1. INTRODUCTION
Statistics point out that approximately one out of every six people will have a depression (with varying
degrees of seriousness) at least once in their lifetimes. The magnitude of this number is all the more
shocking if one confronts it with the general ignorance about the problem. Even people
well-informed about other health issues will often be caught totally by surprise by a depression.
I know, I was one of them. Since our early school years we get tons of information about healthy
eating, on the perils of smoking and heavy drinking, on avoiding sunburn, etc, etc. But mental
health, largely because of the prejudice surrounding any kind of mental illness, is to a large
extent ignored. This is more of a tragedy if one realises how far-reaching are the implications
for a person's life and productivity, and most importantly, how depression could be avoided altogether
if only people knew how to recognise the early symptoms.
First of all, forget purely psychological explanations of the illness. Clinical depression is a physical
illness which so happens to affect the brain. In this respect, it is fundamentally different from momentary
bouts of the blues or melancholy. As you read through this document, please always bare in mind that
whenever I mention "depression", I am specifically referring to the physical illness more properly
described as "clinical depression". One also finds the very same word "depression" used
in the context of other mental disorders (such as manic-depression[11]) of which I will
not speak. It is very important to keep this distinction in mind. As an example,
consider the people who suffer from bouts of melancholy all through their lives. They often describe
their subjective feeling as that of being "depressed". However, when one takes a closer look
at more objective indicators, they do not show the symptoms of a clinical depression. This document
does not apply to them.
There are many reasons why the psychology myth still lingers. At the core, this myth probably stems
from the ghost in the shell view of human cognition [1]. Since many
people still believe that there is an immaterial soul separate from the physical body, the thought that
the soul can be affected by a physical illness clashes violently with their worldview.
One of the enduring myths about clinical depression is that you can suddenly lift it up
simply by convincing a depressed person that life is good and worth living.
Likewise, a depressed person will not be magically cured if all their problems are suddenly solved. In fact,
it was my experience (and that of many others) that the factors which contributed to the depression
were long past and resolved. But they had their physical toll in the brain, and that could not be
suddenly undone.
Our use of language compounds the problem. All too often will a perfectly healthy person (brain-wise,
of course) say that they feel depressed, when all they have is a momentary case of the blues. It is
far from my intention to dictate how people should use language, but this example illustrates my case.
Curiously, one of the tell-tale symptoms of a depression is an inability to have strong
emotions, including sadness and the blues.
Another important aspect to retain about depression is that it is not an on/off condition.
There is a continuum between a perfectly healthy brain and one from a severely depressed
person. My estimate is that in a modern society, those who could be classified as
perfectly healthy are a minority. Moreover, just like physical fitness goes through
ups and downs throughout a lifetime, the brain health of a typical individual will
also fluctuate. It is only when the fluctuation deeps significantly low for an extended
period that the diagnosis of a depression is typically made. Elaborating further on this
note, the good news is that a very large number of people who strictly speaking are not
depressed and have largely satisfactory lives, could still feel better and happier if they
took better care of their brains. The advice herein contained is also for them.
At this point you might be wondering about my qualifications for providing what could be
considered medical advice. You are very right in questioning anything you find on the Internet,
even more so should health be the subject. The information contained in this document stems
largely from the counselling and the discussions I had with the professionals who treated me.
As far as I am aware, both the model explaining depression and the description of my recovery
treatment represent the current state-of-the-art.
Furthermore, I tried as much as possible to separate between what is largely consensual
among the medical community, and what is controversial or just speculation.
Read the text carefully: you will see that conjectures are clearly indicated as such.
However, and I cannot stress this enough, if you have a depression you should be
treated by a professional anyway. You will encounter this advice several times
in this document. Do not read it simply as a disclaimer. If I could choose the one thing
that people should remember from this document, it would be the importance of being
treated by a competent professional. And by competent, I do mean competent.
In many countries, depressions are sometimes handled by GPs or even psychologists.
In my experience, many are not properly qualified. Try to find a good clinical psychiatrist instead.
Remember that you are putting your health and well-being in their hands.
You may raise the question of why have I bothered to write such a lengthy description of
depression if I advise people to seek professional help anyway. In a sense, you are asking
for a rationale for this document. Well, I would not have written it if I thought
it was irrelevant, dangerous, or simply superfluous. Quite on the contrary: I see
good reasons that justify it, as follows.
- The focus of the document is an objective description of clinical depression, explaining
the physical illness which progressively takes it toll on the brain. If more people were
aware of this fact, they would not be as complacent when the first symptoms appear. Moreover,
they would feel less stigmatised and reluctant about seeking professional help.
- By being better informed, people would realise the importance of seeking competent
help. Many GPs and even psychologists are not properly informed about depression, and they can
even inadvertently give their patients plenty of bad advice. Worst of all, the situation can
worsen dramatically before the patient even realises what is wrong with the advise they are being told.
This happens frequently, believe it or not. The only solution is for people to be better
informed and able to spot whether or not their GP is competent enough to treat them.
- The enormous cost of health care in affluent societies often translates into health insurers
pressuring for the cheaper solution of relying solely on antidepressants. In countries where
the GP stands as the "gate-keeper" for specialised treatment, people may find it difficult
to convince their GP to send them to a specialist. The result is treatment based largely on
medication, with little or no coaching.
- Lifestyle plays a large role in the development of depression. Again, by better understanding
the problem from an objective perspective, people will more easily assimilate the need to take
good care of their sleep and to avoid overloading their brains.
The remainder of this instalment is structured as follows. I will begin by explaining what
exactly is a depression and how the problem develops in the first place. Special attention
will be given to a description of the most typical symptoms which accompany each stage of
the illness. The next step is more personal: it describes the lifestyle changes I had to
take to make my brain recover instead of sinking deeper into the illness.
The resulting table of contents is printed below.
- Part I
- 1. Introduction
- 2. What is Depression?
- 2.1. Normal Neuron Communication: the Role of Serotonin
- 2.2. The Stress System: Adrenaline and Cortisol
- 2.3. The Buildup to a Depression
- 3. Giving your Brain a Chance: a Personal Tale
- 3.1. General Lifestyle Advice
- 3.2. Daily Routine
- 3.3. Tips for Good Sleep
- 4. The Recovery Process
- 5. Conclusion
The next instalment will cover a range of miscellaneous topics concerning depression:
- Part II
- 1. The Controversy about Antidepressants
- 2. Suicide
- 3. The Role of Sports
- 4. Depression and Ageing
- 5. The Genetic Link
- 6. Is Depression on the Rise?
- 7. Quantifying Depression
- 8. The Burnout Syndrome
- 9. Happiness
- 10. Facing the Prejudice
2. WHAT IS DEPRESSION?
If I were asked to come up with an alternative wording for what we call depression, I would
say it's a problem of chronic brain overload. The key is to understand that the brain---just
like all the other organs in the body---has a limited processing capacity, and if you
constantly exceed it, disease will ensue.
Consider the liver. Most people know that alcohol is broken up by this organ. It is also
known that even a healthy liver has a limited throughput measured by the amount of alcohol
it can process by unit of time. Should a person constantly overflood their liver with
alcohol, as typically happens with alcoholics, the organ has very little chance of recovering
from the abuse. Over the course of many years, disease such as cirrhosis is likely to develop [2].
Similar examples could be given for the kidneys, the gall-bladder, and many other organs
in the body. Occasional excess (particularly if you are young) is well tolerated, as long
as there is enough of a rest period for the organ to recover. The brain is no different.
So, what does the brain process? In short, information. Our cognitive functions are realised
by the neurons in the brain, which communicate with each other by means of neurotransmitters.
When you perform a task that requires concentration, this requires heavy processing by the
neurons in some specific parts of the brain, forcing them to dispense their precious supplies
of neurotransmitters to get the job done. And what happens when that supply runs out?
Well, evolution has provided us with a system which can compensate in case of an emergency.
This is the stress system, and its constant abuse is what leads to a depression.
Note: I will not elaborate into what is actually happening
and in which parts of the brain. Rather, I will simply present a model which abstracts
from the physical details. Neuroscientists are likely to disapprove of the simplifications,
especially concerning the myriad of other involved neurotransmitters which I will not mention.
However, I personally think that it is still a valid model for the purpose of understanding
the behavioural patterns which cause the illness. For a detailed description of the physiology
of depression, the reader is referred to [3].
2.1. Normal Neuron Communication: the Role of Serotonin
Communication between neurons relies on molecules called neurotransmitters. Without
going into the details of this process, it suffices to say that for a neuron to transmit
information to another neuron, it must release a neurotransmitter in the small gap between
the two neurons, called a synapse.
More than 300 different neurotransmitters are known to be used in one role or another
by the human brain. One of them in particular, serotonin, has
been identified as playing a major part in the physiology of clinical depression.
Depression affects the area of the brain responsible among others for memory, learning,
and tasks that require concentration and organisation [3]. When the neurons in this area
are using it, you typically feel good and restful. In this sense, one can say that
reliance on serotonin is the hallmark of a healthy brain.
Given that serotonin must be released into the synapse in order for communication to occur,
one can imagine that neurons might spend it at a higher rate than they are able to
produce it. This does indeed occur, and sleep plays a vital role in
replenishing the supply of serotonin. It is also the reason why towards the end of a
hard day's work we do feel more tired and sleepy. In a sense, it is your brain warning
you that it is time to stop.
It is fundamental to realise that different activities will exhaust your supply of serotonin
at different rates. High concentration activities, such as reading, writing, or engaging
in intense conversation, are very demanding on the brain. Likewise are activities where
learning a new task is involved, or which require planning and organisation. On the other
hand, watching some silly things on television is a lot less demanding, while sitting in the park
watching the flight of birds is not demanding at all.
It is now time to bring psychology into the picture. You might have been
wandering if my description of depression would be a purely mechanical one, without any role
for psychology whatsoever. In my experience, psychology (as far as depression is concerned!)
is overrated, but that does not mean that it is irrelevant. In the above example,
psychology is important when another variable is included: your attitude towards the activity
plays a large role in the rates at which serotonin is spent and replenished. Basically,
performing an activity with pleasure will be much less demanding than otherwise.
This is an important factor in the so-called burnout syndrome, one of the
primary causes of depression, and one which I will address in Section 8 of the second
instalment of this series.
Crucial to my goal of demystifying depression is being able to visualise the problem.
Being a scientist, I found that charts and graphs helped a lot in my understanding,
and I reckon that even those averse to anything vaguely reminiscent of mathematics
will probably benefit from seeing a few pictures illustrating the text. I will do
my best to overcome the limitations of ASCII art, but bear in mind that these graphs
are much more intelligible when you can show them in colour.
Figure 1 shows the progression of an individual's maximum normal capacity
(in effect how large is the supply of serotonin), and the actual used capacity
(how much serotonin is effectively used), during the course of an extended period.
Notice that there moments when the demand is higher, perhaps because of extra
work, but that the maximum capacity was never breached.
^
|
|========================================
|
_________
| ___________/
\___________
|______/
|
|
|
|
|
|
|
----------------------------------------->
Figure 1: The double line "=" at the top indicates the maximum normal capacity
of a healthy individual. The single line "-" below represents the actual used capacity. Note
how the maximum normal capacity was never exceeded.
2.2. The Stress System: Adrenaline and Cortisol
What would happen if the used capacity in Figure 1 were to approach the maximum limit?
Obviously your brain would not just shut down. When this happens, evolution has provided
us with an emergency mechanism which can compensate for the lack of serotonin: the stress system.
The stress system relies on two key hormones: adrenaline and cortisol.
In short, adrenaline works in the short term, while cortisol has large momentum and works
in the long term. (Adrenaline is also known as epinephrine in North America.
To be exact, the terms noradrenaline and norepinephrine are used to refer
specifically to the neurotransmitter as opposed to the hormone, since they are different molecules.
Moreover, there are many other neurotransmitters involved: check reference [3] for details.
The purists will excuse my exclusive use of the word adrenaline throughout the text).
It is important to realise that the stress system can also be activated if your brain
perceives danger or any kind of threat. In the first stage, this triggers the release
of adrenaline into the bloodstream to prepare the body for action. As a result,
your heart beats faster, you begin to sweat, your breath becomes shallower, and your
senses become more acute [4].
This is the so-called fight or flight response to the stressor event, and
was quite adequate during most of our evolution, when these events were quite
specific and usually short-term: escaping from a lion, chasing away a rival gang, or
facing up to the impudent adolescent trying to woo your mate [5]. Problems with
chronic stress arise because in a modern society we cannot escape easily from the stressor,
be it an overbearing boss, crowded cities, or traffic jams. Furthermore, no matter
how hard we try to delude ourselves with the pretence of civilisation, at heart we
are still primates, and consequently, factors such as social status also play an important
role as sources of stress. Moreover, primates have evolved the capacity to stress up the
body in anticipation of a possible danger [3]. Again, this was
an advantageous adaptation in the context where it evolved, but nothing but trouble for
the modern human.
The effect of the stress hormones on the brain is curious and not what you might expect.
The initial surge of adrenaline will make you feel good, though not quite in the same
way as with serotonin. The difference is that adrenaline will make you feel euphoric and
accelerated, whereas serotonin produces a state which could be described as that of quiet bliss.
However, as far as the communication between neurons is concerned, adrenaline can compensate
for low levels of serotonin. There is, alas, a serious drawback of adrenaline: together
with it comes cortisol, the yang of the stress hormones.
Just as your levels of adrenaline start coming down, so rises the amount of cortisol flowing
through your veins. Moreover, cortisol has a much larger momentum than adrenaline, which
means that even though it builds up slowly, it also takes a long time to go back to normal.
And should you constantly be engaging in activities which require adrenaline, so will your
levels of cortisol slowly increase. In a sense, you can think of cortisol as a measure of
the weighted average of your recent levels of adrenaline. I have tried to capture this
feature in Figure 2.
^
| @@@@@@
@@@@@@@
| @
@
@
| @
@
@
| @
@
@
| @
@
@
| @
@
@
| @
@
@
####
| @
############
@##########
| @ ###########
@ ###########
| @#########
@@@@@@@@@@@@@@@@@@@
------------------------------------------------------------>
Figure 2: The interplay between adrenaline ("@") and cortisol ("#").
Together with the rise of cortisol and the decrease of adrenaline, come the nasty side-effects
of the stress hormones. It is at this moment that you feel bad, anxious, and
having lots of negative thoughts. And this is perhaps one of the critical features
of stress which flies against common sense: you only feel its bad aspects
when your body is stressing down and progressing towards a more relaxed state.
When you are building up on adrenaline, in effect stressing up, you might
even be feeling good! This explains what is popularly known as the adrenaline rush
and the consequent adrenaline crash.
Having too much cortisol flowing through your veins has another nasty side-effect:
the recovery time from any adrenaline surge increases. In a sense, the relation
between adrenaline and cortisol goes both ways: the adrenaline curve influences
the cortisol curve, and vice-versa. Figure 3 tries to capture this reaction effect
by showing the adrenaline response curve for three individuals subjected to the
same physical exercise. Notice how the more serious the depression (which translates
into higher levels of cortisol, as you will soon understand), the longer it
takes for the body to go back to normal.
^
^
^
|
|
|
| @@@
|
@@@
|
@@@
| @ @
|
@ @@
| @
@@@
| @ @
|
@ @
| @
@@@
| @ @
|
@ @@
| @
@@@
| @ @
| @
@
| @
@@@
| @
@ | @
@@
|@
@@@
| @
@ |@
@ |
|@
@ |
|
---------------------> ----------------------->
--------------------------->
Healthy
Mild
Severe
Figure 3: The adrenaline response curve for respectively: a healthy individual,
a mildly depressed, and a more seriously depressed one.
Now, a healthy brain will never require too much adrenaline, even in emergency situations,
and therefore the occasional crashes will be too minute to be noticed. A healthy person
will therefore hardly feel stressed, if ever. Moreover, since the measure of how good
you feel is related to the total amount of neurotransmitters available, a healthy brain
with plenty of serotonin will feel ecstatic if adrenaline is added to the
mixture. This can be achieved with aerobic exercise, and explains what is commonly
known as the runner's high. In a sense, it is as if the brain were overflooded
with neurotransmitters. (A depressed person will not experience the runner's high.
In fact, they should be extremely careful with exercise, as I will explain later in more
detail).
To complete the picture of how chronic stress causes depression, there remains one critical
factor to be explained: high-levels of stress hormones will over time diminish your brain's
ability to produce serotonin. Looking at Figure 4, you can see that chronic stress will
diminish your maximum normal capacity. The exact mechanism by which this happens is still
subject to discussion, but the general consensus is that sleep is the key. The reason is
that higher levels of stress hormones mean less sleep, which is fundamental for the brain
to restore its ability to produce serotonin.
On the speculation front, recent findings have implicated neuron death as the physical
underpinning of depression. Furthermore, it seems that the opposite process, termed
neurogenesis, is crucial for the recovery, and happens naturally in healthy individuals [3,6].
Furthermore, evidence indicates that sleep is fundamental for neurogenesis to take place.
If indeed so, then depression would arise because elevated stress levels cause people to sleep less,
which then leads the brain to fall behind on its natural regenerative processes.
^
|
_________
|
_______/
|
/
|======================
| ______/
========
|_______/
==========
|
|
|
|
|
|
@@@@@@@@@@@
|
@@@@@@@@
------------------------------------------->
Figure 4: Whenever the energy requirements ("-") go over the maximum normal
capacity ("="), the body compensates by resorting to the stress system (here represented by adrenaline "@").
The problem is that the stress hormones have a negative effect on the maximum capacity.
2.3. The Buildup to a Depression
At this stage you are in possession of all the ingredients necessary to understand how
depression develops. The negative effect of the stress hormones on the maximum normal
capacity is the key to comprehend the buildup process that makes a depression
feed on itself, like a positive feedback mechanism.
Let us go back to Figure 4. Imagine that you would chronically go over your limits,
thus forcing your body to constantly rely on the stress hormones to compensate for
the lack of serotonin. On the long term, your maximum capacity would therefore be
reduced, making it much more likely that you would have to resort to the stress
system to compensate. And thus the feedback begins: your maximum capacity is diminished,
forcing you to use the stress system all the time; and because of all the stress
hormones flowing through your veins, your brain has no chance of recovering, and
your maximum capacity diminishes even further.
This may sound very mechanical, but I would say that it is the key element
that leads to the development of a full-blown clinical depression.
Alas, it is also something that most doctors fail to realise. And if you are still
clinging to "psychological" notions about the illness, it is time you put them
into perspective. Psychology plays a role in the factors that lead to the initial
dip of your work capacity, but after a certain stage the problem just feeds on itself,
and it is crucial to understand that to avoid falling prey of this downward spiral.
Even though the graphs might give the impression that this is a phenomenon that
happens very quickly, in reality the process typically takes many years to
develop. Moreover, the progressive increase of the levels of stress hormones
in your body provide a very good advance warning, if only you know how to read them.
I will now provide a basic description of what to expect (and what to do!) at
each stage of the process. Beware that different people have different symptoms,
so your mileage may vary.
-
In the very early stages, a depression will not feel like a depression at all.
The small amounts of stress hormones could in theory be measured---your blood
pressure would be slightly higher than otherwise---but in practise it would
be difficult "to extract the signal from the noise". Subjectively, you might
feel a bit down and tired, especially during those periods when you are crashing
down from the adrenaline, but most people would still not say that they
feel depressed. Also, you would start sleeping a bit less than usual, and
not feeling quite as fresh when you wake up.
The problem is not very serious yet, and I think that most people could
recover on their own if they were to simply take a long holiday and to
make sure that they sleep well. There is some evidence that if done properly
moderate amounts of aerobic exercise might help at this stage. However,
be sure to read Section 3 of Part II before you decide to embark on any
exercise routine. In fact, I would rather advise people not to begin exercising
than to risk having them over do it and making their condition worse.
I know this flies against some commonly held beliefs, but sports alone
can worsen a depression. If you do not believe now, read carefully both
instalments of this document and you might understand what I mean.
-
As the amount of stress hormones increases, you will start feeling some of their
nasty side-effects. This is largely person-dependent, but most people start
having problems with their digestive system, headaches, and having more frequent
nightmares. Since stress depresses the immune system, people also tend to fall
sick with infections more often [7]. Only a minority of people suffer from sleep
paralysis [8], but it is also a good indicator of elevated stress hormones.
An objective measure such as blood pressure should be controlled: it will definitely
be higher than normal, and a good doctor would not fail to recognise it. At this
stage you are very clearly sleeping less than normal, waking up early in the morning,
feeling tired and "lazy" about getting up. Subjectively, you should notice that you
do not feel things quite as intensively as you used to: you feel empty, morose, and
definitely "depressed" most of the time. Other subjective indicators include loss
of appetite and sex-drive, feelings of guilt, lowered self-esteem, and detachment
from hobbies or friends [9].
At this stage you should not be complacent about the problem. The best thing
you can do is to go see your doctor. Take also into consideration that you
have been putting too much pressure on your brain. Really do give it a rest: take
a long holiday, make sure you sleep well, and be careful not to get any extra
responsibilities. Antidepressants are very effective at this stage, especially
if combined with minor lifestyle changes. (And yet another reason why
you should see your doctor!)
-
As the buildup towards a depression continues, you get to the point
where it is impossible not to notice that there is something definitely wrong.
At this point, most people start having serious problems with anxiety, stress,
panic attacks, hyperventilation, bouts of psychosis, etc. Your sleep will
definitely be a mess, your blood pressure will be high, and your ability to
focus at work seriously compromised.
If should definitely seek professional help at this stage.
In particular, do not make the assumption that your GP will be qualified to
treat you. They may, or they may not. Unfortunately, many doctors still
do not quite understand what is going on. My experience in this area was
quite bad: I spent more than one year jumping from doctor to doctor,
with the problem constantly aggravating, and getting all kinds of bad
advice. In short, you need to stop. Your maximum
capacity will probably be so low that you cannot even work full time.
Also, specifically ask your doctor for antidepressants. In the country where
I live, the Netherlands, this is bit of a taboo subject, so depending on where
you live, you might need to convince your doctor not to be stingy and stubborn.
Should they suggest that you start exercising, just ignore that advice.
It is a very good indicator that they do not have a clue of what is going on.
Also, you will need to make changes to your lifestyle. Section 3 describes
my personal experience in that regard.
-
In the last stages, the maximum capacity is practically nil, and the level of
stress hormones so high that people cease to be able to function. The stage
of a clinical depression is very difficult to describe in words, but I will
do my best. The anxiety transforms itself into a "fire" which constantly
burns inside your head; you will feel desperate, much more than you ever
felt in your life, as if you could never be happy again; and you will definitely
be suicidal, to the point of actually planning suicide or even attempting it
(with success in many cases, tragically). During this stage, people can
barely sleep, if at all.
To an outsider, the fact that a clinically depressed person is pretty much
confined to bed is often misinterpreted. People often think that a clinical
depression is a simply a state of apathy. Quite on the contrary: remember
that the blood pressure and heart rate of a depressed person are extremely
high. Rather than apathy, depression is an overwhelming fire which will not
subside and burns you from the inside.
Unfortunately, it is only at this stage that many people finally concede
that they need professional help to treat them. Needless to say, you will
need to make drastic changes to your lifestyle if you want to recover.
You should also be very patient: it will take a long time before things go
back to normal.
Most important of all, a clinical psychiatrist is the proper
specialist to accompany you during this period.
^
|
|
|
@@@@@
|
@@@@@
|=====
@@@@@
| =====
@@@@@
| =====
@@@@@
|
=====
| @@@@@
=====
| @@@@@
=====
|@@@@@
=====
|
=====
|
=====
------------------------------------------------>
Figure 5: The buildup towards a full-blown depression: as the levels of adrenaline rise,
the maximum capacity diminishes, forcing the body to rely increasingly more on adrenaline, thus beginning
a downwards spiral.
3. GIVING YOUR BRAIN A CHANCE: A PERSONAL TALE
I saw "Sideways" a few weeks ago. If you have not seen it yet, give it a try: it is a good film
and tells an interesting story. For the purpose of this discussion, the relevance comes from
the fact that one of the main characters had been chronically depressed for a few years. While
watching the film I could not help but to think that he would probably continue depressed for
many more years (happy ending notwithstanding), since depression-wise his lifestyle was appalling!
The point of this digression is that plenty of people with depression are not being properly
treated. Antidepressants revolutionised medicine's approach to the treatment of depression,
and even though they are generally effective and an indispensable tool, sole reliance on drugs
neglects valuable lifestyle advice. This is an especially important consideration for the
more severe depressions, where drugs alone may not suffice to bring the illness into remission.
In the following sections I will describe the lifestyle changes I had to follow to recover
from my depression. Before you proceed, take heed of two very important observations:
- You must be mad if you are relying on the Internet as a substitute for a doctor.
If you have a depression you should be treated by a specialist! Only they
will be able to provide you with the coaching most appropriate for your case.
- The advice was meant for people with severe depressions, and is overkill for a mildly
depressed individual. If you had a mild depression in the past, you are therefore likely to
find this guide to be too strict. Concerning mild depressions, you are absolutely right.
In order to recover from a depression, one must first understand the problem. If I have been
successful in carrying my message across, by now you should have understood the critical
aspects: avoiding raising your adrenaline levels, and make sure you sleep well and a lot.
In practise, achieving these goals can be much more difficult than it seems. It takes
some time before a person learns how to properly listen to their bodies; moreover, it
is easy to fall victim of the "adrenaline trap", since people get fooled by
the immediate positive reward (the adrenaline rush), but fail to associate it with the
delayed negative effect (the adrenaline crash).
The following three sections cover the different aspects of the lifestyle changes.
The first category deals with general advise which one should always have present.
It was for me the hardest to assimilate, especially since I had to overthrow some
long held misconceptions about the nature of physical exercise. (And one which
I am sure will raise controversy amongst the audience). The next section deals
with the daily routine. Even though more flexible in nature, I quickly realised
that there were good reasons behind my counsellor's insistence that I followed
its guidelines. At last, the third section focuses on tips for good sleep.
These are by no means specific to a clinical depression, but especially important
for someone with the illness.
3.1. General Lifestyle Advice
These are just the general tips that one should have always present going through the day.
It might take a while to get used to them, but in time they will become second nature. Moreover, remember that
depression is not an on/off condition: this same advice is also useful for healthy people who wish to remain
that way. Obviously, a healthy person does not need to follow them very strictly, but they remain nevertheless
good lifestyle advice.
- Avoid excitement like the plague!
This is perhaps the most important. Excitement means adrenaline, and by now you must have
realised how important it is to cut down on the release of this hormone. Beware that activities
which might make you feel temporarily good are often exciting and laden with adrenaline, and will
thus make you feel worse afterwards!
This particular example also illustrates how plenty of so-called professionals will often be
totally clueless about depression and likely to provide their patients with bad advice.
I refer in particular to many naive psychologists who base their counselling on platitudes
such as "you must do whatever makes you feel good" (obviously reminiscent of
the myth of psychology). It is true that pleasure is very important, and finding activities
which make you feel good is fundamental. However, care should be taken
that this subjective feeling good is not caused simply by an adrenaline rush. A good
professional will be able to tell the difference, and with time so will you.
- Do not hurry
Hurry means adrenaline: see above example. In practise, it may be difficult to avoid hurrying,
but you can do your best to plan your activities in such a way as minimise the chances of
it happening. If you need to catch a bus or a train, don't do it at the last minute; it
is better to wait five minutes than to rush. Switch off the telephone: it avoids running towards it;
make use of voice-mail instead. Also, do not be afraid to let the world turn without you for a while!
- Beware of sports
This was probably the hardest one for me to understand. Sports made me feel good, and I thought
I could "sport my way" out of the depression. Now I know better. The problem is that sports
do indeed give you an immediate good feeling, and we interpret this short-term positive response
as if sports improved the depression. However, that good feeling is caused mainly by adrenaline,
which is just an illusion. Moreover, since the crashing down can take a long time, people fail
to associate that delayed negative response with the physical activity they had some days before.
And thus the myth endures. (There are however circumstances in which sports can indeed help
with depression. Please read Section 3 of Part II for details).
- Listen to your body, not to your brain
The rationale is of course that adrenaline can make your brain feel good, even as it revs up the body.
In practise, most people have difficulties in learning to read what their bodies are telling them:
in the first stage, help from a good physiotherapist might be required.
- Rest after every activity
Rest is important for the adrenaline levels to come down.
However, remember that it is when your body is stressing down that you feel the nasty side effects of stress.
Therefore, in the early stages it will be very difficult to rest: in serious cases, people will have
such anxiety crises that they will want to devour their own flesh. In spite of this, you must resist
the temptation to get up and do sports or physical activity! The withdrawal symptoms are very tough to
endure, but you must go through this stage if you are to cleanse your body from all the adrenaline.
Thankfully, after this critical initial stage you will not have anxiety crises anymore when you start resting.
In any case, do make sure that you rest a few times during the day, especially after lunch (the good old siesta),
and after any physical activity.
If you are thinking that the kind of language I am using is reminiscent of that used to refer to drug
addiction, then you are right on spot. Adrenaline might be a natural drug produced by the brain,
but the effects of its excessive use are not unlike those of cocaine or heroin. I cannot make
more precise comparisons, but perhaps someone in the audience who has the experience of both
depression and drug addiction will be kind enough to report on the similarities/differences.
- Do not perform multiple activities simultaneously
Be especially aware that your whole life you might have been doing this, so it will take time
before you realise all the parallel tasks that you have been imposing on your brain! A few examples
to get you started: listening to music while doing housework, having a television on in the background,
and reading the newspaper while having breakfast.
Multitasking is very demanding on the brain. Do not think that since you are doing two things
simultaneously, you will be finished quicker and therefore stress your brain a bit less.
Quite on the contrary. Consider E(a), E(b), E(a+b) to be respectively the amount of
effort required to perform activities a, b, and a plus b simultaneously.
Bear in mind that E(a+b) > E(a) + E(b).
- Practise relaxation exercises
Yes, I am referring to stuff like meditation and yoga. They actually work, despite all
the silly new-age nonsense that surrounds them. If you cannot stand the airy-fairy aspects,
try to find a good expert who does not preach them.
Personally, I found that one of the most relaxing things you can do is to lie in the sunshine.
This might no be an option if it is winter and/or you happen to live in a cold country,
but if you can, do it as much as is safely possible. (But take into account the usual advice
concerning the dangers of catching too much sun, obviously! Like in all things, moderation is the key).
- Make a conscious effort to do things with pleasure
This could take a fair amount of brainwashing, but the idea is that before each activity, no matter
how small, you think I love doing this. For best results, say it loudly. Also, only do
things when you really feel pleasure in doing them, and do them only for as long as that pleasure
remains. Should you lose interest or feel tired, then stop.
- Take appropriate medication
If your gut reaction is that antidepressants are evil, consider informing yourself properly.
The truth is that modern drugs are quite effective and generally safe (I am referring in
particular to SSRIs and more recent classes [10]). They do have side-effects,
but these are usually mild and quite bearable compared with the illness itself. For best
results, have a clinical psychiatrist prescribe them to you: they are generally well informed of the
different side-effects and can choose the drug best suited to your case. Also, remember that
antidepressants usually require around three weeks before they have an effect. Three weeks
are an eternity for someone with a depression, but do not stop taking them just because you
do not see an immediate result.
3.2. Daily Routine
I will now make a brief description of the typical daily routine. This advice assumes that the person
is in a serious condition, but there are still a few good pointers to extract even for mildly depressed
individuals. Also, as the condition improves, one does not need to be as rigorous as in the early stages.
- Take your time to do the morning activities
You surely do not want to rev up your body immediately after waking up! Take your time to get up,
to shower, to get dressed, and to breakfast. If it takes you less than one hour and
a half to perform these activities, then you are doing them too quickly.
- Take a walk in the morning
The idea is to have a qualitative walk. Pay attention to the colours around you,
to the smells, the sounds, the shapes, the people, etc. This will help to diffuse your
thoughts, and to avoid the obsessive thinking that accompanies depression. Also, since
you must limit physical activity, walking every morning is important for your body to
burn excess sugar. Walk for about half an hour, and do not forget: lie down for another
half an hour afterwards! (Remember Figure 3: your body will take longer than usual to
get back to normal).
- Find an activity that gives you pleasure
Remember that depression affects the part of the brain responsible for high concentration
activities, planning, and organisation. For this reason, you must find an activity which does
not demand too much of these abilities. This could prove
difficult, as often people who have depressions are those whose hobbies are concentration-intensive.
Forget reading, writing, and the Internet. What you need is something like gardening,
painting, or bird-watching. Just make sure it is not physically demanding either!
Towards later stages, you will be able to watch some things on television. Just
avoid excitement. In fact, you should probably stay way from cinema altogether,
not to mention the news! Instead, watch some documentaries or silly sitcoms.
- Eat properly and avoid heavy meals
Digestion is also quite demanding on your body, and therefore it is better to have
more meals rather than bigger meals. Also, a depression is really a bad time to
be thinking of diets. Eat well and make sure you get all your nutrients.
Some people also swear by the importance of drinking water regularly during the day.
The rationale is that dehydration is a stressor event, thus triggering the physiological
reaction we aim to avoid.
- Have a siesta
Even if you cannot sleep, it is important that you lie down for a while until your body
is (relatively) rested. We all have a natural dip after lunch, and it is a pity that
in modern societies people have lost the siesta habit.
3.3. Tips for Good Sleep
To conclude, I will present just a few tips on how to get a good night's sleep.
These are especially important during a depression, but again, they also apply
to anyone.
- No activities before going to sleep
You must avoid at all cost any adrenaline coming into your system before sleep time.
Be especially careful of anything exciting or stressful.
Yes, this includes most of television and even reading!
Avoid also any physical exercise before going to sleep. Always
have in mind that a person with a depression will need longer than normal for
the body to recover from any physical effort. Even healthy individuals
should avoid doing sports at least a couple of hours before going to bed.
- Follow a steady sleep routine
Try going to bed always at the same time everyday. We all know how working in shifts
and jet-lag affect sleep: do not emulate them by going to bed at random times each day!
- Give your body time to crash down
You cannot fall asleep while there is too much adrenaline running through your veins.
It can take a while (even hours) before you crash down, and often people lie awake in
bed waiting for sleep to come. The problem is that after a while it is very easy to
start obsessing about not sleeping, which is a sure way of keeping yourself awake.
The idea is to only get ready for sleep once you have crashed down and feel tired.
Before you actually get into bed, just lie there for a while (even with your clothes on),
until you feel rested and tired.
- Go to bed early
There are several reasons why this is a good practise: foremost to be able to wake naturally
rather than with an alarm clock; but also to avoid being out of synch with the solar cycle,
and to give your body time to crash down.
- Make your bedroom your sanctuary
Do not have an office in the same room as where you sleep. Dedicate one room
simply for sleeping, and make it as uncluttered as possible.
4. THE RECOVERY PROCESS
Depending on your age, your general health status, how serious the depression was, and how well the recovery
progresses, it typically takes between two months and two years before you can be fully recovered. Do not despair,
however, because this certainly does not mean that during all this period you will feel as bad as in the beginning.
The first few months are the hardest, but after that things will slowly improve, and little by little you will get
your happiness and normality back. Moreover, remember that you only feel the nasty aspects of a depression
when you go over your limits: you just have to be patient and to realise that your limits will indeed be very
short during an extended period.
In the buildup towards a depression, you probably spent years sleeping less than normal. During the critical
stage of a clinical depression, you probably will not be sleeping much if at all. Since it is during sleep
that the brain recovers, it should not come as a surprise that the huge sleep deficit must be compensated for with
unusual amounts of sleep. This does indeed happen. It can take several weeks or months for the body to crash
down, but when it does, you will feel as tired as you have never felt in your life. And you will start sleeping
like you have not slept since you were a baby: it is not unusual for people to spend several weeks sleeping
10, 12, or even 14 hours a day. Do not fight against it!
Your sleep will slowly go back to normal after this period. However, during the entire recovery you will
still sleep a bit more than the proverbial 7-8 hours. Again, it is crucial that you do not fight against
it. Furthermore, try as much as possible not to cut your sleep short: it is better to wake up naturally
rather than with an alarm clock. It is mainly for this reason that I strongly suggest that you go to
bed early every night.
Figure 6 shows how the recovery should progress as far as your maximum capacity is concerned: from an
initial state of practically nought, it will slowly start increasing. Also notice that the amount of
activity that you perform during the day must also slowly rise. You need to push your brain a little
so it continues recovering. As an analogy, think of physiotherapy on an injured limb: one needs to
slowly and progressively increase its activity, always careful not to go over the limit. The same
thing happens with the brain.
When you go to sleep at night, you should feel sufficiently tired, but not anxious. If you do not
sleep much, and feel stressed an unrested when you wake up, you have probably done too much activity
in the day before. However, do not fall for the opposite trap of doing too little. You have to
push your brain a bit, remember.
As the recovery progresses, you will feel not only that you can perform more concentration intensive
activities and during longer periods, but also that your subjective mood improves. At some point
you will be able to start working again, only for a couple of hours each day in the beginning, but
increasingly more until you can work full time again. Finally, your mood should start approaching
normality towards the later stages of the recovery: you should regain the feelings of fullness,
vibrancy, and what is sometimes called the elan vital.
Concerning physical activity, you will notice that the amount of time required for the body to
go back to normal slowly becomes shorter and shorter, as illustrated by Figure 3. You will also
feel that you can do more intense physical activity (such as walking faster) without
your heart racing abnormally. This means that towards the end you will be able to
increase the amount of physical activity, and even to start doing some gentle sports. Just be careful
not to start too early: if it affects your sleep, then cut down on the amount of sports.
Also, be sure to read Section 3 of Part II before you decide to start exercising again.
One last note: towards the final period of recovery, small amounts of adrenaline will make you feel
really good, as if you were "as good as new". Do make sure that you are not fooled by this. Have
your doctor measure your blood pressure to make sure it is really normal. Also, spend a few days
trying to crash down: avoid major intellectual activities or any physical exercise. If
you do not get the nasty side effects of a crash down, then the feeling good was
genuine and there was not too much adrenaline on your system. At last, remember that you are
supposed to continue taking your medication for a while even after you think you are cured.
Beware that if you stop the treatment before you have reached your maximum normal capacity, there is
the danger of a relapse some years down the road.
^
|
|
|
=====
|
======
____
|
====== _____/
| ======
_____/
| ====== _____/
|====== _____/
|______/
--------------------------------------->
Figure 6: As the recovery progresses, the maximum capacity ("=") will increase,
and should be accompanied by corresponding increases of the daily activity ("-"). Be careful
not go over your limits!
5. CONCLUSION
The moral of the story is fairly straightforward: depression is a physical illness which should
be taken seriously and be treated as soon as the first symptoms arise. Like most other ailments,
it feeds on ignorance and complacency, which is all the more tragic if one considers that we
have the medical knowledge and the means to make it a thing of the past. Humanity has been
tormented too much already.
REFERENCES
[1] Wikipedia: Dualism (philosophy of mind)
[2] Wikipedia: Cirrhosis
[3] Taming Stress
[4] Wikipedia: Stress (medicine)
[5] Wikipedia: Fight-or-flight response
[6] Neurogenesis in the Human Brain: Fact or Fiction?
[7] Stress and the Immune System
[8] Sleep Paralysis Page
[9] NIMH: Depression
[10] Wikipedia: Selective serotonin reuptake inhibitor
[11] NIMH: Bipolar Disorder
![]](images/rt_edge3.gif){kind=small}
![[XML]](images/rssblue.gif){kind=small}
![[P]](images/print3.gif){kind=small}
