely to start working towards them. Goals are easier to achieve if we know exactly what they are, and how to measure their completion.
So being able “to wave and say hello to my neighbour”, is a better goal than “being more sociable”.
Mihaly Csikszentmihalyi, in his book Creativity, discusses goals as a way to motivate ourselves towards being more creative and happier in ourselves. He talks about having a reason to get up in the morning – an idea that is echoed in the work on the so-called “Blue Zones” of longevity. Having a reason to get up in the morning is one of the features of those who live healthily into extreme old age.
He recommends starting each day with a specific goal, something to look forward to, so that getting up in the first place is easier. If we can generate the belief that there is a purpose to getting up in the morning, then we are more likely to do so, and to do so with a degree of joy. Such goals do not have to be anything huge, as long as they have meaning for us.
Last thing at night it is recommended that we set ourselves a goal, something that is simple and easy. We can then visualise the chosen event happening. Starting small, with something easy – a single push up – can then be used as a stepping stone to more complex activities.
He discusses this with his concept of Flow in mind, looking to help people develop greater amounts of this beneficial mental state in their lives, but this concept is equally applicable in many other areas of our lives.
The important thing is to take the first easy steps until you master the habit, and then slowly work up to more complex goals.
In the same way, we can use this concept to gradually introduce many beneficial lifestyle changes that can aid our recovery from depression. Looking to set sensible goals, we can then break these down into a series of progressive, easily achievable, microgoals.
Our exercise regimen could start with a single push up, our drive to a greater social life could start with looking up a friend’s number in the phone book. In this way we can bring distant, impossible sounding hopes, which we often ignore, into our current situation.
Then, working slowly, step by step in the here and now, we can bring about lasting and sustainable change, and this will help us get to our preferred future.
Changing our behaviour in small ways can have considerable benefits for our mental health and general well being.