Depression is cancelled. How to return to life without doctors and drugs (R. O’Connor)

Introduction

Why is recovery so difficult? This is an important question that both patients and psychotherapists constantly ask themselves. If we understand the hidden meanings and motives underlying our behavior; we see that it repeats itself again and again, not allowing us to feel good and live the way we want, why not just stop behaving like that? If we have the necessary medicines at our disposal that do not allow us to plunge into the black abyss, if we can look at ourselves and our future even a little more optimistic, why do we remain timid, passive and withdrawn? Why do we persist in harming ourselves with our behavior if we see that it does not lead to anything good? To answer this question, Freud had to invent intricate theories about the death instinct, proclaiming that in addition to the desire to create, enjoy and live, opposite and no less strong desires to destroy, suffer and die live in us. My experience suggests a much simpler answer. People persist in self-destruction because they do not know how to behave differently, and all patterns of depressive behavior are fixed in the brain. How to fix it?

I am convinced that the main reason why depressed people cannot get out of this state — despite psychotherapy, medications and support from loved ones — is that they simply cannot imagine an alternative. We know how to «create» depression — we are specialists in this. Your own perception of the world over the years affects the personality and forms a very specific set of skills. We start acting like we were born blind. In fact, blind people are very sensitive to sounds, smells and much more; can read Braille like a normal book; they have an excellent memory. But it is pointless to ask them to imagine a sunset, a flower, or a Van Gogh painting: they have nothing to turn to, it is beyond their experience. Hoping that we will stop falling into depression is like waiting for a sudden insight from a blind person. But there is one important difference: over time, we can do it.

Many things interfere with positive changes, including unconscious forces — mainly fear. We develop defensive responses that distort reality and make us accept depression or create a subconscious belief that we don’t deserve to feel better. People learn and grow over themselves, gaining experience, but in a state of depression, a person is afraid and avoids experiences that are useful for recovery. In my opinion, if you exercise, accept challenges and take small steps, gradually getting used to the fact that fear cannot kill and impulses do not destroy, it is quite possible to see an alternative to depression. Increasing doses of healthy behavior mean that the illness goes away.

Depression becomes a set of habits, behavioral skills, thought processes, assumptions, and feelings that begin to be perceived as the basis of our personality. They cannot be discarded without experiencing a certain unease — they must be replaced by something. Coming out of depression is like recovering from heart problems or alcoholism. A competent cardiological patient knows that drugs alone are not enough: you will have to permanently change the nutrition system, do physical education, and learn how to cope with stress. A person struggling with alcoholism understands that abstinence alone will not help: it is necessary to master emotions, change the way of thinking and relationships with others. Patients with depression are to some extent shaped by the disease itself. Skills that are developed along with this illness in a futile attempt to avoid pain—such as holding back anger, isolating yourself, putting other people first, being overly responsible—defect recovery. This means that you will have to give up depressive habits that pull you to the bottom and make a person vulnerable to a relapse of the disease.

In the past decade, new technologies have helped scientists gain insights into the workings of the brain and have led to some progress in our knowledge of depression. First, the bad news: depression damages the brain. And now the good news: damage can be reversed by practicing focus and attention. In fact, you can even exceed your norm and feel better than ever. Today, scientists know that the brain doesn’t just store our experiences. Each new experience changes it: structurally, electrically, chemically. The brain itself becomes the experience. If you follow what experiences come into it, you can change it.

Another fact that can be gleaned from new knowledge about the brain is that practice is important for change to occur. You can go to a psychotherapist for years and end up quite good at understanding why we are at a dead end, but when you wake up in the morning, you still feel depressed. Medicines can give you the strength to get out of bed, but it’s the practice that changes the brain. When we do something new, there are connections between previously isolated brain cells. The connections that support depressive behavior are used so much that they are like a network of freeways, so you have to turn off the highway and explore other roads. With proper practice, new paths will appear in the brain, and it will automatically choose them.

Overcoming depression will require a new set of skills. Now we understand: happiness is a skill, willpower is a skill, health is a skill. Skills are needed for successful relationships and emotional responsiveness. We know this because the practice not only improves our condition, but also changes the brain. This approach to life is very inspiring and helps to adapt much more than the opinion that these qualities are sparingly distributed from birth and you cannot escape fate. The skills needed to cure depression will permeate your entire life, and if you don’t stop exercising, the reward can be much more than just recovery.

My goal is to offer a program to people with depression. Members of Alcoholics Anonymous know from experience that it is not enough to just stop drinking: the treatment program must be lived. Like alcoholism, depression is a chronic disease that only goes away if you purposefully try to change yourself. In the book, I explain how depression affects the key elements of personality — feelings, thoughts, behavior, relationships, handling one’s own body, coping with stress. How habits arise and how we begin to consider them natural, part of ourselves, not realizing that they only increase the disease. For real recovery to occur, they must be eliminated and replaced with new skills, which I will describe in detail. For depressed patients, the following exercises can become a life program and help you regain all the richness of colors.

I firmly believe that a person is able to cope with depression, although drugs and traditional psychotherapy alone are not enough for this. Now I can back up my confidence with the results of scientific research. The terrible irony of depression is that the sick person begins to blame himself for this. I hope I will be able to show that such an opinion is not an indisputable fact, but only one of the symptoms of the disease, and for a complete recovery, people need new tools and practice in their use. I had the advantage of being able to draw on the vast amount of research and clinical experience accumulated over the past 30 years. They suggested a new way of thinking, acting, relating and feeling — a style designed to replace the old, inefficient way of life, which often only ruins everything. Working in the clinic helped me understand how to apply innovative techniques in real life. Finally, my own experience of dealing with depression and recovery allowed me to test for myself what is useful and what is not.

When I was fifteen, my mother committed suicide in the basement of our house. I returned from school and found that the door was locked, and in the window was my mother’s note that she had gone to the store and I had to wait with the neighbors. I felt something was wrong, I decided to climb into the house through the window, and then my father came home from work. We found the body together.

Mom was sitting at the table at which I played with the set of a young chemist. She had a plastic bag on her head: she put the TU of the laboratory burner into it and opened the gas. Then I found out that before that, my mother had taken a lethal dose of sleeping pills, which my father, a representative of a pharmaceutical company, sold. The body had time to cool down: apparently, she began to prepare in the morning, shortly after we left the house. This was not an attempt to attract attention or a plea for help: she took good care to get out of life for sure.

Two years before these events, my mother seemed happy, confident and open. I remember how happy she was when she was going to parties, how she sang hits of the forties when she and dad were driving in the evening. Today, when I think about it, I realize how much my life has been shaped by the need to understand what happened to it.

I had to understand myself, because I had to deal with depression. A fairly well-trained and experienced psychotherapist, I was unaware of it for a very long time. Several times I found myself in the place of the patient, but I never made a diagnosis for myself, convincing myself that the help of a specialist is needed only for personal growth. And this despite the fact that sometimes I drank a lot, moved away from loved ones, could hardly work. It happened that in the morning I was disgusted by the very thought that a new day had come and life went on. I thought about suicide many times, but I could not forgive myself for this act, just as I could not forgive my mother. I have a family, children, patients, colleagues, and I had no right to inflict such pain on them. Nevertheless, for a long time I felt unhappy, hopeless and joyless, and I really wanted to find a way out. I think those days are finally in the past, although anyone who has ever experienced depression understands: you never know for sure. Although I haven’t sunk to rock bottom, the consequences are showing: I continue to struggle with depressive emotional habits. However, if you understand that the struggle will be long, it is easier to cope with short-term falls. And the progress is clear.

For thirty years I have been involved in the mental health of people: I was a psychotherapist, head of the department, director of the clinic. I have studied psychoanalysis, systemic family therapy, biochemical and cognitive techniques, mindfulness practice, and many other ways of understanding people. I had great teachers and great patients. I do not claim to have a definitive solution to all depression-related problems, but you will not find many people with similar experiences, both personal and professional.

Today, I am convinced that a mental health professional will not understand depression unless they have experienced it first hand. In my field of work, «comprehensive» theories are constantly emerging, flourishing and dominating, which then collapse in the light of new contradictory data. Apparently, many psychologists and psychiatrists are more interested not in looking for practical ways to treat their patients, but in theorizing, adjusting observations to existing concepts or developing new postulates that will explain everything. They are very far from real life. Now I understand that a simple, monofactorial theory of depression is impossible. This disease is partly due to genetics, partly to childhood experience, thinking style, brain structure, ability to cope with emotions, and other factors. Depression affects our entire being.

Imagine if, thanks to medicine, we could reliably detect heart disease, while knowing nothing about the effects of exercise and cholesterol, salt and fat, stress and fatigue. Patients who have been diagnosed will grasp at any straw in the hope of getting better. Some will stop playing sports, and some will take it up with tripled strength. Some will avoid stressful situations, while others will rush to take drugs to lower blood pressure, not suspecting that an unhealthy diet negates all the benefits of pills. Many will die prematurely. Someone will be lucky to get well. Without good controlled scientific studies, doctors will not know what causes death and what leads to recovery.

In relation to depression, we are in this position. We are given all sorts of unsubstantiated advice, some of which are helpful, others not. Some of them were invented just to sell something. Patients have no idea what exactly will help them get better, although in fact a lot is known about healing from depression. Not everything fits into the beautiful framework of theories, disparate facts are difficult to combine, but nevertheless this knowledge can be used.

Depression is a complex condition that blurs Western understanding of the boundaries between body and mind, innate qualities and upbringing, our personality and other people. Apparently, in many patients this condition was preceded by trauma, deprivation and loss suffered in childhood. Most complain of a difficult childhood or difficulties at an older age, which affected low self-esteem, sensitivity to rejection, self-doubt and inability to enjoy life. But these observations are not true for everyone. Some patients have no history of stress, appear to be very resilient, well integrated into society, and develop depression suddenly, unexpectedly, in response to life changes. Obviously, the disease also has a biochemical component, so many people are helped by medications, although most patients do not have enough pills alone.

But wherever the roots of depression may be — in childhood experiences or in the current state of the brain — recovery will come only through constant willpower and self-discipline; managing emotions, behavior and relationships with others. This is a harsh truth, because the patient is not to blame for his well-being. It turns out unfairly: to help themselves, innocent patients will have to work hard. In addition, depressed people are constantly advised to pull themselves together, to pull themselves together, not to give in, which is the most cruel and insensitive advice you can imagine. In addition to giving advice, I want to provide guidance and support to help those who are ill find the resources they need to recover.

Depression makes a person helpless, as if unable to swim. He strains, tries to solve problems, but all efforts are fruitless, because he lacks the ability to stay afloat. With this disease, there is a real battle between different sides of our «I». A person is pulled down by shadows, spirits, aspects of the personality that he cannot cope with and cannot get rid of. The more the patient tries, the more he repeats what he knows how to do, and the worse his situation becomes. When loved ones try to help and express natural concern and concern, the depressed person pushes them away, and then feels even more guilty for not having coped on their own.

People suffering from depression must learn to live differently with themselves and with others: acquire new emotional skills. It takes practice, consistency, flexibility. Instead of slapping the water in a panic, you need to learn emotional habits, similar to the calm, rhythmic movements of a swimmer; learn to stay afloat, feel comfortable in this element. Such people are usually excellent fighters, but to fight is to drown. It is better to try to make sure that the water itself supports the person.

For me, of course, this book is deeply personal. I want potential suicides to stay alive, I want to save people from unnecessary suffering. Much more can be done for this now than in the days of my mother or even in my youth. Hope is given by psychotherapy and medications. Mastering self-control techniques, communication and self-expression skills, testing ideas about the world and oneself can give a person who knows almost nothing but depression a chance to live a full life.

When I worked in a psychiatric clinic, I was deeply struck by how many people do not even know that they have depression. Usually they ask for help not because they feel disgusting, but because something starts to go wrong in their life: children do not obey, problems appear in the family or at work. But it soon becomes clear: the visitor has been depressed for some time, and family conflict and professional difficulties are its manifestation, not the cause. If help had come earlier, life would not have gone downhill. These people almost reach a dead end — stop feeling joy, lose hope, lose ambition, feel helpless and constantly upset, and at the same time think that this is how it should be.

And it shouldn’t be.

Part I. What we know about depression

Chapter 1 Understanding Depression

An epidemic of depression is raging around us. All indications are that the disease starts earlier, lasts longer, is more severe, and affects more people than ever before. Depression is not going to recede, no matter how much we ignore it and despise it. It should be treated as a major medical problem, but this is not so simple. The very idea is frightening: we perceive depression as a plunge into insanity and therefore avoid this topic. There is a natural desire to forget about the problem — in the hope that we are immune to it. Can you remember when you were in pain? Most people wince at this question, but are unable to describe the pain or recall the sensation to their memory. We suppress it, push it away from us, try not to remember, and therefore we can live in peace. But when we hear the sound of, for example, a dental drill, the feeling of pain suddenly comes alive in every detail. We do the same psychological trick with depression. We all feel it, but we believe that it is necessary to expel it from memory. It’s easier to think that depression can hit anyone but us.

But the incidence is constantly growing, and it is getting closer and closer. Since 1900, the “age of first depression” has been decreasing with each generation, and the risk of experiencing it during a lifetime increases. According to the most official, conservative estimates, about 6,7% of Americans experience severe major depression at least once in their lives. If we add to this the so-called light forms, I think the figure will exceed 25%. So, 20 in XNUMX people you meet have probably experienced major depression at some point in their lives, and XNUMX in XNUMX have it right now. According to researchers, almost XNUMX% of the population meets the criteria for some form of depression at any given time, and it’s not just a bad mood that will pass next week, but real life problems.

An epidemic of depression is not the result of growing awareness of the disease. This is real growth in hard terms. Moreover, this phenomenon is manifested not only in American or Western culture. A recent comparative study conducted in Taiwan, Puerto Rico, Lebanon, and several other countries showed that depression begins earlier with each generation, and the risk of the disease continues to increase over the course of a lifetime. Fifteen percent of people with major depression commit suicide.

Clinical depression is a serious, often fatal condition that is difficult to diagnose. However, health economists believe that it leads to no less disability than blindness or paralysis of the limbs. Depression is the second most expensive disease in terms of economic burden on society. This unexpected information comes from the World Health Organization and the World Bank, which measured the years of healthy life lost due to illness. According to their estimates, the direct costs of treatment, necessary medical care, reduced productivity and reduced life expectancy in 2000 in the United States alone amounted to 83 billion dollars a year. In terms of economic impact, depression is only outpaced by cancer, and it is comparable to heart disease and AIDS. The annual number of suicides in the US (33 people!) is about twice as high as AIDS deaths, and there is no reduction. At the same time, the impact of depression is only increasing: if the current trend continues, today’s children will have it already somewhere in their twenties, and not after thirty, as before. Despite this, only a third of patients with long-term depression have ever taken antidepressants, and only a few of them received adequate treatment.

You may ask: if I’m right and depression is indeed so dangerous and widespread, where is the Grand National Fund, leading the fight against this disease? Where’s the Jerry Lewis Telethon or the Annual Depression Run? The answer is obvious: the problem is the stigmatization of the disease. Too many continue to view depression as a weakness of character and believe that a person should pull himself out of the swamp by his pigtail. The hype around the new antidepressants only hurt the cause: it has become the norm to believe that just taking a pill is enough to get better. This attitude is shared by many people: it is shameful, uncomfortable to have depression. And this is quite cruel: instead of admitting his illness and understanding that self-flagellation is its symptom, a person curses himself for weakness and spinelessness. Since the patients themselves think so, it is impossible to step forward and change the beliefs of people who thoughtlessly feed their negative stereotypes. We hide, we feel unhappy, and we curse ourselves for it.

This is the dirty little secret of the economics of psychiatry: if you have depression, you think that it is not worth spending money on treatment, and at the same time you feel guilty about your insecurity and low performance. It is in the government’s interest to make you feel guilty about your condition, and it expects to save on medical care, thereby exacerbating your depression.

From 1987 to 1997, attitudes towards depression in the United States changed dramatically, and this trend is likely to continue. The proportion of those treated for depression has tripled. However, this happened solely due to the appearance of new drugs on the market. In 1987, 37% of depression patients were taking antidepressants. In 1997, there were already 75% of them. Meanwhile, the proportion of people receiving psychotherapy has fallen from 70% to 60%, and so has the average number of therapy sessions. By 2004, one out of every three visits by American women to doctors ended with an antidepressant prescription. Most experts agree that a combination of medication and psychotherapy works best. However, studies of such a combination are practically not carried out, since pharmaceutical companies finance science, which are not interested in substantiating such conclusions. Thus, psychotherapy for depression has become an exception, and a prescription from a doctor has become the norm. Depression has become a purely chemical problem, and the need to deal with life’s stresses has disappeared.

Then information began to leak out that the drugs, in general, are not so good. We learned that in testing they were only marginally more effective than sugar pills, and that the researchers used indicators designed to exaggerate the benefits of these drugs, and in the long term, people who took them had relapses of the disease. It turns out that side effects are much more common and serious than we were led to believe, and depression cannot be dismissed as some kind of chemical imbalance in the body.

Despite growing public awareness and all sorts of pills, depression continues to be diagnosed surprisingly rarely. The study, which showed a significant increase in the popularity of treatment, also noted that the majority of patients receive no care at all. Many do not even suspect that they are sick. When I worked at a rural Connecticut mental health center, new patients came in two to three times a week complaining of anxiety and depression, sleep problems, and other physiological symptoms. They lost ambition and hope, they felt lonely and rejected, they were tormented by guilt and obsessive thoughts. Some even considered suicide, but still didn’t call it depression. They just came to the conclusion that everything in life is wrong and nothing can be done about it. Such people went to the doctor with pain and malaise, insomnia, low energy, and received useless prescriptions and procedures, if they were not sent home as hypochondriacs at all. Some self-medicated with alcohol and drugs. Their families did not know what to do: neither moralizing nor sympathy helped. As a result, a person actually in a state of depression fell into a vicious hopeless circle. Such a life is very painful, especially if you blame yourself for everything and do not understand that it is a disease.

Without proper treatment, this problem destroys life. Men who develop major depression early (before age 22) are half as likely to marry and have intimate relationships than those who have depression onset later or not at all. Women with early onset depression are half as likely to graduate from college and have significantly lower incomes14.

The real tragedy is that in the field of mental health, where, in principle, little can be done, depression is one of the few diseases that can be successfully and effectively treated. Many high-quality, objective studies have shown that the therapy works and most patients recover quickly. Although full recovery is often a slow and difficult process, it is achievable.

Janet was admitted to a psychiatric hospital with acute depression. She was very agitated and embarrassed, could not collect her thoughts, could not go shopping and take care of the children. She was haunted by suicidal thoughts and impulses, although she consciously did not want to take her own life. Janet could not sleep, felt hopeless and helpless, completely lost interest in daily activities. She was convinced she was going crazy.

All this apparently began after Janet discovered that her husband was cheating on her. He probably felt ashamed, and he promised that this would not happen again, but for her the world collapsed. Within a few weeks, her ability to function normally deteriorated dramatically. Her husband took her to the family doctor, and together they came to the conclusion that urgent hospitalization was needed.

After spending a week in a psychiatric clinic, Janet began to feel much better. Shortly before discharge, she went home for the weekend. Everything was going well until she found a letter from her husband’s mistress, written during her stay in the hospital. The husband again tried to convince Janet that everything was in the past, but her condition deteriorated sharply, and she had to spend several more weeks in the hospital.

Depression is a complex condition that is useful to think of as a disease. Biochemical processes in the brain during depression are different from the norm, and similar differences can be found in animals that look «depressed». In the long term, it appears to cause brain cells to die and some areas of the brain to shrink (see Chapter 4). Helping the patient to understand that he is ill can greatly relieve him of the guilt and self-blame that accompanies depression. People can learn to respond differently to stress and take steps to significantly reduce future attacks.

But if it is a disease, why does it appear? If Janet’s husband didn’t go left, would she be depressed or not? Prior to the onset of the illness, there was nothing to indicate her vulnerability. Janet believes that she had a breakdown and considers herself mentally ill, but isn’t it because her husband turned out to be a scumbag? Is it Janet herself or her marriage? If the latter, how might the pills help her feel more confident and capable? If it’s Janet, maybe some part of her personality sees the truth more clearly than she and her husband are able to admit?

Very many survivors of real depression easily agree that some biochemical changes have occurred in them. Mood swings, distortion of perception of oneself and the world seem to them so deep and comprehensive that it seems intuitively reasonable to consider: our “I” was attacked by something alien. We don’t feel like ourselves. Something very powerful from the outside has invaded and changed us.

But when first confronted with this disease, most recognize that the feeling that seems so alien is ominously familiar. They remember how many times in childhood and adolescence they felt exactly the same — alone, helpless, abandoned. Maybe in their memories their parents remained kind and loving, and they themselves wonder why they felt so unloved. They probably believed that they had to be perfect, and they tried very hard, but they failed and understood the futility of their attempts. As adults, they decided that they had grown out of this, but everything repeats itself. Winston Churchill called his depression a black dog — a familiar animal that quietly enters the room in the evening and sits at the feet.

Depression is a disease of mind and body, past and present. In psychiatry, there are battles between opposing camps: some want to treat the brain, while others want to treat the psyche, and the latter are losing. The side that wants to heal the brain has the full support of the pharmaceutical industry, conventional medicine, and the sensationalist media. Unfortunately, patients are forced to rush between two fires. The family doctor, backed by pharmaceutical companies, is likely to say, «Take this pill,» and if it doesn’t work, the sufferer will have yet another defeat on an already long list. The mental health professional will probably say, «Let’s talk about this,» and the patient may feel that he is being treated condescendingly, that he is not understood, because how can a simple conversation alleviate this terrible condition?

This is not an «either-or» question. Both approaches are correct. Psychotherapy and drugs can cause similar changes in the brain. During depression, biochemical processes take place, but the person becomes vulnerable to illness due to life experience. The current attack may be perceived as an external event, but this event was set in motion by a change in the brain.

Robert was in his thirties when he went to bed for 14 months. He didn’t want to admit to himself that it was a deep depression. A highly intelligent person, he suddenly began to search for the meaning of life. Unable to answer existential questions, he found no reason to get up, although he did not feel depressed either — just emptiness. The wife did everything to get him out of bed — she invited doctors, family members, appealed to a sense of duty towards the children. A bitter confrontation began between the spouses. But one day, when his wife had already given up, Robert decided to get up and go back to work. I met him fifteen years later. He had other attacks that kept him in bed for weeks, but they never lasted as long. A few years ago he divorced: his wife was tired of his coldness.

Robert decided to start treatment because he was afraid of slipping back into old habits. Now he lived alone, and his house was literally littered with rubbish. There were days when he simply could not get up, and if he succeeded, he still put off starting any business all the time and could not cope with himself. He was worried about his wife, who launched a dirty divorce process. He still didn’t see any point in life, but he wanted to deal with the divorce. Robert strongly objected to any medication, and since he never had a significant bout of depression during our work together, I did not insist.

Robert’s family history is very typical of depressed men: a critical, withdrawn and hostile father and a narcissistic, self-absorbed mother. He felt that he could neither satisfy his father nor interest his mother, but since children cannot look at their parents objectively, they build into their personality the attitude of their parents towards them. And if you are treated like garbage for a long time, you begin to feel accordingly. The child does not understand that the father is too picky — he just feels that he does not meet his standards. Instead of realizing the coldness of the mother, the child thinks that no one can love him. These feelings pass into adulthood and become the basis of characterological depression — an existence without joy and hope.

I decided to use Robert’s strengths: his intelligence, intellectual interest in the meaning of life and the understanding that the world of feelings is a foreign territory for him. So that he could better understand his condition, he offered to read something. Robert was captivated by Alice Miller’s Prisoners of Childhood5, which was a very accurate description of his childhood and his parents. He learned that depression was not a feeling, but an inability to feel, and began to understand that when he was drawn to bed, it was a reaction to some interpersonal event. Now he wanted to learn how to respond correctly.

Subsequently, Robert began a relationship with Betty. With his permission, the girl came to me. Her affection for my patient was obvious, but I was particularly pleased with her «cruelty out of mercy» approach. She helped Robert open the doors to the world of feelings, did not let him retreat, teased and made fun of him, pulling him out of the coldness. He was so moved by her obvious love that he did not allow himself to act according to the usual scenario — like an aloof, self-absorbed block of ice. Instead of constantly thinking about the meaning of life, he began to enjoy this life for the first time.

The crisis in treatment came a few months later. Betty decided to move out of our small town where there was no work for her. In another state, she had relatives who would help start everything from scratch. Robert could have come there too, but suddenly he had obsessive thoughts. He was afraid that his wife would break into the house and steal something — something that should not fall into her hands, in his opinion. With his head, Robert understood that this concern was a mere trifle compared to the opening prospects. He learned to understand depression and saw that he was simply translating the anxiety associated with change and responsibilities into simpler things. However, it was very difficult for him to get all this out of his head, and I had to make him imagine life without Betty in all its details.

I met Robert again three years later: he came to our town for another court session in an endless divorce process. He and Betty lived together, he worked and was happy. For at least three years he had no signs of depression.

So what helped Robert? Psychotherapy? His relationship with Betty? Something other? How destructive was his marriage? After all, the fact that Robert fell ill was at least partly an escape from his wife’s whining. Maybe the drugs would help him faster, and maybe more effectively?

To understand the situation, one must ask the question: what made Robert and Janet react to life’s stresses in the way they did? This is what makes them different from others. Many wives in Janet’s position would question their marriage, not themselves. Others would simply shrug off their husband’s affair. What made Janet so vulnerable? Why did Robert lie dormant for so long, and then one day pull himself together? To what extent did his coldness and inability to feel, which seemed to be part of his personality, contribute to depression?

William Styron, National Book Award winner, wrote Darkness Visible6 about his battle with depression. He described his experiences with the word “madness”, believing that “depression” simply cannot express this state: “This is a weak shadow of a word for such a serious illness … A bad mood develops into a storm — a real roaring storm in the head. Clinical depression resembles it like nothing else — and then even an uninformed layman will express sympathy, and not the standard reaction to the word «depression» — something like «So what?», Or «It will pass», or «Everyone has bad days» «.

Styron is right. People are ashamed that they are depressed, they believe that they must pull themselves together, they feel weak and inferior. Of course, all these feelings are symptoms of the disease. Depression is a devastating, life-threatening, and much more common illness than you might think. If you think that depression is weakness and inferiority, let me cite a number of individuals who have suffered this condition: Abraham Lincoln, Winston Churchill, Eleanor Roosevelt, Sigmund Freud. Terry Bradshaw, Drew Carey, Billy Joel, Thomas Boone Pickens, JK Rowling, Brooke Shields, Mike Wallace, Charles Dickens, Joseph Conrad, Graham Greene, Ernest Hemingway, Herman Melville, Mark Twain.

In most outpatient settings, patients with depression make up a significant proportion of patients. At the clinic, we observed a significant discrepancy between the reason for the visit and the diagnosis: only 12% of first-timers said that depression was their main problem, but 45% of our patients were diagnosed as a result of one of the depressive disorders. Usually a person comes not because he has recognized depression in himself, but when it has reached the point at which a life crisis sets in: family troubles, alcohol and drug abuse, problems at work. At the reception, we see a sad, tired, defeated person who cannot sleep, is irritable, has lost hope and curses himself for all this. Depression often matures in us so slowly that neither we nor our loved ones notice the changes that are striking at first glance to an objective observer. When I first decided to try drug therapy and consulted with a psychiatrist friend, I asked if he thought I was depressed. He was surprised that I didn’t know about it.

Depression most often strikes early in adulthood, but 10% of children have their first attack before age 12, and 20% of older people report depressive symptoms. Both of them are treated surprisingly little. An estimated 6 million older adults suffer from some form of depression, but three-quarters of these cases go undiagnosed and people do not receive treatment despite regular medical care. Depression in old age is dismissed as inevitable, but it’s actually caused by poor health and sleep disturbances, not grief, loss, or social isolation. Nearly ¾ of elderly people who committed suicide in the week before death were seen by a doctor, but in only 25% of cases, the doctor was able to see depression. In nursing homes, most patients are given some form of antidepressant. But what is the reason — in their depression or in the fact that they want to make them less sensitive to the conditions of life? If they see that the world treats them as unnecessary and forgotten, and they are right in this, can we call it depression?

25% of women and 11,5% of men have experienced a bout of depression at some point. However, the relatively low incidence among men may in fact contain an error associated with diagnostic methods. Our society forbids men from expressing and even experiencing the feelings associated with depression, and so they turn to alcoholism and drug addiction, violence and self-destructive behavior. For every woman who commits suicide, there are four male suicides—a stark contrast to the published figures. In the Amish19 culture, where it is not customary to play macho, the prevalence of depression in both sexes is the same. Sex differences are discussed in more detail in Chapter 7.

Suicide, the worst outcome of depression, is officially the tenth leading cause of death in the US20. I have already mentioned that there are 33 suicides annually in the US, but the true prevalence of the phenomenon is probably twice as high, since the police and medical examiners prefer not to call ambiguous deaths alone a suicide. Takes the life of one person out of every two hundred, and although I personally believe that sometimes suicide can be a rational choice, getting rid of a terminal illness or severe disability, the fuzziness of the statistics suggests that we do not have reliable data on how many suicides were caused by depression, and how many «rational» motives. In my experience, there are many more of the former. Among adolescents, suicide rates have quadrupled in the past 25 years. A few years ago, in a small town near my clinic, eight young men committed suicide within one year. They were typically recent school graduates, were often intoxicated, and had not given «emergency signals» before. Angry, upset, having experienced a sudden disappointment, the child gets drunk, takes up arms, and is not far from the tragedy.

When I was working in Chicago, I met Jane. Her twenty-year-old son shot himself while she was sleeping in the next room. He was a young guy, and no one would say that he had depression: rather, he was a bully. He already had a drive to the police for minor offenses, at the age of 15 he was even sent to a reform school. After that, he lived with Jane, then with friends, periodically worked, drank heavily and often fought.

That night, two unpleasant events happened to Jimmy, which probably pushed him to the abyss. First, in a local brothel, he met an ex-girlfriend, and she tried her best to get him. Then, in another bar, he ran into his father. Dad, a real city alcoholic, barely recognized his son. And when he found out, he asked for money.

He returned home around midnight. Mom woke up, got up and asked how she could help. He drank beer and read a magazine and acted perfectly normal, so Jane went to bed. And Jimmy went to his room and wrote a short message, more like a will than a suicide note. He wanted his motorcycle, kite and hunting rifle to remain with his brother. Then he took this gun and shot himself.

Jane kept asking me why. I couldn’t tell her what seemed to me the real answer to that question, because that would be too cruel. In my opinion, both she and her son were largely victims of chance. If you take a group of impulsive drinking young people who have alcohol and rejection in their lives, but no prospects in sight, and leave them alone with a gun, some of them will shoot themselves. Who exactly will take his life on a particular night, decides only the law of averages. Do they have depression? Sure, but they can’t admit it or show it.

Jane is like most of the people I know who have experienced the suicide of a loved one. You definitely can’t put up with it, but you gradually learn to live with it. For more than a year she suffered from depression, suffered from terrible headaches (a psychosomatic symptom that mimics her son’s wounds), and could not work. She was overwhelmed by stress, and she went from doctor to doctor in search of pain relief. The antidepressants didn’t help. All I could do was listen to her mourn. Eventually the headaches became less frequent and she began to have a little more vitality. But every time I hear about teenage suicide, I think of her.

Chapter 2

Everyone has experienced feelings of depression. We all feel sad sometimes. Sadness, disappointment, fatigue are a normal part of life. There are many similarities between sadness and clinical depression, but the difference between them is like between a runny nose and pneumonia.

Depressive disorders are a disease of the “whole person”: it affects the body, feelings, thoughts and behavior and, in addition, can make us feel that it is useless to seek help. The good news is that 80-90% of people with depression can be helped. However, there is bad news: only one in three sufferers seeks to be cured. Even worse, nearly half of people view depression as a character flaw rather than a disease or emotional disturbance. And the worst thing is that only half of all cases of depression receive an accurate diagnosis, and of these cases, only one in two receive adequate treatment.

We confuse depression with sadness and grief. However, its opposite is not happiness, but zest for life: the ability to experience a full range of emotions, including joy, delight, sadness, and grief. Depression is not an emotion, but a loss of sensitivity, a big heavy blanket that, leaning over, cuts off a person from the world and at the same time hurts. It’s not sadness or pain — it’s a disease. When we feel very bad, we are sad; preoccupied with themselves and helpless — we experience the same as people who are depressed, but they are not able to get rid of this mood without outside help.

A hallmark of depression is a consistently sad mood or emptiness, sometimes perceived as tension or anxiety. Life is not fun. People with mild disease can mechanically eat, work, play, and make love, but see no point in it. With a deeper defeat, a person refuses all this, feeling that he is too tired, tense, that he is too bitter. Often there is aching fatigue, inability to concentrate, a feeling of own uselessness.

The experience of losing a loved one or something important hurts like depression, but really sick people usually have low self-esteem, there is a feeling of hopelessness, self-flagellation, and this is rarely found in the case of simple grief. In a state of depression, you may feel like a powerless victim of fate, but in addition, consider that you do not deserve better. If you have grief, you usually remember that one day it will pass.

Depression is often associated with a set of physical symptoms, the key of which is sleep disturbance. Some cannot fall asleep or wake up early without feeling refreshed. Others may sleep too long, but they don’t rest either. Obviously, insomnia leads to increased fatigue, emotional alienation, clouded thinking, and these are also symptoms of depression. Appetite may increase or deteriorate, there may be problems in sexual life, chronic and acute pains are observed that are not relieved by standard treatment. However, some physical problems—Lyme disease, diabetes, thyroid disease, anemia—cause symptoms similar to those of depression, and depression can cause physical changes that are similar to those of other illnesses. If you’re feeling depressed, it’s important to make sure there’s no underlying health issue, so you should get checked out by your doctor. However, if you are aware of your illnesses and at the same time experiencing depression, do not think that it will disappear after you cope with physical problems.

Suicidal thoughts and impulses are often present in patients, the risk of suicide is quite real. Some such ideas are repeatedly pursued, they are afraid of them, and this hurts them. For others, such thoughts appear like a bolt from the blue, without any connection with emotions. The desire to turn the steering wheel and crash into oncoming traffic occurs frighteningly often, although no one admits it.

To relieve depression, many resort to alcohol or other intoxicating substances, but this at best brings only temporary relief, most often the person begins to hate himself even more for having succumbed to the temptation. Alcohol is initially used as an antidepressant, but long-term use can lead to chronic depression and no doubt does not contribute to good life decisions — and this is enough reason for depression.

After listing all these signs, it may seem that a person in a state of depression is easy to recognize. It’s really not difficult if a person sees it himself. When a normal mental state abruptly changes into a pathological state, depression is perceived as something alien — as a problem that needs to be dealt with. But often the disease gradually becomes part of the «I»: a person does not remember and cannot imagine anything else but this depressive state.

Living in depression

The symptoms of depression are painful, debilitating, but especially difficult to recover from its effect on the inner world. Because of her, we look at life differently. Illness changes our way of thinking, makes us feel weak, worthless. It takes away social skills and harms relationships, completely deprives self-confidence. Depression permeates our entire being like metastases. And since it harms perception, we become blind to changes within us, only occasionally remembering that we were once happy, confident, active.

To understand the meaning of our existence in this world, to foresee the future and comprehend the past, we weave legends. A very simple story — «Mary likes me.» If I think so, I assume that she will be glad to meet me and will be able to understand my point of view. This story is expressed in words, but it affects my feelings, behavior, even my body. If I think this girl likes me, I will probably feel good around her. I will treat her with more respect than anyone else, I will be able to feel safe and relaxed with her, and my body will release less stress hormones. This will also affect my expectations: under normal conditions, I will assume that I will be sympathetic to her in the future; that she would enjoy the same pleasure as me; that she agrees with my opinion. Therefore, the stories we create become self-fulfilling prophecies: in this case, I treat Mary as if I liked her, with her I am more open and relaxed, and our affection for each other will grow.

However, depressed people have a number of highly distorted stories, and since these are self-fulfilling prophecies, they support and reinforce the illness. We, affected by this disease, differ from others in the perception of the world and ourselves, in the interpretation and expression of feelings, in the way of communicating with others. We feel we are unable to live up to our own standards and the world is hostile or rejects us. We are pessimistic about change. In relationships with others, we exhibit unrealistic expectations, are unable to state our needs, mistake disagreement for rejection, and act restlessly and insecurely. Finally, we have no idea about human emotions. We no longer remember how it is to feel normal, and we are afraid that true feelings will tear us apart or make others reject us. We learn what I call the skills of depression: denial and suppression of feelings, the desire to deceive the world, to be content with little, to demand nothing. Our stories become so detailed and intertwined that we create a whole world of depression, sadness, hopelessness, frustration and self-blame, apathy and self-isolation.

The main message of this book is that we can fix and restore ourselves by learning to think, feel, and act in a new way — that is, by mastering constructive behavior. When we try new skills, at first they seem alien and unnatural to us, but they can become a habit, become part of us, replacing our former being. This process changes our expectations and perceptions. Instead of: “I can’t do anything right,” we begin to think: “I am no worse than others.” There are now many exciting new studies showing that if any new skill is trained with concentration, consciously and uncritically, the brain can be reprogrammed. As we practice a new behavior, it becomes easier and more natural, and since depression is such a big mess, you can start changing from anywhere. Let’s say just get out of bed in the morning and think that if you pull one imaginary thread, good consequences will manifest themselves in different areas of our lives.

However, before moving on, let me explain what I mean by depression skills. In a state of depression, a person works more than others, although the efforts bring him little joy. Thanks to hard work, he perfectly learns certain skills. He becomes like a weightlifter, pumping only the upper body: the muscles of his arms and torso will be powerful, and his legs are rather frail — it is easy to knock him down. A person becomes a master of depression: he is overadapted and gains skills that at best help him to keep going, and often only spoil the matter.

Many survivors of severe depression testify that they suffered for years, sometimes decades, before anyone was told about it. They felt so alone and so self-blaming that, in their opinion, nothing could be done, no one would understand them. At the same time, they looked normal — they lived their lives, smiled, achieved success in their studies, careers and family life. This ability to keep a good face when playing poorly is a core skill of depression. Not every patient knows how to constantly deceive others, but each of us tries to do it every day and, of course, feels even more alienated. Often a suicide attempt, a breakdown, or a psychiatric hospitalization is like shouting, “Look! I can no longer act in this play. I feel very bad! Help!» This becomes a turning point, a clear message to yourself and others that terrible torments are hidden under external well-being and a good face.

We learn these skills out of necessity. At first they serve their purpose, but then they get stuck in our brains and become part of a vicious cycle that reinforces depression and makes recovery more difficult. The harm from many of these habits is obvious or will be proven in the near future, so for now I will just briefly comment on them.

Emotional Skills of Depression

• Isolation of affect. «Affect» is simply a synonym for the word «emotion». Isolation drives a wedge between our experience and how we feel about it. We understand what is happening around us, but we do not experience the emotions that seem to accompany this. Such psychological isolation is useful for surgeons, rescuers, police officers — all those who need to remain calm in extreme stressful situations. However, people with depression learn not to show their feelings or even feel them, because in the past this only worsened their suffering. In some families and under certain circumstances, showing how you feel is dangerous: it gives others a weapon to use against you. But if a person turns off feelings, he becomes a «cold fish» and repels people who could become his friends without having time to get to know them.
• Somatization. It is the expression of feelings or interpersonal messages through the body. We all know such people: they suffer from unrelieved pain, cannot recover from fatigue, they are irritated by many stimuli, they vomit easily or have irritable bowel syndrome. The body seems to speak for them: “You can’t help me,” or “My suffering gives me the right to special treatment,” or “I suffer, so don’t ask me to do what I have to.” Somatization allows people to express feelings without taking responsibility for them.
• Negation. Here is an example: a patient with depression is driving an adult son around the city, whose license was taken away because of drunk driving, and listens to his attacks: “What, you can’t drive faster? You don’t know how to drive at all. You are always late everywhere. You can’t do anything right.» When the patient told me about this, he was more worried about his son’s bad behavior than his own passivity under a hail of insults. When I asked how he felt, the patient was completely unaware of his anger, but continued to be depressed. The old observation that depression is anger turned inward is often quite true.
• Repression. Today it has received two meanings, both of which are important for understanding depression. The first is the opposite of isolation: the patient experiences a certain feeling, but does not realize what event caused it: for example, a sudden surge of sadness, imperceptible to him, but obvious to an objective observer. Criticism, disappointment, a thought, an unpleasant memory that flashed through the mind can become such an event. The event itself is quickly forgotten — it is suppressed by the mind, but the feeling remains. Here we come to another, more common meaning of the word «repression» — «forgetting» events that are too painful to remember. This is a common phenomenon in trauma — sexual violence, military operations, disasters. Such events, of course, are not truly forgotten: they return in nightmares or manifest themselves in some other way. During depression, the person who has had a traumatic experience uses repression to keep the experiences associated with the event out of consciousness.

The emotional skills of depression also include intellectualization, projection, exteriorization (the transition of action from the internal to the external) and internalization (the old stereotype, which has some truth in it: men blame others, women blame themselves: both are wrong), addiction to anger (ranging from temper tantrums to physical abuse; the person does not take responsibility for their behavior and expects to be quickly forgiven), anhedonia (complete loss of joy), feelings of hopelessness and apathy, which can isolate the person from sensations. I will cover them in more detail in Chapter 6.

Behavioral skills of depression

• Procrastination. It can be considered a skill because it keeps you from giving your best. There is always an excuse: “Now if I had more time!”
• Lethargy. If the mind is clouded by sitting in front of the TV, drowsiness, fatigue, many opportunities can be missed. But when depressed, chance can seem like a challenge to be avoided.
• Working until you drop, inability to prioritize, mindlessly moving forward. A person does not check whether he is going in the right direction, and thus does not take responsibility for the decisions he makes.
• Obsessive and compulsive behavior. Psychologists understand these patterns of behavior as the connection of real existential fears with behavior and thoughts that can be controlled to one degree or another. As we shall see, depression and fear are closely related: one triggers the other, and a potentially endless feedback loop is formed.
• Aggression, violence and acting out. Violence is often a response to shame. Through aggression, a person can feel strong again without having to face the things that made them ashamed in the first place. Unfortunately, then it usually becomes even more embarrassing.
• Victimization and self-harm. By sadistically treating oneself or allowing it to others, a person can again feel reality, gain focus, calmness and control in severe adversity. This process, as well as other depression behaviors, is covered in Chapter 7.

Cognitive skills of depression

• Pessimism. By expecting the worst, we protect ourselves from disappointment. Many depressed people are deeply disappointed by being abandoned, betrayed, or abused by loved ones. A person’s expectations can be deceived by other events, such as failure to achieve goals.
• Negative internal dialogue. The thoughts «I can’t», «I’m hopeless», «I’ll never succeed», «I’m disgusting», «I’m trapped» run through a person’s head like loud background music. I discuss the inner critic in more detail in Chapter 9.
• Passivity. Patients with depression usually believe that powerful external forces act on them, they decide little in life and therefore do not really influence their destiny.
• Selective attention. Paying attention only to what confirms our expectations, we avoid stress and feel safer in the world that we have built for ourselves. Such behavior becomes automatic and unconscious, so we do not notice the chances to stand out, we do not see the love and respect from others, the beauty of the world, and so on. This helps the depressed person to maintain stability.
• depressive logic. I discuss it in chapter 8.

Interpersonal Skills for Depression

• Search for accomplices – limiting the social circle to people who do not expect much from you.
• Social isolation, avoiding contacts that can challenge depressive thoughts.
• Dependenceshifting responsibility for your life to others.
• Antidependence. A person behaves as if he does not need anyone. Something like feigned independence, although in reality the fear of needing is great and is masked by coldness or false superiority.
• Passive Aggression. I devoted a lot of space to it in Chapter 7.
• Permeable boundaries of personality. A person does not determine what actions, feelings and expectations of others should influence him, but simply is influenced by this.

Depressive attitude towards yourself

• Unattainable goals — poor results. We think we have to do great things, yet we see ourselves as incompetent and incapable. However, we keep trying: “This time it will be different, this time I will succeed, and then I will be happy.”
• Lack of goals — excessive guilt. The opposite situation: to avoid disappointment, we may not set any goals for ourselves. At the same time, a person in a state of depression is not an imposing, satisfied bumpkin, floating through life and not worrying that he is not really trying.
• Passive aggression against oneself. I’m leaving the tidying up of the kitchen for later, because now I feel too depressed and loaded. But later I lose my temper and get angry at myself for leaving this mess. In addition, I will feel hopeless and helpless, convinced that I will never change and will never keep up with life. Chapter 12 has more to say about how depressed people harm themselves.

Depressive attitude towards your body

• Cyclical exhaustion / decline.
• Lack of exercise.
• Neglect of medical care / turning to charlatans.
• Defensive Eating Behavior: A person clogs their senses with food.
• Abuse of alcohol and drugs.

This neglect or harm to the body is considered a skill of depression in the sense that it helps to avoid facing reality. This is a direct expression of the belief that we do not deserve to be treated well. Chapter 11 covers this topic in more detail.

Depression is the displacement of the natural, spontaneous and honest aspects of the personality by these destructive habits. A person loses a part of himself, feelings and experiences that we consider unacceptable and expel from our lives gradually become silent. To recover, you need to restore these lost elements. “The true opposite of depression is not joy or the absence of pain, but vitality: the free, spontaneous expression of feelings.” This is the ability to experience the full range of normal sensations in response to what is happening: to rejoice at the good, to get angry when your foot is stepped on, to be sad when you are disappointed, to treat your family with warmth and love, and not to fence yourself off from reality with a dull gray veil. When patients understand, in therapy sessions and in real life, that although repressed emotions erupting are painful and disturbing, they can be used to combat depression, the attitude towards one’s own feelings begins to change. They stop avoiding unpleasant and exciting experiences, due to which the connection with the lost aspects of the personality is restored, integrity is restored and recovery occurs. Now that we know that destructive emotional habits arise and operate due to the formation of new connections in the brain, we also understand that it is possible to wean ourselves from them and change our lifestyle for the better. And through practice, new skills, which at first may seem strange and uncomfortable, penetrate our nervous system and become part of us.

Chapter 3. Diagnosis

Identifying an emotional problem is one thing, making a psychiatric diagnosis is quite another. At what point does the depressed mood that everyone experiences from time to time become a disease requiring treatment?

Currently, psychiatric diagnosis is based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as DSM-IV. It has not been easy to create a standardized nomenclature of emotional states and mental disorders, in part because so many conditions themselves are controversial topics in contemporary culture. For example, is alcoholism a disease, a habit, or a weakness? Is bulimia a disease or a cultural conflict over what a woman’s body should look like? Why do Vietnam War veterans suffer from post-traumatic stress syndrome much more often than those in previous armed conflicts? Should naughty teenagers who do not get along with their parents be forcibly hospitalized? The answers to these questions make us think about fundamental values: can we make decisions on our own, or are they already programmed by heredity, nervous system, early childhood experiences? If everything is predetermined, how will this affect social relations, the concepts of guilt, crime and punishment?

Depression as a diagnosis does not affect so many pain points in society, but similar contradictions arise here. In particular, until the appearance of the third edition of the DSM in the 1970s, many psychiatric diagnoses were strongly influenced by Freud’s theory. Since, according to this theory, depression is caused by a rigid, punishing superego, and it does not develop until the twelfth year of life, it was believed that depression could not be in children. In subsequent editions, this and other gaps in diagnosis have been corrected through a phenomenological (i.e. causal) approach: if a set of symptoms is observed often enough and becomes a problem worth tackling, and objective observers can reliably identify it in the same patients, this set symptoms are named. At the same time, there may not be a good explanation for the theory of the origin of a particular group of symptoms that occur together. Undoubtedly, the drafters of the new DSM hoped that a classification system that gives users the confidence that they are observing and accounting for one phenomenon will help to better explain the underlying mechanisms of symptoms and improve treatment.

However, this approach also has its drawbacks. He undoubtedly contributed to the medicalization of complex emotional-behavioral conditions, such as alcoholism, depression and post-traumatic stress syndrome. He allowed treatment X for one diagnosis and Y for another, regardless of the person’s true needs. The saddest thing is that now patients hope to be cured of the disease with a new pill, confident that without it they can do nothing to help themselves.

In the case of depression, the phenomenological approach has led to a certain fragmentation of the diagnosis, which emphasizes artificial differences, minimizes commonalities, and contributes to the trivialization of research. The DSM-IV lists several different conditions associated with depression. Below I give a description of them and available data on frequency and prevalence. But keep in mind that the differences between them can be quite arbitrary. As conceived by the creators, the DSM is a scientific tool that helps clarify the diagnosis, and not the bible that this guide, unfortunately, has become for the majority.

deep depression

Major depression is a very serious illness. Usually both the patient and his family see that something is going wrong, but often do not know what to call it. In the simplest case, the patient feels, looks, and acts like someone with depression and talks about it to others.

Nancy is deeply depressed. She was able to hold on to a responsible job and successfully takes care of her family, but most of the time she feels unhappy. Nancy looks tense and sad, thin, modest and worried. Hesitantly speaks out, although quite smart. Constantly belittles herself and believes that she is unable to withstand stress. He is always afraid of messing up something, although in fact he does things very well. Suffering from recurring migraine attacks that bedridden her several times a month. Because of this, she has to take expensive medications. The family budget is very tight, and the insurance does not cover the cost of medicines, so she feels guilty that she has to spend so much money on treatment.

Nancy describes her depression as a well. When she is very ill, she gets stuck in the mud at the bottom. The mud is infested with worms and rats, and she can only fight back to avoid being eaten alive. The best thing she can do for herself in this situation is to get close to the edge, lean her elbows against the walls and look at a life she can’t really participate in. Most of the time it is somewhere along the way to the bottom. Nancy remembers what good health and fullness of vitality are, but she simply cannot find them.

Formal diagnostic criteria for major depression include depressed mood or loss of interest or pleasure in daily activities for at least two weeks, accompanied by at least four of the following symptoms:

• Significant weight loss without diet, or weight gain, or change in appetite.
• Almost daily insomnia or hypersomnia (excessive sleep).
• Slow down or increase activity levels.
• Fatigue or loss of energy.
• Feelings of worthlessness or excessive guilt.
• Decreased ability to think, concentrate, or make decisions.
• Recurrent thoughts of death, suicide, suicidal ideation, plan or attempt at suicide.

These symptoms should not be the direct result of medication, drugs, or a physical condition, and not a simple reaction to grief. The patient usually describes a depressed mood as feeling sad, hopeless, or despondent. Sometimes people deny this condition, and it can only be revealed during a conversation with a specialist (the therapist says: «Your words sound sad,» and the patient begins to sob) or inferred based on facial expression or body language. Some emphasize physical complaints or speak not of sadness but rather of irritability.

According to the most rough estimates, in Western countries the proportion of people suffering from major depression at one time (“point prevalence”) is 3% of men and 8% of women. The lifetime risk (the chance that a person will develop the condition at some point in their life) is 7–12% in men and 20–25% in women. The risk does not depend on nationality, education, income level and marital status. The significantly higher incidence among women raises the issue of gender discrimination in diagnosis, as in our society it is generally believed that men should not be told about the experience of sadness, worthlessness and hopelessness — the primary criteria for this diagnosis. On the other hand, women may be more vulnerable or simply have more reasons to be depressed. I will deal with these topics in more detail in Chapter 19.

There is strong statistical evidence that recent stress may precipitate a first and/or second bout of major depression, and subsequent episodes may follow much less stress. In my experience, patients are usually able to explain what made them depressed in the first place, but it is not so easy in subsequent episodes.

Dysthymic disorder

Deep depression is an acute phase, a crisis. Dysthymic disorder is a chronic disease. A necessary criterion for this diagnosis is a depressed state for the main part of the day for many days for at least two (!) years. In addition, feeling depressed must be accompanied by at least two of the following symptoms:

• Poor appetite or overeating.
• Insomnia or hypersomnia.
• Loss of energy or fatigue.
• Low self-esteem.
• Trouble concentrating or difficulty making decisions.
• Feeling of hopelessness.

Note that secondary symptoms are very similar to those of major depression, except for changes in activity levels, thoughts of death and suicide, and the addition of low self-esteem. Obviously, the distinction between major depression and dysthymia is rather arbitrary and concerns more degree than quality. Nevertheless, such a distinction has been made, and some scientists test medical interventions on one population or another, with little regard for error probabilities and diagnosis. All newer antidepressants have been tested for major depression and few have been tested for dysthymia because dysthymia is a time-consuming and expensive study.

Chris’s condition fits the description of dysthymia. This smart, intelligent, strong woman with an amazing sense of humor was unhappy most of her life. She grew up in the family of an alcoholic mother and a very strict father, and as a child tried to make them happy — an impossible task. As a teenager, she became rebellious and got into all sorts of trouble. The first time she married a man who abused alcohol and practiced domestic violence. Empowered by Alcoholics Anonymous, Chris was determined to put her life in order. She has a new husband, but they can not find a common language. It is very easy to piss her off, and her husband retreats. She constantly struggles with a sense of dissatisfaction, although she understands that this, coupled with her angry appearance, repels people. But she can’t contain herself.

Chris describes depression as a big soft blanket. It does not give comfort, but it is safe and familiar. Sometimes she thinks she has the right to get depressed, give up the fight, sit comfortably in a chair, watch old movies and feel sorry for herself.

The point prevalence of dysthymic disorder is estimated at 3% and the lifetime risk at 6%. Once again, female gender is associated with a higher risk expectancy, with nationality, education, or income irrelevant.

People with dysthymia are sometimes referred to as preoccupied healthy people, but this is very, very far from reality. Imagine that for two years, most of the time you live with a feeling of depression. It is difficult for you to do ordinary things, you cannot enjoy life, you feel unhappy, you sleep badly and do not find the strength to somehow change the situation. Such people would be more accurately described as «walking wounded»: they go through life, but their life is usually unpleasant, cruel and short. This is not the stereotype of the self-contained neurotic created by Woody Allen — it is rather constant torment and sacrifice.

In the behavior of such people, the influence of their mothers, who acted in this way, is often noticeable. Children suffering from dysthymia are often restless, tense, have difficulty communicating with peers and do not keep up with the school curriculum. They know very well that something is wrong with their mother, and the guys think that they can do something to help. Often these children adapt and become pseudo-adults, appearing tough and independent. They can take care of their mother by taking over her responsibilities: cooking, doing housework, babysitting with younger siblings. When a woman recovers and returns to normal activities, she may face a sharp response: getting her mother back, the child may experience anger, which he suppressed all the time of emotional loneliness. He becomes naughty and tests whether she can really be relied upon. The mother, still vulnerable, cannot understand why the child is not grateful to her for returning to her duties, and she may develop a relapse of the depressive state. Depression embraces such a family in a vicious circle.

Other depressive disorders

This vague term is applied to all patients who show some signs of depression but do not meet the criteria for a narrower diagnosis: their symptoms are not sufficiently severe and prolonged, or most of the criteria for major depression and dysthymia are met, but not all. This category includes women suffering from depression associated with the menstrual cycle, as well as patients with schizophrenia or other psychotic (that is, associated with psychosis) disorders with comorbid depression, but still excludes people experiencing grief, experiencing depression due to loss , life conflicts or health problems. In other words, this diagnosis includes a wide range of people with depression that has no clear external cause but is severe enough to interfere with the ability to function.

It is estimated that 11% of the population meets the criteria for various depressive disorders at one time, a staggering figure that puts this diagnosis at the top of the list in the United States27. The cumulative point coverage of major depression, dysthymia, and other depressive disorders reaches 20%. This does not mean that 20% of the population will develop depression at some point in their lives: 20% have it right now! One of your five friends, family members, work colleagues is sick. And there is no more common disease.

difference without difference

If you haven’t noticed a big difference between major depression, dysthymia, and other depressive disorders, don’t be embarrassed. These subtle differences sometimes find use in science, but more often they are used to confuse and intimidate the public. Well, let’s recap. In deep depression, you feel terrible, confused, lethargic or agitated, feel guilty, contemplate suicide, your sleep, appetite and sex life are disturbed, and all this happened to you quite quickly. To qualify as dysthymic, you must experience some or all of these symptoms, but not intensely, but for a long time, at least two years. If other disorders are present, you simply feel many of the same symptoms, but not as much as with major depression, and not at all for as long as with dysthymia.

Some scientists insist that these conditions are completely independent, just as a runny nose can be caused by a cold, an allergy, or a deviated septum. In particular, these scientists advocate the concept of dual depression—dysthymia with major depression—and put forward the idea that because diseases involve different processes, a person may have the misfortune to catch both diseases at the same time, and not just feel worse after a while. However, the majority of patients do not see these differences. They just know that most of the time they feel bad, and sometimes they are completely disgusting. Patients know, and more and more scientists and psychiatrists recognize, that other depressive disorders are usually an early stage or a slightly milder form of dysthymia. Dysthymia is what people with major depression feel when they get a little better, and major depression is a more severe version of dysthymia. And no matter what you are sick now, it is far from complete recovery.

In particular, follow-up of 431 patients for 12 years after an episode of major depression showed that they continued to experience the same state on average about 15% of the time. But that doesn’t mean the other 85% didn’t have symptoms. On the contrary, 27% of the time they felt dysthymia, and 17% — other depressive disorders. The more time they spent in that state, the more likely they were to slide back into a deep depression.

Bipolar disorder

This is another type of depression that is of great concern and appears to be qualitatively different from major depression, dysthymia, and other depressive disorders. Bipolar I disorder (manic depression) is usually characterized by episodes of major depression punctuated by periods of mania. A manic episode must meet the following criteria:

1. A distinct period of abnormal, persistently elevated, expansive, or irritable mood.

2. At least three of the following in one period:

• inflated conceit / ideas of greatness;
• a pronounced decrease in the need for sleep;
• speech pressure;
• jump (whirlwind) of ideas;
• pronounced distractibility;
• increased goal-directed activity or psychomotor agitation;
• Excessive involvement in a pleasant pastime, despite the negative consequences.

3. Symptoms must be severe enough to cause significant impairment of functioning or endanger the patient or others.

4. Symptoms cannot be caused by schizophrenia or alcohol or drug abuse.

Walt has bipolar disorder. He is a big man, a truck driver, and in his normal state he seems like a pleasant person with a good character. However, for the past five years, he has found it difficult to keep a job because of his strange behavior. Periodically, he becomes obsessed and constantly thinks about sex. If an attractive woman is nearby, he cannot focus on anything other than sexual fantasies. Sometimes he loses contact with reality so much that it seems to him that it answers his thoughts. In this state, he spends money, which is already scarce, on prostitutes; squanders funds in gambling; does everything to impress a woman. Walt rightfully considers himself attractive, strong and charming, and during these periods he only cares about the realization of his hyperactivity: he can stay awake all day or talk endlessly. One day he showed up at my house uninvited to show off his new car, the only time a client has gone so far beyond that. But Walt just wanted to share his joy.

In other periods, a man is tormented by severe depression. Walt goes to the other extreme: he thinks he can’t change anything. He barely has the strength to get out of bed. He tries to work, but because of his lack of self-confidence, employers do not trust him. Symptoms of obsessive anxiety appear: Walt can return home ten times to check if he turned off the coffee maker. He constantly apologizes for everything.

The average age of onset of bipolar disorder is in the early twenties. It affects men and women equally. According to statistics, 0,4–1,2% of the population develops bipolar disorder during their lifetime. 0,1–0,6% of people suffer from attacks of this disease at the same time. I suspect that the true prevalence of bipolar disorder, or the more severe type II bipolar disorder, is much higher than official statistics show. There is a strong genetic correlation: in the immediate family of patients with bipolar disorder, a lifetime incidence of morbidity is 12%, and another 12% develop major depression.

If left untreated, a manic episode lasts an average of six months, while an episode of major depression lasts 8 to 10 months. Over time, these episodes become more frequent. Among patients, there is a high rate of suicide (15% untreated), accidental deaths from risky behavior and comorbidities. Many people with bipolar disorder who do not receive proper treatment die from alcoholism, lung cancer, accidents, and sexually transmitted diseases. During an attack, they feel so invulnerable that they simply do not take precautions that most of us would consider simple prudence.

There are other subtypes of bipolar disorder. Bipolar II disorder is characterized by episodes of major depression interspersed with hypomania (an abnormally elevated and expansive mood that does not affect the ability to objectively perceive reality; «hypo» is «less than» mania). Such people are singled out in a special subgroup. Anyone who is able to move from the abyss of deep depression to a dizzy, agitated or very focused and productive state and repeats this cycle over and over again is not just a depressed person.

In addition, there are types III, III½, IV and even IV½ bipolar disorders. (I’m not kidding: scientists argue about their differences, although they may seem insignificant to the layman.) For example, according to one definition of bipolar III disorder, a depressed person who is taking an antidepressant (or switching to another) suddenly has a full-fledged manic episode. And such phenomena are far from uncommon. Other scientists define bipolar III disorder in a completely different way, so I will simply not mention it. If someone gives you one of these diagnoses, make sure you understand very clearly what they are talking about, especially before you start taking antidepressants.

I previously thought bipolar disorder (type I) seemed to be a completely different issue, although episodes can look and feel like major depression. I have argued that genetic factors play such an important role in this disease, the manic episodes are so characteristic and specific, and the disease itself reacts so peculiarly to certain drugs, that it makes sense to consider type I bipolar disorder primarily as a biogenetic disease. It causes a chemical imbalance in the brain leading to unique mood changes.

However, the inexplicable fact that sometimes taking antidepressants can turn an ordinary depression into a powerful manic episode suggests that there may be more in common between them than meets the eye. And I continue to see people with bipolar I disorder who, as children, experienced the indifference, deprivation, and mistreatment associated with major depression or dysthymia. Many clinicians expect breakthroughs in the next few years in our understanding of the brain and gene links between mania and depression, as well as anxiety, attention deficit hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD). This could lead to better drugs and therapies for such conditions.

Ted Turner, who was named Time magazine’s Person of the Year in 1992, may have been the first to publicly admit to being treated by a psychiatrist. His story will be of interest to those who are interested in issues related to success and personal life, as well as to those who are fascinated by the interweaving of genetics, biochemistry and family dynamics that underlies depression and bipolar disorder.

For many years, Turner was troubled by obsessive thoughts that he would not live longer than his father, who committed suicide at 53 (a common fear among children of suicide). Ted talked about suicide quite often and ruthlessly drove himself to success in a rivalry that did not bring him pleasure. Having devoted a lot of time to sailing and having won the America’s Cup, he constantly told a friend that he never liked this sport, and in general it was “cold and wet” there. Ted’s attention was always riveted to the finish line, he was looking for some kind of achievement, which, finally, would be enough to find spiritual harmony.

Ed, Turner’s father, apparently was a tortured man and at the same time psychologically mocked his son. If Ted failed his father, he beat him with a hanger, and when he did something really bad, his father made him beat himself with a razor-sharpening strap. During World War II, Ed served in the Navy, his wife and daughter had to move from base to base with him, and Ted, who was then only six years old, remained in a boarding school. In the fifth grade, the boy was sent to a military school, but no grades, no achievements were good enough to please his father. When Ted was in his early twenties, Ed shot himself, forcing his son to rescue the family’s heavily indebted billboard advertising business. Working feverishly and risking recklessly, he not only rebuilt the business, but founded the media empire from which CNN grew.

But with the death of his father, Turner lost the model against which to measure his progress. He drank, debauched, then forgot about his children, then intimidated them, but as a boss he was just a real devil. Finally, in 1985, he decided to seek help from a psychiatrist in Atlanta.

First, the doctor prescribed him medication for bipolar disorder. With this disorder, patients can exude self-confidence and energy, go without sleep, consider themselves capable of great things, and enjoy risk, so it is sometimes difficult to tell where, in people like Turner, illness ends and personality begins. Besides, it can be difficult to get such a patient to agree to treatment, but Ted was willing to cooperate.

When Turner’s condition stabilized thanks to the medicine, psychotherapy helped to cope with the father’s shadow. Like most children of strict, emotionally cold fathers, Turner did not develop an internal mechanism of self-satisfaction. Most members of suicidal families believe that suicide is a normal outcome of life and is not something to worry about. Despite the years that have passed since then, Turner’s psychiatrist does not disclose the details of this case, but it is clear that Ted had to work hard to come to terms with the presence of his own children and a woman in his life.

Turner is a classic example of how achievement is not the same as happiness. How we live leads to harmony, not what we do.

Depression, anxiety and stress

Before moving on to discuss other types of depression, I want to touch on the relationship between depression and anxiety. Evidence suggests that most patients with depression and bipolar disorder experience severe anxiety, and it is often difficult to tell which diagnosis is the underlying one. A very common scenario is that a young man in his twenties has a minor relapse, the most problematic symptom of which is anxiety. If help is given quickly, that’s all, but if a person does not receive good treatment, anxiety exhausts him. He feels that he is losing control over the situation and sees no hope for improvement, he quits his studies / work, acquiring depression as the main problem. The mania associated with bipolar disorder is often thought of as a defensive response to anxiety, its complete opposite: I can do anything, nothing can harm me.

Although most recover from an episode of severe depression, they become more vulnerable to stress and anxiety. The STAR*D study, a large program still run by the National Institute of Mental Health, showed that only 30% of patients experienced significant improvement after the first phase of treatment. That is why it is necessary to inform the public that depression is a chronic disease that decreases or increases throughout life, especially if it is poorly treated.

Proper treatment of depression increases the likelihood of a full recovery, but most patients will still be vulnerable. The best prognostic indicator is the duration of the first episode, from the start of treatment to recovery, so early detection and effective treatment of the disease should be a priority. Over time, the likelihood of relapse increases: ¾ of patients can expect the next episode within five years. The main risk factors for relapse are psychosocial: the degree of anxiety and self-destructive behavior, as well as self-doubt, that is, those symptoms that are much more reliable to treat with psychotherapy instead of medication.

The largest comorbidity study in the United States found that among those who experienced an episode of major depression in the previous year, 51% had an anxiety disorder during the same period, 4% had dysthymia, and 18,5% had alcohol or drug abuse. A much more recent study by the National Institute of Mental Health found that 53,2% of 2876 participants with major depression met the strict criteria for anxious depression. Researchers have shown that in people with anxious depression, the side effects of drugs occur more often and are more intense, and remission occurs less frequently and takes longer to achieve. Depression and anxiety are always closely related: the vast majority of patients have a combination of symptoms that can be diagnosed in two ways, depending on minor shifts in emphasis. Most scientific papers show that anxiety and depression are detected together in 51-68% of cases. Increasingly, both psychiatrists and other doctors agree that these conditions are, if not identical, then at least incredibly similar. I see anxiety and depression as the fingers of the same hand, the tops of the same mountain.

There are other fingers on this hand: PTSD, stress-related physical illnesses, perhaps cognitive disorders, such as attention deficit disorder. It makes sense to believe that a person is suffering from a general disorder syndrome, the symptoms of which are depression, anxiety, PTSD, autoimmune diseases, cognitive impairment, and what I call a non-specific illness. I think it is worthwhile to assume that all these conditions are interconnected, they are the result of current stress on the body and mind, vulnerable due to genetic predisposition or trauma and stress in childhood and adolescence. The majority of people with depression experience a combination of the symptoms of all these diagnoses, just as it is not uncommon for ordinary people to experience some of the symptoms of depression. Perhaps anxiety is an initial reaction to excessive stress and a panicky attempt to escape from the inevitable. Depression, on the other hand, is damage to the nervous system and psyche that occurs if stress lasts too long. Anxiety and depression wear out the body and the immune system, leading to somatic illness. The distinction between acute PTSD, anxiety, and depression can be a matter of degree: how deep and severe the trauma is. The diagnosis partly depends on which symptoms are experienced most painfully, which signs are more. It also depends on which doctor you went to, as the diagnosis will be influenced by his education and personal preferences.

It should be noted that a small but extremely important study is being conducted in the United States on the prevention of depression, anxiety and other serious mental illnesses. Data from other countries show the influence of childhood experiences on the development of depression in adulthood. So, in British observations of 1142 participants from birth to 33 years old, it was found that the development of adult depression is strongly influenced by lack of maternal care, neglect, conflicts between parents, cramped living conditions and social dependence. In the United States, such results are viewed sideways: mental illness is considered to be a disease of the brain, which implies that factors related to development and the social environment do not matter. At a recent conference, the director of the National Grand Depression Foundation confessed to me that she does not believe that mental illness can be prevented.

But adult patients keep coming into our office and saying that their depression is related to past trauma or deprivation. Should it be denied? Can’t we help people take better care of their children to make them less vulnerable to depression? Or build our society so that everyone has less chance of getting this disease?

Other types of depression

Adjustment disorder

Adjustment disorder with depressed mood or with anxiety and depression is diagnosed when depression appears as a clear reaction to external stress. It’s not the same as grief. Grief is in many ways perceived as depression and similar to it, but in this case, people usually come to their senses without the help of a specialist. To a certain extent, this is also a question of the depth of the state. Most grieving people continue to understand that life goes on and that there is good in the future. When a pleasant event occurs, they are able to experience joy. They do not have reduced self-esteem, there is no irrational guilt. People with adjustment disorders and concomitant depression are much worse off. They feel hopeless, helpless and empty, there is no place for joy in their lives. Patients indicate exactly why they feel this way: loss, death of a loved one, illness, some kind of blow to self-esteem — but do not yet meet the criteria for dysthymia or major depression. Unfortunately, this diagnosis has almost no prognostic value: it is impossible to say whether the patient will recover in a month, or this is the first attack of depression that will last a lifetime. My advice: if you see that within a month after the stress that knocked you down, you cannot effectively eliminate it or there is no improvement, contact a psychotherapist.

Major depression with psychotic symptoms

Sometimes the depression is so severe that the person begins to experience symptoms similar to those of schizophrenia: hallucinations or delusions, often taking the form of an accusing voice. When depression reaches this stage, a good psychiatrist should be consulted immediately. It is difficult to cure it, since most antipsychotics make a person so lethargic and sleepy that it is difficult for him to fight depression, and since the patient does not have a firm connection with reality, psychotherapy is also difficult.

atypical depression

This term is applied to a small subgroup of patients with unique symptoms. These people do not suffer from the insomnia that usually accompanies depression, on the contrary, they sleep too much. They overeat, gain weight, feel heaviness in their arms and legs — their limbs seem to be poured with lead. The rejection is very pronounced, forcing to avoid relationships or making them stormy and dramatic. With this diagnosis, a person reacts strongly to MAOIs (monoamine oxidase inhibitors).

Depression, panic and phobias

Although the forms of depression that we discussed are in the DSM, I want to address a common and dangerous phenomenon that has no officially recognized diagnosis. Very often, especially in the first episodes of major depression, the patient experiences extreme anxiety and panic attacks. As mentioned above, depression and anxiety are closely related, perhaps as different aspects of the same stress response. If uncontrolled anxiety is not addressed in the early stages of therapy, it often develops into a phobia or multiple phobias and takes on a life of its own, and an ingrained phobia is very difficult to get rid of. Therefore, it is extremely important to urgently address the treatment of panic and anxiety.

Anyone who has experienced a panic attack at least once in their life knows what a terrifying condition it is. But fear can be removed if you learn to understand and control your own reactions. A sudden deep depression feels like an alien invasion: you no longer feel like yourself. Phobic-prone people often experience depression in this way, because their minds are able to “split”: at the moment when the ground seems to be slipping from under their feet, they suddenly feel like a different person, seized by a panic attack — frightened, with jumping thoughts, a frantic pulse unable to catch his breath and calm down. Quite naturally, there is a fear that the unbearable tension will never end. At this point, the therapist or psychiatrist should help the patient regain control of the situation by explaining, “This is a panic attack. I know it’s terrible, but it will pass and you will get better. This happens with many people. It’s just a reaction to stress.» Then you need to continue to talk about the patient’s situation. A panic attack can be called emotional burnout: such a diagnosis does not stigmatize and implies the possibility of recovery.

The general anxiety experienced by the patient can easily become attached to a specific object or situation: driving, going to work, a phone call, crowds, heights, enclosed spaces, eating. In fact, phobias of this kind are generated by a defensive reaction: the patient’s mind tries to make the panic more bearable by limiting it to a specific situation. But since once a phobia is difficult to overcome, it is better to put the patient face to face with the situation he is afraid of. At this stage, anxiolytics (mild tranquilizers) can be of great help because they provide almost immediate relief, while antidepressants and psychotherapy provide an opportunity to cope with stress. Patients can benefit greatly from learning relaxation techniques, such as breathing techniques or mindfulness. It must be explained that regular exercise will significantly weaken the flow of stress hormones. This will not happen immediately, it will still be uncomfortable from time to time. However, the patient must not be allowed to become overwhelmed by fears and depression in the long term, but must be returned to normal activities as much as possible. I have seen too many lifelong injuries caused by the lack of intensive, emergency care needed in such a situation.

Postpartum depression (PPD)

After the birth of a child, many women develop severe depression. No, not a fairly common mild and transient postpartum sadness, but a serious pregnancy complication that occurs in almost 15% of mothers. PPD includes all the symptoms of major depression — insomnia, loss of appetite, guilt and self-blame, obsessive thoughts. But this kind of depression tends to focus on the baby and motherhood. A woman considers herself a bad mother, unable to take care of her baby; feels that she does not love him or that the child does not love her; that she had made a terrible, irreversible mistake with no hope of redressing the situation. Ironically, the lack of proper treatment allows this mental condition to really affect the relationship with the baby. In the worst case, PPD can turn into postpartum psychosis, and the new mother will have delusional ideas, for example, that the child is a product of the devil and should be destroyed.

Fortunately, the disease rarely goes that far. Motherhood should be a time of great happiness, otherwise something must be done. If you suspect that you have PPD, sign up with a good psychotherapist as soon as possible. I emphasize: for good. I have seen many examples of harm from professionals in good faith trying to help new mothers like any other group of patients. I think this is because moms are extremely sensitive and vulnerable, and the specialist feels the need to fix the problem immediately, so he intrudes with advice, because of which the woman gets even more reasons to blame herself for everything.

Apparently, the PRD is another example of the impact of stress on a vulnerable person. In this case, the stressors are the sudden hormonal changes associated with childbirth (which we don’t fully understand yet), the equally dramatic increase in workload, and the insomnia and stiffness that women in labor face. Factors that increase vulnerability include past depression, marital problems, and lack of social support, although we know there are mothers who are hit like a bolt from the blue by PDD. In many cases, depression begins during pregnancy for one of the same reasons — due to hormonal changes and stress. Often, the expectation of a baby exposes problems in a marriage that existed before, but have become more obvious. Sometimes the husband reacts negatively to pregnancy, or friends and relatives turn out to be envious or insensitive.

Unfortunately, the use of antidepressants during labor preparation and breastfeeding is complex. There is increasing evidence that the use of SSRIs (a new class of antidepressants — selective serotonin reuptake inhibitors) in early and late pregnancy is associated with congenital malformations in the child, mainly of the cardiovascular system, but the increase in risk is small — about 2% compared with 1% in mothers not taking SSRIs. But, of course, other risks may show up later, as often happens during pharmaceutical research. Mood stabilizers are also associated with risk to the fetus. Therefore, there are no easy solutions for a depressed pregnant woman. It can be very difficult to give up SSRIs, and, of course, the risk of a recurrence of a depressive episode increases, but one must also think about the effect of drugs on the child. Please weigh the pros and cons of antidepressants (Chapter 13). It is essential to strike a balance between the severity of depression in the mother and its impact on the child, on the one hand, and the increased risk of birth defects, on the other.

Seasonal affective disorder (SAD)

This ambiguous diagnosis is given to people who regularly become depressed in response to changes in daylight and seasons. The DSM compilers state quite confidently that some people experience depression regularly—usually it starts in the winter and resolves in the spring—and that this is not due to lack of exercise, limited socialization opportunities, or deprivation of stimuli, but, apparently, to a lack of sunlight. In the depressive phase, the patient is sad, anxious, irritable, and socially withdrawn. Such people become sleepy, sleep too long, gain weight, have an acute need for carbohydrates. Women suffer from this disorder four times more often than men, with more than half additionally complaining of premenstrual mood problems. If the patient moves closer to the equator for the winter, the symptoms usually decrease. At first it was thought that phototherapy and regular use of powerful fluorescent lighting could help, but more recent studies have not been able to prove the benefits of these techniques. However, it doesn’t hurt anyone to sit quietly in good light, read a book, or meditate.

I have always been skeptical about this diagnosis, as I believed that all depressed people simply get worse in winter. But then I met Noah, a man with a severe pattern of seasonal bipolar disorder. In August, he begins to worry about the upcoming classes (Noah works as a teacher at a prestigious school in New York) and by October falls into a deep depression. He is sure that he does not work well — and everyone sees it; cannot sleep, loses interest in food, and gets caught up in an obsessive cycle of negative thoughts. He becomes just another person — tense and nervous, he is uncomfortable. Noah feels he is barely able to express himself, despite good feedback from students. Then, around January 12th (we’ve been tracking this for a few years), he gets better. By March, he enters a pronounced hypomanic state, becoming energetic, self-confident, open and full of ideas. Students come to his lessons for fun, but in fact they find the quality of teaching in spring worse than in autumn. In this state, it is very difficult for him to concentrate and sometimes he makes decisions that he later regrets very much. The best time of the year for him is the beginning of summer.

Chapter 4

Over the past decade, new information about depression has both worried me and reassured me. Here’s the really scary news: depression affects the brain. During really severe depression, the brain loses its resilience, so when something good happens to us, it no longer affects it. We lose the ability to produce dopamine, one of the main neurotransmitters in the pleasurable system. Endorphin receptors are degraded — hormones of joy associated with chocolate, sex and «runner’s euphoria». According to some studies, the hippocampus — the central processor of all emotional information — shrinks by 20% with each episode of major depression. This likely explains the concentration and memory difficulties that accompany depression, because the hippocampus is essential for moving memories from short-term storage to long-term storage. It is also one of the organs known to us that forms new brain cells, and the process itself seems to be associated with learning. Some antidepressants restore the ability of the hippocampus to generate new cells, at least in laboratory animals. One recent study showed that cognitive behavioral therapy also leads to the growth of the hippocampus. However, it appears that recurrent episodes of depression lead to an overall reduction in brain volume. Depression seems to cause specific changes in brain activity that are stored as vulnerability and manifest when something sad happens to the recovered patient or he experiences stress. Other work has shown that people with depression are indeed more likely than others to respond to stress and loss with self-flagellation, feelings of helplessness and embarrassment.

But don’t get scared. A growing body of research suggests that through focus and exercise, we can change and repair our own brains. Scientists have noticed that it is affected by regular classes. So, taxi drivers have enlarged areas of the brain associated with navigation and orientation, while violinists and guitarists have enlarged areas responsible for the work of the fingers. In one study that I particularly liked, a group of students were taught to juggle. After three months of daily exercise, the experimenters, using advanced imaging techniques, noted an increase in gray matter in areas associated with eye-hand coordination. Then for three months the students were banned from juggling, and the growth stopped.

So, for the first time in the history of psychology, researchers are trying to see if we can somehow make us feel good, not just recover from illness. Mindfulness meditation research shows that regular practice rewires the brain. Meditation increases activity in the prefrontal cortex, which many scientists consider to be the seat of self-awareness. In addition, meditation seems to help create new reflex arcs in the brain along what Daniel Goleman calls “highways” through the rational, consciously controlled part of the brain, as opposed to “back roads” from the center of fear to the immediate impulsive search for relief.

The new concept of a plastic, changeable brain resolves the long-running debate about whether depression is caused by early childhood experiences or neurochemical imbalances: stressful emotions can cause imbalances that can become chronic. But whatever the cause in the past, the patient must recover in the present. Depression, like agoraphobia, a disorder that we know how to treat, causes functional autonomy: once started, it continues even after the immediate cause has been removed. The patient can fully see the world, but the symptoms take on a life of their own. In agoraphobia, the patient receives medication, learns relaxation skills, and anxiety decreases, but he still does not leave the house. The psychotherapist then uses the «psychological crowbar» or «dynamite» to force the patient to go out and experience the outside world without his symptoms, and after a little practice the disorder is cured. In depression, pain and suffering can be alleviated with medication, but the patient is likely to retain a lack of self-confidence and assertive behavior skills, painful modesty; his image of himself can be distorted, he will chew on thoughts and put everything off until later, abuse alcohol, easily get stuck in a loveless marriage or in a dead end job. To achieve full recovery, the patient must deal with all these problems — with a therapist, as this book suggests, through a targeted program of developing the necessary skills in oneself.

A disease that causes itself

In my book Active Treatment of Depression, I propose a model of depression that captures much of the current knowledge on the subject. Let me briefly describe this model and its individual elements, and then talk about what it means for the patient and their loved ones.

The main assumption underlying this and most other approaches is that depression is the result of exposure to current stress on a vulnerable individual. Stress is enough for a person to cross the invisible line and fall into a vicious cycle of depression, formed from repressed thoughts, self-destructive behavior, guilt and shame, neurochemical changes, discrimination and stigmatization. These elements both evoke and reinforce each other: depressive thinking provokes more shame and guilt; they can lead to self-destructive behavior, which again reinforces guilt and shame, ad infinitum. If nothing is done, it will only get worse. The patient is trapped and unable to get ashore without outside help — medicines, therapy and elimination of at least some of the sources of his stress.

Here are some factors that seem to increase a person’s vulnerability to depression.

• Genetic predisposition. There is a certain hereditary element in depression: when one of the identical twins falls ill, in two cases out of three his brother or sister will also become depressed. One study showed a significant thinning of the cerebral cortex in families with depression, which scientists suggest may indicate inherited genetic vulnerability.
• Difficult relationships with parents at an early age. Every day we learn more about how experiences in early childhood affect the development of the brain and thus lead to problems in adulthood. If the primary caregiver is not on the same emotional wavelength as the child—perhaps because of their own depression—the child may never develop healthy self-esteem and a sense of being worthy of love. He may lose the ability to trust others or control his impulses.
• Poor interpersonal skills. Shyness and social phobia are highly associated with depression. Feeling awkward or embarrassed in social situations leads to the fact that a person begins to avoid them, this makes him even more withdrawn into himself, and then negative thoughts can peck the patient to death.
• Lack of social support. Many of my patients are isolated from the world not only by depression, but also by life circumstances. These are the only children in the family; people working in positions with minimal social connections; divorced; rejected by the family; living in the wilderness. Others are married, but without love, and the relationship alienates and hurts. If a person has no one to rely on in difficult times, he feels loneliness and danger.
• Unstable self-esteem. If rejection hurts you a lot and undermines your self-image, and good things bring only temporary and weak pleasure, this is a characteristic feature of depression. I like the analogy with a car’s lubrication system. Engine oil reduces friction between moving parts, keeping your engine running smoothly and efficiently. The oil needs to be changed regularly because dirt accumulates in it, but in general the system does not require much maintenance. However, if the oil pan is cracked or the gasket burnt out, the oil begins to leak or burn out, and it has to be constantly topped up. A depression-resistant person seems to have a good, impenetrable lubrication system: he is able to adapt well in life and only occasionally needs the support of others, he is not confused by loss or failure. But in many depressed patients, something “cracked” and the lubrication system went wrong. In order to live normally, they need more or less constant support, love or success, although their own behavior can interfere with the achievement of all this.
• Pessimistic thinking. There is solid evidence that when depressed, a person thinks in a characteristically self-critical way that is quite different from other people’s thinking. We will cover this in chapter 8.
• Early loss or traumatic experiences in childhood and adolescence. The death of a parent can be a nightmare for a child. The world on which he relied collapsed, disappeared forever. Some children reject attempts to console them, believing that they must be brave, or, conversely, are afraid of the power of their feelings. Surprisingly, many feel guilty and responsible. Other childhood traumas are frighteningly common. In one study, 22% of 17 mostly middle-class adult participants reported being sexually harassed as children. More than a quarter said that their parents were drinking or taking drugs, and these problems indicate neglect of the child. Those who reported such childhood experiences were much more likely to become depressed, attempt suicide, abuse alcohol and drugs, experience anxiety, and have other health problems, such as stroke or cardiovascular disease, as adults. In my experience of working with patients over the years, most people with major depression will admit to being abused or neglected in childhood. Usually these are not horror stories about beatings and incest, although they are not uncommon, but emotional abuse. One or both parents constantly undermine the child with harsh criticism or cruel, personal, emotional scourging if the child has annoying or uncomfortable needs and desires. Parents yell at the child simply because of a bad mood (as well as in a state of intoxication or a hangover), deprive him of attention and affection because he did not please them with something.
• Childhood problems with siblings also associated with adult depression. Many of my patients with this diagnosis felt they were secondary. They were rejected and intimidated, sometimes to the point of physical and sexual abuse.

Stress

There are acute stressful situations that can push a vulnerable person into the abyss of depression.

• Disease. Some diseases, such as migraine, multiple sclerosis, or a heart attack, cause depression much more than the accompanying pain, stress, and disability, which suggests that the diseases are also physically associated with depression. However, the depressive cycle itself can start any serious illness, as a person is afraid of long-term consequences, experiences a breakdown, and it is difficult for him to concentrate. There is a qualitatively new stress associated with the need to obtain good medical care and, accordingly, costs.
• Defeat. In our competitive society, status is determined by money, not by your contribution to the cause or love for you. In such conditions, the loss of a job or social position can be fatal for a person. Most of us depend on a job that makes us feel competent and useful, so knowing that losing it is just the result of the global economic crisis doesn’t make us feel very good.
• Termination of important relationships. A person experiences grief much like depression, and it can indeed lead to depression. The loss of a relationship means the loss of an important source of love, self-assertion, and comfort.
• Loss of role status. We can lose our status when we stop being a real breadwinner, a sports star, a sex symbol, a mother. Some change is inevitable, but many build their self-esteem on the shaky ground of a particular role and feel frustrated if forced to adjust to the loss of it.
• Other blows to self-esteem. They are very individual: for example, an injury that makes you no longer able to run, or age-related memory problems.
• social stress. Depression can be caused, for example, by severe economic uncertainty or the threat of terrorism.

Vicious circle

Some aspects that come along with depression are very supportive and reinforce other manifestations of it.

• Self preoccupation. If a person is asked to do something in front of a mirror or video camera, this often lowers self-esteem, causes unrealistic expectations about their results, feelings of guilt and inferiority65. In a state of depression, patients often focus on the inner world, they develop a harsh inner critic (see chapter 9), convincing them that everything goes wrong because of them.
• depressive thinking. All studies show that depressed people develop marked differences in the way they think. I will explain this in more detail in Chapter 8.
• Self-destructive and self-sabotaging behavior is a hallmark of depression. Alcohol and drug abuse, procrastination, disorganization, shyness, insecurity, lethargy, passivity — all of these behaviors resonate with the vicious cycle of depression. They feed depressive thinking, feelings of guilt and shame, and seem to remind the person that he is not in control. The consequences of such behavior patterns strongly affect the personality: the sufferer is no longer able to enjoy the benefits that school, training courses, and other opportunities provide. These habits repel mature and full-living people from the patient and attract others who are dysfunctional. Lack of exercise and grooming adds to the problems. I will cover this in detail in Chapter 7.
• Guilt, shame, low self-esteem. A piercing feeling of guilt, inferiority, uselessness or unworthiness of love that cannot be erased, no matter how charming and prone to self-sacrifice you may be. It will not help and assurances that you are loved and not accused of anything.
• Fear of losing control of emotions. A very lively problem for patients, although the professional literature pays little attention to it. It’s the fear that you’re literally going crazy, that you’re having a nervous breakdown and you’re going to be taken to the hospital. The feeling that some nightmarish, irreversible changes are taking place, which have no name. This horror is often the key motivation for suicides, but even the very experience of fear of this kind changes self-perception for a long time — a person may never again experience that naive self-confidence that he once relied on so much.
• Impairment in most aspects of life. Due to depression, we think less effectively, it is difficult for us to concentrate, make decisions, remember and absorb new information. All of these can have lasting consequences, sometimes referred to as «collateral damage». During a period of depression, a person makes decisions that can destroy his future: drop out of school, get addicted to drugs, break or ruin good relationships. Because of the damage done to social skills, you can lose loved ones. Children with depression experience learning difficulties and may have serious problems at school, which then take a long time to manifest themselves. They also suffer socially — they become objects of aggression, it is difficult for them to make friends. Damage to self-esteem can last a lifetime. “The fact that a depressed person feels terrible is bad in itself, but even worse is that depression can ruin his life”66. Some of these cognitive impairments may persist even after successful treatment and require a specific rehabilitation program.
• Persistently dysfunctional social circle. By pushing away those who expect a lot from you, you risk staying with people who support your depression. At worst, you can slip into roles that require self-sacrifice, hard resigned work, where you need to take care of others, being content with the smallest piece of the pie. When the patient begins to recover, he finds that everyone around him takes advantage of his condition. So, the mother of four children never showed her depression and eventually locked herself in the garage, trying to poison herself with gas. When she returned home from the hospital, she saw that her husband and children wanted to see her in the role of a housewife, lonely pulling a strap, tirelessly working in the kitchen and around the house. When she tried to get a part-time job, she had to listen for a long time about the inconvenience she caused to everyone. The woman tried to explain her feelings to the family, but no one wanted to listen to her.
• Acceptance of the «role of the patient». This sociological concept is that because a person is ill, he temporarily «off the hook» and ceases to accept his share of responsibility. If depression is long enough, both the patient and those around him stop expecting mature behavior and responsibility. Within the family, there may be a name for this — a nervous breakdown, fragility, weakness. I don’t know if there is anything worse in the world than this kind of pity, but sometimes people who have been depressed for a long time decide that this is the best they can hope for.
• Physiological symptoms. My patients have chronic physical or disease states bordering on recognized diseases (see Chapter 11). Years of stress, lethargy and insomnia lead to the fact that depression begins to really affect the brain, endocrine and immune systems. It does shorten life and increase the risk of other health problems: patients with depression go to the doctor more, have more surgeries, have more non-psychiatric emergency calls than others in general.
• Neurochemical changes. We have already talked about the effect of depression on the brain. These changes are a very powerful factor in the vicious cycle and are probably the ones that cause sleep disturbances, an inability to feel good, low self-esteem, and obsessive negative thought patterns in the first place.
• Somatic changes. With depression, we expect certain health problems: that is why they are asked about when visiting a psychotherapist. First of all, these are sleep disorders. Studies have shown that REM sleep patterns are different from the norm when depressed, and if a person cannot sleep well, it is extremely demoralizing. There is a violation of appetite both in one direction and in the other. Interest in sex is often lost, problems with libido appear. All these symptoms exacerbate the patient’s sense of loss of control over the situation: something is happening to him, but he does not understand what it is.
• Discrimination and stigmatization. People are ashamed of depression, and our attempts to change society’s attitude towards it have largely been in vain, so shame is approved. Depression is not only biochemistry, genetics, wrong thinking and self-destructive behavior. This is also the result of how society treats the sick. Sometimes you have to explain to the patient that he is being discriminated against: they require additional payment for insurance for “mental illness”, they are not invited to social events. If the therapist does not acknowledge the stigmatization and discrimination felt by his patient, he is essentially saying that the patient is just making it up.

I was not the first to draw attention to the cyclical nature of depression. Observers describe a variety of aspects: very often the behavior of the sufferer has negative consequences that only worsen his situation. As soon as a person crosses the threshold of a depressive cycle, the door slams behind us. It is no longer possible to return to a healthy state by a simple effort of the will, because the patient is trapped in a constantly repeating process — in a vicious circle, which itself creates the conditions that support it. The method of seeking love repels her; the method of achieving success guarantees failure. The sufferer himself generates disappointment, rejection, low self-esteem and experiences that increase his sense of hopelessness. These “skills” of depression become “default” paths in the brain, and since the patient looks at the world exclusively through the prism of depression, he sees no way out.

Trauma, stress and depression

My model helps explain the current epidemic of depression. Like all epidemics, it is only accelerating, but not because each patient infects two or three people. Rather, the point is that more and more people are becoming vulnerable, in part because childhood experiences prevent the development of an adult self. Then they have to face the stressful, complex world of adults to which they are not adapted. Let me explain this in more detail.

After nearly a century of Freud’s exclusively mind-centered domination of psychiatry, the Vietnam War reminded us that there is also a brain. Soldiers returned with symptoms that would become known as post-traumatic stress syndrome (PTSD): nightmares, images of the past so vivid that one feels as if one is on a battlefield; avoidance of everything related to this experience; risk of violent behavior; hypervigilance; dissociation. We now understand that these symptoms are, at least in part, due to the tremendous physical trauma inflicted on the brain by emotions. With any injury, when a person suddenly feels fear for his life or a loved one, the brain releases an excess of cortisol (a stress hormone, a kind of element of the “fight or flight” reaction). Normally, after the stimulus stops, stress hormones stop being released, but if we continue to experience fear and see images of the past, excess cortisol can damage the hippocampus, part of the short-term memory system. It temporarily stores memories of events about two weeks ago, which are then woven into our story about ourselves. If there is a lot of cortisol in the hippocampus, memories of emotional events are extremely vivid — for example, we remember exactly where we were on September 11, 2001. Excess cortisol short-circuits the hippocampus, interfering with the process of weaving recent memories and sending them to long-term storage. Therefore, a person suffering from PTSD does not remember the traumatic experience, but relives it again. It’s like the difference between remembering and dreaming: when I remember something, I know I’m in the present and I’m just looking back into the past. But when I dream, my only «I» is in the dream. With PTSD, a person has waking nightmares, and it is not surprising that he develops hyper-alertness: he sleeps with a landing knife under his pillow, and his wife is afraid of him.

But for PTSD, you don’t have to have combat experience: any situation in which you feel terrified and fear for your life is enough. The longer the experience lasts, the more likely the reaction is. Today, the incidence of post-traumatic stress disorder in the US is 5% of men and 10% of women. The higher prevalence among women is because the victimization and helplessness that accompanies rape and harassment can tip the scales towards PTSD instead of the normal stress response. However, there is undoubtedly a continuum here: there are many cases of «moderate» PTSD that does not meet formal diagnostic criteria, but can make life unhappy. Rape, harassment, battering, victimization, and helplessness easily lead to traumatic reactions. These, in turn, bring us to the next topic, chronic stress and complex PTSD.

Judith Herman, in her classic book Trauma and Recovery, opens the eyes of clinicians to the fact that the effects of exposure to prolonged, repeated violence and total control, which she calls complex PTSD, are in many ways worse than simple PTSD. She draws attention to the fact that the experience of a battered wife or a child being abused is not so different from the experience of prisoners of war: they learn helplessness, hopelessness, live in constant fear, receive brain damage associated with physical or sexual violence. Given all the data I know about domestic violence and child abuse, I’m giving a conservative estimate: about 30% of Americans suffer from complex PTSD. As I said before, most of my patients, even those from “good families,” report situations that border on violence and abandonment. This is not necessarily beating or sexual aggression. Abuse can be emotional: child abuse and sadism, petty control, expectation of perfection, yelling, insults, shaming, humiliation, demands to walk the line just to show who is in charge, intimidation or humiliation for the sake of sadistic pleasure … And the next day, the parent behaves as if nothing had happened, or arranges thoughtful emotional scenes: in tears, he asks for forgiveness, shifting his problems to the frightened child. However, most adult patients are shocked to learn that such childhood experiences are comparable to violence. Children understand that they were treated wrong, they feel the alienation of their parents, but depression makes them believe that it was not their parents who were cruel to them, but they themselves were to blame for something. Remember Robert from Chapter 1: if a person is treated like dirt for a long time, he begins to feel like dirt.

Renowned neuroscientist Alan Shor has done a great job of showing the connection between childhood experiences, child brain development, and adult mental health. Shore was able to understand and explain many of the independent observations that troubled psychotherapists. In particular, why most adult survivors of childhood abuse or severe early attachment disorders are stricken with borderline personality disorder. Why many adults who had cold or emotionally closed caregivers as children suffer from addictions. Why a significant proportion of victims of sexual abuse at a tender age now have autoimmune disorders. Since this was only sporadic evidence, responsible psychotherapists have refrained from hypothesizing that child abuse causes borderline personality disorder or autoimmune diseases, or that parental rejection is directly related to alcohol and drug abuse. Shor, having an encyclopedic knowledge of literature in various fields, was able to substantiate the mechanism of these causal relationships. His conclusion is that childhood experiences—not just trauma or neglect, but simply a bad relationship between parent and child—lead to damage to the structure of the brain itself. These damages, in turn, lead to decreased ability to experience and control emotions, an unstable self-concept, damage to the immune system, difficulty forming relationships, decreased ability to focus, concentrate and learn, impaired self-control and other problems.

When I talk about these findings in my talks, many listeners react with skepticism: “You mean that everything that happens in childhood can cause damage in the brain that persists into adulthood? Does it affect our relationships, our health, our ability to think?” It may not be worth using the overly provocative term “brain damage”, but I want to draw the attention of readers. Childhood experiences certainly affect the brain physically. Everything we think about, feel and remember is somewhere in its structures. The brain contains our experience. If childhood was filled with bad impressions, it leaves scars in him. Of course, if they weren’t there, it would be pretty easy to stop the self-destructive behavior when it was pointed out to us. But instead, one has to find a way to reverse, heal, or grow new neural circuits to heal those old wounds.