- Will Depression Last Forever?
- Why Depression Relapse Happens
- Potential Triggers for Depression Relapse
- Signs of a Depression Relapse
- Avoiding the Return of Depression
- Can Depression Ever be Good for You?
- Harry’s story: overcoming severe depression
- Recognising that I needed help
- Therapy has changed me as a person
- No one should struggle alone
- Ending the Nightmare
- Can You Cure Depression?
- Why depression happens again
- The warning signs
- How to prevent a recurrence
- The Difficult Truth About Depression: It’s a Forever Kind of Illness
- Managing chronic depression
- Varieties of chronic depression
- Antidepressant options
- Additional issues
- Depression: Q and A
- How long does depression last?
- How can you help someone with depression?
- What is the outlook for people with depression?
- Mental health helplines
Will Depression Last Forever?
Treating depression can be frustrating, especially given the trial and error often involved with finding the right medication and the right therapist. Getting to a good place in your therapy may take months or even years, during which time you might ask yourself, “Will this feeling ever go away?”
If it does go away — which is the goal of treatment — you might naturally start to worry that the symptoms will come back. According to Mental Health America, more than 21 million children and adults battle depression every year, fewer than a third of whom receive adequate treatment. Consequently, many people risk a depression relapse.
Dan Collins, 49, a senior director of media relations in Baltimore, knows all too well what depression feels like — the first and second time around. Collins experienced his first depressive episode at age 16 and then had a depression relapse more than a decade later, at age 28.
“I had a very deep feeling of hopelessness, like there was nothing I could do to fix my situation,” Collins says. “I also had a high degree of anxiety, almost panic sometimes, that made concentration on anything nearly impossible. I couldn’t find a therapist fast enough, someone to ‘please stop the pain,’ and I drove from bookstore to bookstore, trying to get my hands on every book I could find on the topic of how to treat depression.”
Howard Belkin, MD, JD, an assistant professor at the Oakland University William Beaumont School of Medicine and a psychiatrist at the Birmingham Counseling Center in Royal Oak, Mich., says that Collins’ experience is fairly common. “Sometimes even with excellent expert treatment, depression can return and become chronic,” he says.
Compounding this is the fact that relapses seem to feed on themselves. Experts say it’s likely that at least 60 percent of those who’ve had a depressive episode will have a second, 70 percent of those who have had two episodes will have a third, and 90 percent of those who have had three will have a fourth.
Why Depression Relapse Happens
There is no single answer to explain relapses, says Michael Brodsky, MD, a psychiatrist and medical director of Bridges to Recovery, a mental health facility with multiple locations in California. “For some, the life stressors that triggered the initial depression become intensified and re-trigger a depression,” he explains. “For others, no treatment or inadequate treatment prevents the depressive syndrome from ever really resolving. Instead, more serious depression symptoms become dormant before a different stressor causes them to flare up.”
Some research suggests there may even be a biological predisposition to recurrent depression. And other evidence indicates that people may relapse because they discontinue depression treatment prematurely. “Often, patients begin to feel a little better and stop therapy or medication before they are completely well,” says Dr. Belkin.
Potential Triggers for Depression Relapse
Each person also has personal relapse triggers, some of which you can control and some you can’t. These may be interpersonal or family stress, financial problems, job loss, and other real-world issues. “The stress of our fast-paced modern world certainly has an impact,” says Thomas Gazda, MD, a psychiatrist with Banner Behavioral Health in Scottsdale, Ariz. What is pleasurable to one person, he says, can be a trigger for depression in someone else: “For some, the holidays are stressful, and for others, they are enjoyable and relaxing.”
One common trigger for depression relapse is a dangerous love entanglement. It’s a phenomenon that engulfs people who become depressed within a high-conflict intimate relationship, says Dr. Brodsky. “They receive depression treatment and recover, then stop their treatment and return to the relationship, only to become depressed again in a matter of months.”
Being aware of and avoiding such situations or triggers that set off depression symptoms are steps you need to take whether you’re going through depression treatment or have recently recovered.
Signs of a Depression Relapse
Expect all-too-familiar feelings — signs of depression relapse are similar to symptoms of the initial onset of depression. “The earliest sign is often a change in sleep patterns,” Dr. Gazda says.
Sadness, irritability and anger, problems with appetite, feelings of guilt, lack of energy, and feelings of hopelessness are also potential signs. “And, of course, suicidal feelings are signs of serious illness,” Belkin adds.
Avoiding the Return of Depression
To prevent a depression relapse, continue to follow your doctor’s advice. “Go to therapy sessions, talk with family members, take prescribed medication, and avoid alcohol and drugs,” Belkin says.
It’s also important to keep busy with productive activities and be around other people, strategies that have worked well for Collins. “I have continued the sport of fencing, which I first started at age 23,” Collins says. “Making friends and getting exercise are great for mental health. And last year I decided to audition for roles in a community theater production and got cast as Jimmy Tomorrow in Eugene O’Neill’s The Iceman Cometh.”
Renew your commitment to positive lifestyle habits — get restorative sleep, engage in meditation or other stress-reducing techniques, and eat a diet that includes all colors of the rainbow, says Gazda, who notes that relapsing more than three times may mean maintenance therapy for life is a must.
Most important in the prevention of depression relapse is to stay aware of its very real possibility, not as a source of anxiety but as a proactive step for well-being. If you sense depression symptoms returning, get help immediately.
Recovering from depression isn’t easy. One of the hardest things is that you just don’t know what to expect.
It’s not like healing from an injury. If you broke your arm, your doctor could give you specifics about your recovery. He or she could tell you — at least roughly — how many weeks you would need a cast and when you will be healed.
Unfortunately, depression isn’t like that. Each person’s recovery is different. Some recover in a few weeks or months. But for others, depression is a long-term illness. In about 20% to 30% of people who have an episode of depression, the symptoms don’t entirely go away.
You may also have trouble figuring out how you feel. If you were depressed for a long time before you got treatment, you may not remember what feeling normal is like.
You need to know that you’re not alone. According to the National Institute of Mental Health, about 19 million Americans are living with depression right now. And treatment works. The National Mental Health Association says that more than 80% of people who get treatment say it helps. If you stick with it, the odds are very good that you will feel better.
Can Depression Ever be Good for You?
It was a difficult moment for Joan. “What do I have to be depressed about?” she asked her mother. “I’ve got three great kids, a terrific marriage, a wonderful relationship with you and Dad. How can I be depressed?”
In a review of three new books on the state of mental health today, Marcia Angell discusses the huge uptick in depression (as well as other psychological disorders) in recent years. Joan, it appears, is not alone. According to Angell, ten percent of Americans “over the age of six” take antidepressants.
The article – and apparently the books, which I have not yet read myself – takes on the pharmaceutical industry, suggesting that the evidence that medication cures depression is driven by the industry itself. In my own experience, there are certainly times that medication helps. Sometimes it softens the pain enough for a client to engage in the psychotherapeutic process; and sometimes it does the job by itself. Or maybe it’s just that the medication makes it possible for someone to tolerate the pain until it goes away – since depression does often eventually go away on its own. There is evidence that talk therapy is effective on its own as well, possibly because it changes the same brain chemistry that medication targets (although Angell’s review questions the very idea that depression is related to brain chemistry at all!).
But talk therapy does something that meds can’t do – it can help a client figure out what is causing a particular depressive episode, and sometimes understanding what the pain is about is enough to make it lift.
But there is another dimension to the issue of depression. In the July, 2011 issue of Prevention Magazine, author Ginny Graves says that depression serves a purpose in our lives. Graves writes, ” ‘Depression may be nature’s way of telling you to stop and focus on what’s troubling you, so you can move past it and get on with your life,’ says Paul Andrews, PhD, an evolutionary biologist at Virginia Commonwealth University. He, along with his colleague J. Anderson Thomson, MD, a staff psychiatrist at the Student Health Services and Institute of Law and Psychiatry at the University of Virginia, have become controversial proponents of an idea that actually dates back to Aristotle, that depression may lead to better mental health.”
These authors suggest that depression forces us to go inwards and ruminate on something that is problematic or troubling. In some cases, internally mulling over a painful experience can gradually lead to healing – what psychoanalysts often classify as “healthy mourning.” In some cases, however, just what we are mourning is not so clear, and we someone else to help us sort it out. Sometimes we also need the presence of another person to make it safe enough to mourn.
This is what happened to Joan. She went to the psychiatrist, hoping that he would give her something that would bring her energy back. Like her primary care physician, the psychiatrist asked a lot of questions. Besides the excruciating lack of energy, what other symptoms was Joan experiencing? Joan couldn’t think of anything. He asked about her appetite. “I can’t stop eating,” she said. “I always used to have a decent body; but now I’m fat and bloated and miserable. What about how she was sleeping? Joan was tired all the time and could have slept twenty-four/seven; but she forced herself to get up and be available when her children were home. When had she first started feeling this way? Joan had to think about it. Finally she said that she thought it had started sometime during the summer, and had gotten slowly worse over the fall and winter. Before this period of time, the psychiatrist asked, had she felt this way before? No, Joan had always been an energetic, active person. That was why her mother had worried so much about her.
Under the gentle probing of the psychiatrist, Joan started to realize that the loss of energy and all of the other symptoms had begun to sneak up on her as she prepared for the past September, when all of her children were in school for the first time. Now that they were talking about it, she remembered that she had been worried about what she would do with her time. “My oldest is fourteen,” she said. “I’ve been a stay-at-home mom for most of my adult life. And I’ve loved it every minute. I was happy that my babies were growing up…and I was also so sad…”
The psychiatrist asked Joan if she thought she could go without medication for a little while longer. “I think,” he said, “that it would be a good idea for you to talk out some of these feelings. If the talking doesn’t start to make you feel better in a few months, then we’ll revisit the question of meds.”
Joan started psychotherapy. Once a week she met with a therapist, who listened as she talked about how much she loved her children and how sad and empty the house felt without them around. The therapist asked about Joan’s interests other than the children, and she asked about her marriage. Joan loved her husband very much, but explained that they had a traditional sort of marriage. “He works long hours, and often even on the weekends. I take care of the house and the children.” But they had a good sex life and always had at least one “date night” a week.
It did not take long for the therapist and Joan together to understand the meaning of her depression. She was mourning the end of an era in her life. No longer was she the center of her children’s world. Her role as Mom was still central, and she knew her family still needed her – but not in the same way. She began to talk to her husband about the possibility of him spending a little more time with her. He was thrilled. “You’ve always been so busy with the kids – and you’re a great mother, so I didn’t want to take you away from them. But I’ve missed you!!” he told her.
On one of their “dates” he surprised her again. “Have you thought about going back to work?” he wanted to know. “Or maybe going to school to find a new career? You’re going to need something to feel involved in – the kids are going to keep growing up, you know.”
With her husband’s encouragement, Joan began to consider possibilities. As of this moment, she hasn’t made up her mind. But she’s considering becoming a therapist. “Maybe I can help other people who are struggling with these same issues,” she says.
*names and other identifying information have been changed
Harry’s story: overcoming severe depression
It’s a vicious cycle that, without help, is almost impossible to break.
Recognising that I needed help
The first big step for me was accepting, or as is often more difficult, realising that I was mentally unwell. It took me a long time to do this. The days I spent lying in my bedroom on my year abroad, telling myself I was ‘just bored’, was me refusing to accept the reality that was my mental ill health.
Likewise, in my final year, when my depression reached its peak, I would progressively miss more and more lectures and seminars, leave social outings early or skip them altogether, spend more and more time alone in self-imposed isolation, and tell myself that it was just because I’m introverted, or that I was ‘tired’. And I was tired, but not for lack of sleep; this was actually a symptom of my depression.
I had, however, been seeing my GP on and off for a number of years about my mental health. I first went while I was still at school, but I had always refused treatment, always believing that I was in control enough that I didn’t need it.
Yet, in late April 2017, it all became too much. After somehow finishing my dissertation, I knew I couldn’t go on and started to consider temporary withdrawal. It was a step I was so reluctant to take, as at the time, it symbolised failure, it was me letting my depression defeat me by rendering me completely unable to carry on with ‘normal’ life.
However, I was wrong. Taking this step was nothing of which to be ashamed. It’s a sign of strength to know when to bow out. Accepting that I needed help and that I was unable to continue my studies at that point was an unbelievably difficult decision, but taking a break to focus on my mental health, to recover, has been so much better for me in the long run.
Therapy has changed me as a person
I self-referred for cognitive behavioural therapy (CBT) soon after leaving university. This was such an important step for me. Simply by removing myself from my university studies, I began to see a slight improvement in my mental health, but without CBT, I would not be where I am today.
CBT helped me understand what was causing my depression and that withdrawing from society and wallowing in self-pity was only making me feel worse. Changing my attitude and adopting a positive outlook for the future, seeing myself in a position where I understood my depression and where it did not have an uncontrollable impact on my day-to-day life, was life-changing.
Actively seeking to get mentally healthier and focusing on rebuilding a sense of routine in my life (which is possibly the most important aspect in allowing yourself to maintain good mental health) allowed me to get into a position where I was looking for part-time work whilst on leave from university; work that I found at the Mental Health Foundation.
At my lowest point, I was scoring in the ‘severe’ bracket of depression, but when I was discharged after a couple of months of CBT sessions, my mental health had improved so drastically that I scored at the lower end of ‘mild’.
I’ve seen a huge improvement in my mental health and am a completely different person as a result. My depression is still there, I think it always will be, but I can manage it to the extent that it doesn’t affect my ability to function in day-to-day life.
No one should struggle alone
There are so many other people just like me who struggle with depression and that is why it is so important to raise awareness in order to prevent others from reaching the same horrible depths that I did. The work the Mental Health Foundation does in this regard is vital.
No one should face mental health problems alone and this is why I believe that Curry & Chaat is such an amazing thing. If we all talk about our mental health, we’ll break down the stigma and help others to become more aware of the onset of mental health problems and as a result people will feel more inclined to seek help when they start to experience the symptoms.
I want to help create a world with good mental health for all and I hope my story has been helpful or even inspiring.
Sign up for Curry & Chaat
The aim of Curry & Chaat is simple: get together with friends, enjoy a delicious curry and raise money for the Mental Health Foundation and our vision of a world with good mental health for all.
Ending the Nightmare
An excellent student, a talented singer and musician, a competitive athlete. That’s how I appeared on the outside as a young child, but I felt as though I were trapped in a nightmare that would never end. Years later, and after a lot of hard work, my bad dream is finally over.
Fear of Being Alone
Growing up, I knew I was different. I lived with my mother and brother. My parents were divorced. My father had left and he never came back. It wasn’t the easiest of circumstances, especially for a six-year-old.
As I later discovered, the abandonment triggered my anxiety attacks. I feared being alone, unwanted, unpopular, and unloved.
First period, ninth-grade religion class: The teacher asked me to walk in front of the class and set up a presentation. Simple enough, right? I couldn’t do it. I was having an anxiety attack—soaked in sweat, shaking, and nauseous. My symptoms began every morning from the moment I stepped foot inside the school building.
All I wanted to do was run away, but that wasn’t an option. It would blow my cover. When I wasn’t suffering an anxiety attack, I was wondering when the next one would happen or if anyone could tell. The worrying and the panicking left me with barely any strength to get through the day.
Searching for a Solution
Throughout my childhood, I was no stranger to the doctor’s office. My mother tried everything she could in hopes of a breakthrough. I was on multiple medications, some habit-forming, but they only made me feel like a zombie. Years of seeing a therapist and talking about my anxiety and depression did little to address the heart of the problem. There were times I thought suicide may be the only way to make the pain stop.
By age 16, I had shut down socially. Most of my peers were going to parties, playing sports, and dating. But I was a prisoner in my own home. The anxiety became so unbearable, I dropped out of high school. Problem solved? No way. It followed me to work.
Then one Sunday morning, my wake-up call came from a “Parade” magazine article. You know, the one that comes with the newspaper. Freddie Prinze, Jr., was on the cover. The article detailed the pain of losing his father at a young age. He, too, felt unhappy and alone as a child. I felt as though I were reading my own life story. The only difference? He was now a success.
That article inspired me to explore a new treatment option for myself. I wanted to turn my life around as well. So, I hit the library and Internet to research cognitive-behavioral therapy, also called CBT. I began to realize how my negative thoughts controlled my physical well-being.
Immediately, I made a plan to take charge of my life. The items included things I’d learned:
- Positive self-talk
- Stopping “what if” thinking
- Changing negative thoughts into positive ones
- Eliminating caffeine
- Improving my diet
- Regular exercise
- Deep-breathing exercises
Turning the Corner
Shortly after beginning CBT, I was able to discontinue medication and stop seeing a therapist. I never returned to high school, but I did go to college. After graduation, I pursued a career in television news. I began at a local affiliate in a small city. Several years later, I worked my way up to a major cable news network.
My relationships have changed for the better, too. I’ve made new friends and reconnected with many from my past. I now have the active social life that I was never able to have as a teenager with anxiety.
The Power To Change
My mother once told me, “Michael, you are a survivor.” The anxiety isn’t completely gone, but whenever it returns, I hear her voice in my head. I know the feeling will pass, and I will be OK. Her positive affirmation, along with my coping strategies, make the most difficult of circumstances seem manageable.
You have the power to change your life, if only you will give yourself a chance.
Can You Cure Depression?
Depression, recognized in the DSM-5 as major depressive disorder (MDD) and sometimes called clinical depression, is a common mental health condition. In 2016, more than 16 million adults experienced at least one major depressive episode.
While depression can be treated, and symptoms can be alleviated, depression cannot be “cured.” Instead, remission is the goal. There’s no universally accepted definition of remission, as it varies for each person. People may still have symptoms or impaired functioning with remission.
Depression also has a high risk of recurrence. At least 50 percent of individuals who’ve experienced one episode of depression have one or more depressive episodes. Individuals who’ve had at least two episodes may have at least one more depressive episode.
As with any chronic condition, even though it may recur, there are treatments available to reduce the severity of your symptoms, manage your condition, and give you support.
Why depression happens again
While not everyone who experiences a depressive episode goes on to have another one, many individuals do have another episode. It’s not always known what causes this. Further, there isn’t one known cause of depression in general. It’s thought that a variety of things are involved, including biological, genetic, environmental, and emotional factors.
If you have a recurrence, that doesn’t mean you’re weak or that you did anything wrong. Sometimes depression can be triggered by stressors like losing a job, a serious illness, the loss of a loved one, or substance use. Other times, a recurrence can happen because the medication you were taking isn’t the best one for you, or because it’s time to try a new therapy.
Talk with your treatment team about your risk of recurrence, and what to do if this happens. This can help alleviate any anxiety you might have about possible recurrences. Knowing there’s a backup plan, should you need it, can be reassuring.
The warning signs
Depression can manifest in different ways for different people. Some people may sleep too much, while others might have difficulty sleeping. Keeping a log of your specific symptoms can be helpful, especially when discussing treatment options with your doctor.
That being said, there are some common signs and symptoms of depression, which includes:
- lack of energy or increased fatigue
- changes in weight or appetite
- feeling restless or agitated
- moving or talking slower than usual
- loss of interest or pleasure in activities or things that were previously enjoyable
- trouble concentrating or making decisions
- sleep disturbances, such as waking early in the morning, oversleeping, or not being able to sleep
- feelings of guilt or hopelessness
- feeling sadness or empty
- physical aches or pains, or digestive issues that aren’t helped by treatment, or might not have any clear cause
- thoughts of death or suicide
To be classified as depression, symptoms need to be present most of the day, nearly every day, for at least two weeks. You don’t need to have all — or even most — of these symptoms to be diagnosed with depression. If you think you or someone you care about is living with depression, it’s important to speak with a healthcare professional.
If you’ve experienced a depressive episode before, you might be able to recognize the symptoms of a recurrence. Sometimes, the symptoms of a recurrence can be as simple as not being able to sleep or having trouble concentrating.
If you think you might be at risk of having another depressive episode and are worried, talk with your treatment team — your doctor or therapist — about things to watch out for. They’re familiar with your situation and your personal risk factors, and their feedback can be very helpful.
It can be hard to self-evaluate, especially if your thought processes are being affected by depression, so having outside feedback about symptoms to watch for can make a big difference.
How to prevent a recurrence
Treating your depression can help reduce the risk of another recurrence. Treatment commonly includes a combination of some form of talk therapy, as well as medication.
Sometimes people experience a recurrence of depression during their treatment, and that’s okay. Your treatment team can reevaluate your treatment plan and see if it needs to be changed or tweaked.
Follow treatments prescribed by your doctor
Sticking to your treatment plan can help reduce the risk of recurrence. This can include:
- attending psychotherapy regularly
- completing any assignments given
- taking medications as prescribed
- avoiding drugs or alcohol, which can cause depressive symptoms and interfere with medications
If you’re currently on a medication for depression and it’s not working, you may need to work with your doctor to change medications. Sometimes it takes trying several different medications to find the one that’s best for you. As with many medications, there can be side effects, which typically go away after a few weeks.
It’s important to never stop an antidepressant abruptly, since this can cause an increase in symptoms and possibly trigger a recurrence.
Self-care can also help with preventing depression symptoms and recurrences. Adequate rest and sleep can impact the health of both your body and mind. A healthy diet with essential vitamins and minerals is also important for general health, and regular exercise can increase feel-good chemicals in the brain.
If you’re having difficulty sleeping or need assistance with a meal plan or exercise routine, talk with your doctor about these things. They might be able to assist with relaxation techniques for sleep, or if need be, prescribe something to help. They can also provide you with recommendations for a nutritionist or exercise plan.
You don’t have to do this alone. Depression is an illness and isn’t something you can fight with willpower alone. Talk with your doctor and have a support team in place.
Although recurrence is common, it doesn’t mean this is permanent. There may be no technical “cure” for depression, but with assistance and treatment, depression — even recurrent depression — is treatable.
With the mental health care system broken, and many clinicians feeling as though they can offer only stop-gap measures to try to turn back the tide of depression, I think it can be useful for patients themselves to understand that a complete strategy works well more than 90 percent of the time.
No patient should assume that everything has been done that can and should be done to cure them, without reading this blog.
Here’s the strategy (psychotherapy, as a foundation, with other treatments added, as needed):
1. Psychotherapy. No scientist has ever proven that depression is entirely a brain illness divorced from the life stories of those who suffer from it. In every patient I have ever met who suffers with depression, the illness has had roots in unresolved emotional conflicts from the past.
The most talented psychotherapist you can find will be an invaluable resource in conquering your mood disorder. I prefer insight-oriented psychotherapy, but there are very helpful clinicians out there who use cognitive-behavior therapy, or other modalities.
If you don’t “click” with one therapist, or have the sense that he or she is a real expert, switch. There are plenty out there.
Here are some strategies that work well in addition to psychotherapy:
2. Medication. Psychotherapy and medication together is more powerful, often, than either alone. And I would never count on a medicine to work, without any therapy at all.
But today’s medicines can be life-saving. They include relatively new and effective agents like Viibryd, Pristiq and Lexapro. Since combining these with synergizing medicines like Abilify, Adderall and Klonopin may be necessary, opt for a knowledgeable psychopharmacologist to prescribe them. It’s even better if one talented psychiatrist is performing your psychotherapy and prescribing your medicines.
3. Repetitive Transcranial Magnetic Stimulation (rTMS). Exposing certain parts of the brain to magnetic pulses is a very powerful way to treat depression. Many patients who do not respond to medications, will respond to rTMS.
4. Ketamine infusions. While still in the experimental stages at major universities, I have found that giving patients IV infusions of ketamine, just twice a week for 45 minutes each, is a very powerful way to quickly treat depression. This treatment especially works for those whom medicine has not worked, those whom want very fast results while waiting for medicine to work or those whom seem stuck at a partial recovery from major depression and want a more complete solution.
5. Bright light therapy. Exposure to wavelengths mimicking sunlight (without any tanning UV rays) can substantially reduce symptoms of depression. Lights like the GoLite are relatively affordable and can be an extremely effective part of treatment.
6. Vitamins and other supplements. Anyone who is depressed and has no contraindication to taking magnesium, vitamin D and fish oil supplements should consider doing so. I also think maca, a plant-based supplement can be helpful. Your doctor may have other suggestions, too, but make sure to check with him or her before adding any supplement to your diet.
7. ECT. ECT or electroconvulsive therapy has evolved a long way from what people remember. The stigma is entirely unjustified. ECT is painless and well-tolerated and leaves most people without significant memory deficits. If I were depressed and no other treatment had worked for me, I would absolutely be asking my doctor for ECT.
8. Very non-traditional approaches. Some patients who do not respond to anything else can get relief from depression by using substances like marijuana or even oxycodone.
If your mental health clinician isn’t employing a comprehensive strategy to treat your depression, get rid of him or her.
This list, while long, is not exhaustive. I could easily add to it. And that’s the reason why I can tell depressed patients who come to see me and who ask me if they will get better, “We aren’t going to stop short of making this go away completely. I think you can get 100 percent better. And if you were always a little depressed before this terrible episode, you will feel better than ever.”
Make sure to work with and talk to your doctor and/or psychiatrist before attempting these strategies. What may work for one person, could be harmful for another.
The Difficult Truth About Depression: It’s a Forever Kind of Illness
“She’s definitely better,” he said.
“She’s trying a lot of new things. It’s hard to say what’s helping the most.”
“Well, she’ll always have it. I mean, it will never go away completely. But she’s able to manage her symptoms as of late. She’s able to get out of bed in the morning and go to work.”
Wow, I thought to myself, he gets it.
He truly gets it.
In some ways, he accepted the enduring nature of my illness long before I did.
I’m an easy sell — dangerously gullible — so when I hear commercials for new drugs promise an end to death thoughts, fatigue, apathy, and anxiety, I believe them, much like I believed in Santa Claus until my mean cousin made fun of me because I was way past the age to have not figured out it was Uncle Steve who was donning a white beard and ho ho ho-ing between his martinis.
When I decided to go the holistic route, I’d read profile after profile in diet and health books about people who were on four kinds of medication to treat their bipolar disorder, but once they eliminated gluten and dairy from their diet (and added fish oil supplements, a probiotic, Vitamin B-12), they could ditch the meds and enjoy a happily-ever-after life.
Then there was reality, which fails to produce sexy sound bites.
It’s hard to finally swallow the fact that treatment-resistant depression, bipolar disorder, and other severe mood disorders can be lifelong companions because the bulk of health literature focuses on easy cures. Our media won’t promote any message that is complicated or messy, anything short of the quick fix. As Toni Bernhard, author of “How To Be Sick” says, “Our culture tends to treat chronic illness as some kind of personal failure on the part of the afflicted — the bias is often implicit or unconscious, but it is nonetheless palpable.”
I’m just as guilty as the person who hasn’t been fighting symptoms her whole life.
Yesterday I ran into a friend and her husband at church, and the husband told me that his daughter was bipolar and has attempted suicide three times.
“Does she have a good doctor?” I asked.
“Oh yeah,” my friend said, “she’s at the University of Virginia.”
Why did I ask about her doctor?
Because it’s easier for me to hear that a person who tried to take her life three times doesn’t have the right care. If she has a top notch medical team and is still suicidal? That means her illness — which is my illness — is that much harder to treat. It’s serious stuff.
I felt lucky to be having a day without symptoms.
I’m even luckier to have had a string of 13 symptom-free days, as documented in my mood journal.
The difficult truth for many of us with chronic mood conditions is that, while we can experience glorious remissions, we’re never cured. Much like the cancer patient, we need to rearrange our entire lives so that the most important thing we do each day is to stay in remission (if we aren’t depressed) or to aim for remission (if we are depressed). We are always on call for the surprise visits from our illness and can never relax to the point of forgetting we are sick.
I have learned from members of Group Beyond Blue, the online depression support group I moderate, that this kind of vigilance doesn’t have to absorb the spills of joy from your life. If you know that everything is transient — the depressive episodes and the remissions — you are better able to welcome each. As Buddhist teacher and author Pema Chödrön explains, the healing happens in the movement between emotional states or in the natural cycle of our moods. She writes:
We think that the point is to pass the test or overcome the problem, but the truth is that things don’t really get solved. They come together and they fall apart. Then they come together again and fall apart again. It’s just like that. The healing comes from letting there be room for all of this to happen: room for grief, for relief, for misery, for joy.
I posted that quote on my Facebook page awhile back, and a woman disagreed with it. She was bipolar and said that her medication combination has provided her a newfound stability.
I congratulated her.
Part of me envied her.
I do better with lines than with circles.
But my recovery is still very much a work in progress.
Just ask my husband.
Artwork by the talented Anya Getter.
Managing chronic depression
Published: December, 2009
Long-term treatment increases chances of response and remission.
For most patients, episodes of major depression last a limited amount of time. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) specifies that symptoms last at least two weeks, and treatment studies report a median duration of about 20 weeks. But for some patients, the condition becomes chronic — with symptoms lasting at least two years.
The differences between episodic and chronic depression encompass more than just duration. Studies show that, compared with episodic major depression, chronic depression causes more functional impairment, increases risk of suicide, and is more likely to occur in conjunction with other psychiatric disorders. Patients with chronic depression are also more likely than patients with episodic depression to report childhood trauma and a family history of mood disorders.
Because chronic depression lasts longer and tends to be more severe than episodic depression, treatment is more intensive. Relapse is also a challenge. About half of patients with chronic depression who respond to treatment (whether with antidepressants, psychotherapy, or a combination of the two) will suffer a relapse within one to two years if they stop treatment. For that reason, some type of maintenance therapy may be necessary.
By definition, in an episode of major depression, symptoms last at least two weeks. In chronic depression, they last at least two years.
Because chronic depression tends to be more severe than episodic depression, treatment is also more intensive.
Several subtypes of chronic depression exist, but they have similar long-term effects on health and quality of life.
Varieties of chronic depression
Before diagnosing a patient with chronic depression, it’s important to rule out other medical conditions — such as thyroid disease or sleep disorders — that might be causing symptoms.
Several subtypes of chronic depression are described either in the DSM-IV or in the research literature. Although these subtypes differ in some respects, consensus is growing that they have similar long-term effects on health and quality of life.
Dysthymic disorder. The definition of dysthymic disorder has evolved, but the DSM-IV describes it as a type of chronic depression with symptoms that are not numerous or severe enough to meet the criteria for major depression. Dysthymic disorder affects about 6% of the general population at some point in their lives, and 36% of people seeking mental health treatment on an outpatient basis.
When dysthymic disorder occurs on its own (sometimes called “pure dysthymia”), its hallmark is depressed mood, accompanied by at least two additional symptoms of major depression. Some research suggests that dysthymic disorder may cause more cognitive symptoms, such as low self-esteem, difficulty making decisions or concentrating, and pervasive feelings of hopelessness, while major depression may cause more vegetative symptoms, such as poor appetite or overeating, insomnia or excessive sleep, and low energy or fatigue. However, dysthymic disorder seldom occurs on its own — major depression often follows on its heels.
Double depression. Although it is not described in the DSM-IV, the literature defines double depression as an episode of major depression that occurs at least two years after an adult patient — or one year after a child or adolescent — develops dysthymic disorder. More than 75% of patients with dysthymic disorder will experience double depression at some point in their lives. And 25% of patients who seek treatment for major depression will recall having had dysthymic disorder in the past. Researchers do not yet know whether dysthymic disorder is an early manifestation of major depression, or if they are separate disorders with overlapping symptoms.
Chronic major depression. Patients with chronic major depression continually meet the full DSM-IV criteria for a major depressive episode for at least two years. This situation is sadly common. About 20% of patients who develop major depression have not recovered in two years, while 12% have not recovered after five years.
Partial recovery. Some patients continue to experience subthreshold symptoms after treatment for major depression, or relapse within two months. While these less severe symptoms might suggest dysthymic disorder, the DSM-IV defines this pattern — residual symptoms remaining or occurring less than two years after an episode of major depression — as a major depressive episode in partial remission.
Controlled short-term clinical trials have evaluated both tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) for treatment of chronic depression. Most found that antidepressants were effective, and that no particular drug was better than another. Studies lasted from six to 12 weeks and reported that 45% to 55% of participants responded (usually defined as at least a 50% reduction in symptoms as measured by the Hamilton Depression Scale score). But only 25% to 35% of patients with chronic depression were able to achieve remission from the first drug — at least in the short term. This remission rate is similar to the results for patients with episodic major depression, as reported by the STAR*D trial.
It may be that patients with chronic depression need to take an antidepressant for an extended period before they experience any benefit. For example, three studies that continued active treatment for four months found that 30% to 40% of patients with chronic depression who were partial responders at the beginning of the treatment phase ended the studies in full remission.
Other studies report that long-term maintenance therapy reduces risk of relapse. Some clinicians therefore recommend that patients with chronic depression continue treatment for six to 12 months to increase chances of remaining in remission.
Although few studies have been published, most evidence supports a type of therapy designed specifically for chronic depression, known as Cognitive Behavioral Analysis System of Psychotherapy (CBASP). Limited evidence also supports tailored versions of cognitive behavioral therapy (CBT) or interpersonal therapy.
CBASP. This variation of CBT was developed by Dr. James P. McCullough at Virginia Commonwealth University. It is based on the premise that patients with chronic depression think, behave, and communicate in ways that make traditional therapy difficult. They tend to focus on themselves, may be uncooperative, and have difficulty controlling emotions. They also tend to view current situations either as a replay of a negative event in the past or a precursor to a similar situation in the future.
CBASP therapy involves exposing and challenging these perceptions and behaviors. For example, using a technique known as situational analysis, the therapist seeks to help a patient break down a distressing event into a sequence of events, and then find junctures where the outcome might have been different had the patient changed his or her behavior or reactions.
A randomized controlled study of 662 patients that compared CBASP, nefazodone (Serzone), or the combination found CBASP was as effective as the drug — with 48% of patients responding to either one alone. (Combining both boosted response rates to 73%.) A follow-up study, involving a subset of patients who responded to CBASP and continued treatment for another year, found monthly CBASP sessions helped prevent a recurrence.
CBT. This therapy helps patients reframe situations in more positive ways. Because patients with chronic depression may have entrenched feelings of hopelessness, however, CBT techniques may need to be more intensive than usual. One review suggested that therapy take place twice a week rather than once a week, and that it target behaviors or thought processes most amenable to change, increasing the chance that patients will see progress.
During therapy, a patient with chronic depression may make dramatic and self-defeating abstract statements, such as “I’m my own worst enemy,” or “I’m a mess.” It may help to keep the patient focused on specifics, such as details of a particular situation or problem.
Interpersonal therapy. The goal of interpersonal therapy in treating chronic depression is to change the way a patient perceives himself or herself — from being a person with a flawed character (an idea that can develop after years of depressed mood) to being someone with a chronic but treatable disease. Therapy also involves helping a patient to express anger productively, to become assertive, and to take social risks.
Only a few studies have evaluated the use of interpersonal therapy in chronic depression. This preliminary evidence suggests that it may be useful for some patients, but that it requires time and persistence.
Researchers are investigating ways to improve treatment by fine-tuning interventions for particular subsets of patients with chronic depression.
Some intriguing, if preliminary, research on the diverse origins of chronic depression suggests that a patient’s individual medical history may help predict which treatments he or she might respond to. The theory is that there are two basic pathways to developing chronic depression: one in which family history of mood disorders creates genetic vulnerability, and the other characterized by an overly reactive stress response that originated with early childhood abuse or maltreatment. Early studies suggest that drug treatment is more effective for patients with a family history of mood disorders, while CBT may be more effective for those with a history of childhood adversity.
Other research suggests that hormones may affect response to treatment of chronic depression. A study comparing sertraline (Zoloft) with imipramine (Tofranil) for treatment of chronic depression found that women who were still menstruating were more likely than men or menopausal women to experience a worsening of symptoms during treatment — suggesting that hormones and premenstrual fluctuations might affect treatment.
A study in 23 middle-aged men with older-onset dysthymic disorder found that symptoms improved in 54% (7 of 13) who received testosterone injections, and in 10% (one in 10) who received placebo injections. This study suggests, as has other research, that late-onset chronic depression may be related to age-related hormonal changes.
And one study suggests that giving patients with chronic depression the type of treatment they want may improve outcomes. The study randomized 429 patients to treatment with nefazodone, CBASP, or the combination — but investigators also asked ahead of time which treatments the patients preferred.
At the end of the study, patients who wanted medication were twice as likely to achieve remission if they were assigned to the drug, and those who preferred psychotherapy were six times as likely to achieve remission on CBASP. In all, about half of the patients who received the treatment they wanted achieved remission — which suggests that one of the simplest ways to improve outcomes is to ask patients what type of treatment they prefer.
Harvey AT, et al. “Acute Worsening of Chronic Depression During a Double-Blind, Randomized Clinical Trial of Antidepressant Efficacy: Differences by Sex and Menopausal Status,” Journal of Clinical Psychiatry (June 2007): Vol. 68, No. 6, pp. 951–58.
Kocsis JH. “Pharmacotherapy for Chronic Depression,” Journal of Clinical Psychology (Aug. 2003): Vol. 59, No. 8, pp. 885–92.
For more references, please see www.health.harvard.edu/mentalextra.
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Depression: Q and A
How long does depression last?
On average, an episode of major depression lasts 4 to 8 months, although this duration can be shortened by treatment. Most people recover within 3 to 6 months with treatment, although it can take longer than this for some.
How can you help someone with depression?
It can be difficult to know exactly what to do if you think someone close to you may have depression. If you are concerned, here are some suggestions on how to help.
- Spend time with them and let them know you care about them.
- Talk with them about how they are feeling. Listen to what they are saying without being judgemental. Be reassuring and supportive – someone who is depressed may have difficulty talking about what they are experiencing and feel sensitive or defensive.
- Let them know that you have noticed a change in their behaviour and that you are concerned about them. Ask them what they need from you.
- Suggest they talk to their doctor or a mental health professional. Offer to help them make an appointment and go with them. Young people may consider talking to a school counsellor or youth worker.
- Suggest talking to an anonymous phone support line if they are reluctant to seek professional help initially.
- Find out about depression together, or help them get information on depression and its symptoms.
- Encourage them to stay involved with their usual routine and enjoyable activities as much as possible.
- Encourage activities that help promote mental and physical health – healthy eating, physical activity, and regular sleep.
- Discourage the use of alcohol and drugs as a way of dealing with distressing symptoms.
- Ask direct questions if you are concerned about suicide. If there is a risk of self-harm or suicide, make sure someone stays with the person and get medical help straight away.
What not to do when someone has depression
- Don’t put pressure on them or tell them to ‘snap out of it’.
- Don’t avoid them.
- Don’t assume the problem will go away on its own.
- Don’t encourage the use of alcohol or drugs.
What is the outlook for people with depression?
Depression can come and go – many people who have had one episode of depression will have another episode at some time in their lives.
The pattern of relapse (recurrence) of depression varies — some people have long periods free of depression, others have clusters of episodes, and still others have more episodes as they get older.
Nonetheless, most people with depression can be treated successfully and ongoing treatment can help prevent relapses. With proper treatment, most people improve and can get back to their normal lives.
Mental health helplines
If you or someone you know is feeling distressed and/or having suicidal thoughts, see your doctor, phone one of these helplines or click on the links below for online web chat counselling or support. Call 000 if life is in danger.
|Lifeline (24 hours)||13 11 14|
|Kids Helpline (for young people aged 5 to 25 years)||1800 55 1800|
|Beyond Blue Support Service (24 hours)||1300 22 4636|
|MensLine Australia (24 hours)||1300 78 99 78|
|SANE Helpline – mental illness information, support and referral||1800 187 263|
|Suicide Call Back Service (24 hours) – free counselling support||1300 659 467|
Last Reviewed: 12/10/2018