Depression Guide

Part I. Overview

This guide is intended to give those struggling with depression a broad overview of some of the diagnostic symptoms and treatment options available for two forms of unipolar depression in adult patients. These two forms are major depressive disorder (MDD) and persistent depressive disorder (PDD/dysthymia). Many of the concepts and treatments also apply to anxiety disorders as well.

PART II. Diagnostic Criteria for Common Depressive Disorders

What Does Depression Feel Like?

Not everyone experiences depression in the same way. Depression symptoms and the severity of those symptoms can vary. Depressed mood and/or an inability to derive pleasure or joy from once pleasurable activities and hobbies is a defining feature. Loss of energy, changes in appetite and sleep patterns, or thoughts of not wanting to live are common in depression. Everything in life may seem bland and joyless. Motivation may be low and combined with low energy, completing even the simplest of tasks can feel extremely difficult. Physical aches and pains may manifest. One’s ability to maintain employment or relationships can become strained.

Feelings of guilt, worthlessness, and low self-esteem are common. These feelings become further exacerbated as depression starts to erode an individual’s ability to function in day to day life. Depression and anxiety snowball quickly as symptoms lead to negative emotions and negative emotions reinforce symptoms. The less productive one becomes the worse they feel about themselves, and the worse they feel about themselves, the more depressed and less productive they are likely to be in the future.

Let’s take a look at the official diagnostic criteria, specifically for adults:

Diagnostic Criteria: Major Depressive Disorder (MDD)

Major depressive disorder is essentially the “default” depressive disorder. It is the most common type of (unipolar) depression. It has a high prevalence in young adults and is more common in women. So, what is required for a diagnosis of major depressive disorder? According to the Diagnostic and Statistical Manual of Mental Disorders, for a period lasting at least two weeks an individual must have at least 1 of the following 2 symptoms:

1) Depressed mood most of the time and nearly every day
2) Loss of interest or pleasure in nearly all activities most of the day, nearly every day.

Additionally, they need to have an overall total of 5 of these 9 symptoms during the same time period:

3) Weight loss or weight gain of more than 5% of body weight in a month or significant change in appetite (increased or decreased).
4) Insomnia or hypersomnia (excessive sleepiness or excessive time spent sleeping).
5) Psychomotor agitation; purposeless movement such as tapping, pacing, or fidgeting. Or psychomotor retardation; delayed thoughts or movements as if a person is operating in slow motion. These need to be readily apparent to others to qualify, they cannot be subjective feelings.
6) Fatigue or loss of energy.
7) Feelings of worthlessness or excessive or inappropriate guilt.
8) Diminished ability to think, concentrate, or make decisions.
9) Recurrent thoughts of death (not just fear of dying), or recurrent suicidal ideation with or without a specific plan. If you are experiencing suicidal thoughts, please seek professional help. If you have a suicide plan or intent to hurt yourself, please seek emergency medical help now by calling 911 or the suicide prevention hotline at 1-800-273-8255.

Many of these symptoms need to occur nearly every day and for most of the time during those days. These symptoms need to be different from your norm. For example, if you have had low energy your entire life, low energy cannot be considered a symptom unless it has gotten markedly worse (and does not have an underlying medical cause).

Diagnostic Criteria: Persistent Depressive Disorder (PDD; Dysthymia)

Persistent depressive disorder is a less common form of depression. It is generally thought of as chronic depression but with a lower level of severity than major depressive disorder. It should still be treated. So, what is required for a diagnosis of persistent depressive disorder?

For at least two years the individual must have depressed mood for most days, for the majority of time during those days and two or more of the following symptoms:

1) Poor appetite or overeating.
2) Insomnia or hypersomnia (excessive sleepiness or oversleeping).
3) Low energy or fatigue.
4) Low self-esteem.
5) Poor concentration or difficulty making decisions.
6) Hopelessness.

During this period of at least two years, symptoms must not have ceased for any period of time lasting 2 months or longer.

PART III. Cause of Depression & the Medical-Psychological-Biological Construct

What Causes Depression?

Depression can potentially be caused, or contributed to, by numerous things. These causes can vary from person to person and often overlap. Some causes are thought to be: genetics, neurotransmitter imbalances, medical conditions, environment, adverse childhood experiences (trauma), lifestyle habits, coping skill limitations, diet, use of certain medications, alcohol or drug abuse, and others.

The Medical-Psychological-Biological Construct of Depression (and Anxiety)

The Diagnostic and Statistical Manual of Mental Disorders specifically states the need to rule out medical conditions as a cause of psychiatric symptoms (clinicians refer to these other possible diagnoses as “differential diagnoses”). Beyond medical issues, some clinicians believe that determining whether an individual’s depression is caused primarily by psychological or biological factors is helpful in determining the best treatment route. These clinicians use a medical-psychological-biological construct; they view depression (and anxiety) as having either a medical, psychological, or biological origin and adjust treatment accordingly.

If the origin is medical: Treatment is aimed at resolving the medical issue.

If the origin is psychological: Psychotherapy is usually the suggested primary treatment. Medications are likely to have limited impact if the origin is purely psychological. The usefulness of medications in these cases would be limited to alleviation of short-term symptoms (such as insomnia) while working through therapy to resolve the underlying causes. Even then medications would probably not be warranted unless the symptoms are causing marked impairment in functioning.

If the origin is biological: The suggested treatment is medication. Psychotherapy may be helpful in some instances but is likely to have limited effect if the origin is purely biological.

If the origin is a combination of psychological and biological, which is often the case: We combine psychotherapy with psychotropic medications.

Keep in mind this is just a starting point and an overly simplistic way to view depression and anxiety. Depression and anxiety and their underlying pathology are extraordinarily complex. We are not anywhere close to fully understanding the complex interactions going on behind the scenes. We also have no definitive, scientific way to determine if depression has a psychological or biological origin in a typical practice setting. There are many cues that can help us narrow down the possible origin, but this is largely still subjective. It is better to think of the cause or origin as existing on a spectrum. Rather than fitting into only one category, depression is usually caused or reinforced by a combination of psychological and biological factors. These factors exist in various degrees within any given case.

Even if the cause of depression starts in one category, it can become both psychological and biological if left untreated. A stressful psychological life event that surpasses one’s ability to cope in a healthy manner can begin to cause biological changes in the brain over time. On the other hand, biological depression can lead to increasingly poor outlook, lessened ability to use coping skills, and overall inability to deal with psychological stressors one may normally be able to handle. As stated in the previous section, depression (and anxiety) tend to snowball and perpetuate themselves when not treated.

So, where to start? If psychiatric symptoms have a medical cause then treatment is completely different. So, it is best to start there before delving deeper into psychiatric treatment. Let’s take a look at what the medical aspects consist of:

PART III-A. Medical Causes of Depression

There are three main medical subsets of this category:

A. Medical conditions: Thyroid disorders, electrolyte imbalances, diabetes, anemias, autoimmune disorders, inflammatory disorders, Lyme Disease, and other medical conditions can cause or exacerbate depression. Thyroid disorders alone (including sub-clinical hypothyroidism) could be a factor in as many as 10% of patients who meet the criteria for major depressive disorder. Patients are at times admitted to psychiatric wards and diagnosed with psychiatric illness only to later discover they had a medical condition that was causing their symptoms. A thorough medical history and some basic laboratory testing can help rule out medical conditions as an underlying cause. It is important to ensure a medical condition is not causing your symptoms because psychiatric treatments will not fix medical issues. Make sure that your provider explores your medical background and if they are not licensed to order lab tests, they should collaborate with your primary care provider to provide this component.

B. Some prescription medications: There are a number of medications that have the potential to cause or exacerbate depression. If the provider prescribing these does not have a psychiatric background and does not know that you have a history of depression it is very common for this to be overlooked. However, just because a medication can cause depression does not necessarily mean that it will. The risk-benefit ratio should be carefully considered and discussed with your providers before making any medication changes.

C. Alcohol/Drug Abuse: If  alcohol or other drugs are being used, they will contribute to long-term depression. If drug or alcohol history is hidden from a provider, it will be nearly impossible for them to effectively treat their patient. Not only will they not know the proper direction for treatment, but they will not be able to make proper evaluations of response to medications or therapy. Combining psychotropic medications with alcohol or drugs is often dangerous and always counterproductive. Alcohol and drug use is akin to borrowing a high-interest loan. You may feel better temporarily, but the loan needs to be paid back and costs far more than it provided.

PART III-B. Psychological & Lifestyle Causes of Depression

Does your depression make sense given the context of your life?

Do you believe that other individuals would also be depressed if they were living your life? In other words, does your depression make sense? If the depression does make sense, your depression likely has strong psychological underpinnings. It is important to have a general idea of how much of one’s depression is caused by psychological or lifestyle factors. Medication will have limited impact on relieving depression caused by psychological or lifestyle factors. Instead, the primary treatment is therapy and/or relevant lifestyle changes. Medication may still be helpful to treat pronounced symptoms that interfere with daily functioning while working through therapy. Depending on the context of the case, psychological depression may resolve on its own or it may persist and eventually cause a biological depression. Working through therapy and making lifestyle modifications can help prevent this from occurring.

Examples of psychological & lifestyle factors contributing to depression

Precipitating event: A major, possibly traumatic event that led to the onset, or worsening of, an existing depressive episode. This could be a divorce (or breakup), death of a close friend or family member, traumatic event (including those that occurred earlier in life), or other major life changes.

Negative Environment: Stressful, unpleasant, or hostile home or work environment.

Lifestyle Habits: Lack of sleep or poor sleep habits. Generally poor dietary habits, fad dieting, skipping meals, or overeating. Sedentary lifestyle. Consuming too much caffeine or consuming caffeine late in the day. Use of alcohol or other drugs. Lack of balance in social, home, and work life.

Social: Conflict with friends, family, or romantic partners. Loneliness or lack of meaningful relationships. Unhealthy relationships. Lack of goal or sense of purpose in the world. Financial difficulties and stressors.

Negative Outlook: Poor coping skills, attitude, and beliefs. Personality disorders.

Remember that depression is complex and often has both biological and psychological components. Someone may identify psychological factors contributing to their depression while recognizing that these factors impact them to a much greater extent than they should. Sensitivity to these negative events could indicate a possible biological component, particularly if the individual has not always overreacted to negative events.

It is important to understand that medications are not likely to work for someone who feels depressed solely due to psychological or lifestyle factors, when their response to these factors is also reasonable. Antidepressant medications do not make people happy. They are supposed to restore normal biological functioning. In other words, they are intended to prevent depression that does not have a valid cause. Medication may also help prevent someone from being overly sensitive to depressing events, but they will not prevent normal, reasonable feelings of sadness. This is why therapy and lifestyle modifications are typical treatment recommendations for depression that has a psychological foundation.

So what if your depression does not make sense or is much more severe than what seems reasonable in the context of your life? Your depression may have a biological origin:

Part III-C Biological Causes of Depression

When the brain is not optimally performing functions that impact our mood

If the depression one is experiencing does not make sense given the context of their life, or if it is significantly more pronounced than it should be, the depression likely has biological components. There is no definitive way to be absolutely certain ones depression has a biological cause, but there are some cues that are helpful in making that determination. When someone is biologically depressed, the depression would persist, at least to some extent, even if everything in their life was ideal or could magically be fixed. A family history of depression can also be a significant sign.

So what are the actual  biological problem(s) in the brain? This is an extremely complex process and one we do not yet fully understand.  Each unique individual may have various issues which we cannot fully differentiate at this point in time. For the purpose of presenting this in an easy to understand format, we will keep it simple. For a long time the prevailing theory has been that biological depression is due to a lack of certain neurotransmitters (chemical messengers) exerting their intended effects.

The brain may simply not produce enough of the neurotransmitter (for various reasons), cells may lack adequate receptor sites for the neurotransmitter to activate, there may be issues with neurotransmitter transportation processes, and so on. There are three primary neurotransmitters our brain uses to control our mood.

The neurotransmitter trio of Serotonin, Norepinephrine, and Dopamine.

Each of these neurotransmitters serve many functions, but when it comes to our moods they can be generalized as:

Serotonin: General sense of well-being. Low levels may lead to: anxiety, impulsivity, anger, emotional lability. This is the neurotransmitter antidepressant medications have traditionally focused on most frequently.

Norepinephrine: Fight or flight, impacting our attentiveness and energy level.

Dopamine: While dopamine is often (incorrectly) reported to be the “pleasure” neurotransmitter, it is more aptly a motivational or reinforcing neurotransmitter. Dopamine is involved in our brains reward system and reinforces pleasurable experiences and behaviors. Our brain assigns survival value to behaviors and experiences it believes is important to survival and releases dopamine (along with other actions) to reinforce those activities. Sex, eating, acquiring money or valuables, or escaping danger lead to surges of dopamine so that we will continue to pursue these behaviors that are believed to be most important for our survival. Apathy or avolition (lack of motivation) may be caused or exacerbated by low levels of dopamine.

Traditional antidepressant medications may serve several functions. They are primarily believed to work by ensuring the brain has enough of these neurotransmitters available. They typically slow the breakdown of the brains own, naturally created neurotransmitter. Some antidepressant medications may also have additional mechanisms of action. It is believed by increasing the level of serotonin in the brain, the brain may begin to grow new cells. Depression and stress may have hindered this cell growth and even led to atrophy (wasting) of areas in the brain involved in controlling our mood. If the primary or significant mechanism of action is cell growth, this may also help explain why antidepressants take several weeks to reach full benefit. It also not simply a matter of having enough of a neurotransmitter, but having an appropriate balance or ratio of neurotransmitters is also important.

So, what are the treatment options for depression? Here are some of the many:

Part IV: Treatment options

This section provides a brief overview of some of the numerous treatment options or adjunct treatment options available for depression and anxiety. Adjunct treatments are those which would not be effective or appropriate as a sole treatment, but can be effective as one piece of a larger treatment plan. Appropriate treatment for any individual case should be discussed with and delivered by a licensed provider. This is a brief overview of the many different treatment options available. This is not an exhaustive or comprehensive list of treatments nor does it go into extensive detail about any particular treatments. This section is simply intended to spread awareness of some of the many possible treatments available.

Therapy: As previously mentioned in this guide, therapy is the standard treatment for depression and anxiety which has a psychological cause as its foundation. Research has shown cognitive behavioral therapy to be the therapy modality of choice in treatment of depression and anxiety. Over time, the application of techniques learned in cognitive behavioral therapy are believed to lead to beneficial changes in brain activity that make the individual naturally more resistant to depression and anxiety.

Prescription Antidepressant Medications: Selective Serotonin Reuptake Inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), Norepinephrine-dopamine reuptake inhibitor (NDRI), tricyclic antidepressants (TCA), novel antidepressants, monomamine oxidase inhibitors (MAOI), and others. These medications are all largely focused on preventing the breakdown of the neurotransmitters in our brain responsible for our (positive) mood so that more are available for use. Some of these may also have secondary functions, such as having a protective effect on brain cells, spurring the growth of brain cells, partially activating serotonin receptors directly, or increasing sensitivity to neurotransmitters responsible for positive moods. Then there are adjunct medications for unipolar depression such some neuroleptics, l-methyfolate, some mood stabilizers, and so on. Antidepressant medications seem to work in very roughly 70% of cases. However, full remission of symptoms may require adjunct therapy or other adjunct treatment method or medication depending on the individuals case.

Herbal Medications and Natural Supplements: A large portion of prescription medications on the market were derived from a plant or are intended to mimic the effects of a plant. The idea that something cannot be effective simply because it is plant-based is ignorant of this fact. With that being said, research on effectiveness of herbal medications or supplements in treating depression and anxiety is mixed. The general consensus is (arguably) that there are some herbal treatments that may be effective in treating mild to moderate depression or anxiety, such as St. Johns Wort. Unfortunately, these medications and their interactions have not typically been studied to the extent of traditional prescription medications and drug-drug interaction risks may be less predictable. St. Johns Wort in particular, has many potential conflicts with other medications often limiting or preventing its safe use outright. Due to a lack of oversight with herbal medications or supplements, there are many additional roadblocks to their use. Obtaining product in a standardized reliable dosage that is also free from contaminants (such as excess lead) can be difficult. Herbal medications may be a viable treatment option in certain circumstances but should never be taken without first discussing them with your provider. Despite marketing claims otherwise, very few companies have their products tested by reputable sources.

Genetic Testing: This is not a treatment itself but may be used as an aid in guiding the medication selection process. Utilizing a patient’s DNA via a simple cheek swab, it is often believed or purported that genetic testing can determine which medications (within a given class) will work best for a patient. In reality, these tests only report medications a patient is most and least likely to experience negative reactions to and their accuracy or practical application is debated. In addition to screening medications, they may test for genetic mutations in a patient’s ability to, for example, transport serotonin properly, or properly convert folate (b-vitamin necessary to produce neurotransmitters) to its active form. Overall, some clinicians love genetic testing and use it frequently while others believe the tests are useless.

While these tests hold great promise for the future, we personally believe they have very limited practical value currently. The ability to find genetic mutations may hold more practical application than the tests that evaluate individual medications against patient DNA, but even in these cases their usefulness is probably exaggerated. For example, the mutation related to folate conversion is common and supplementation often considered long before testing.

Vitamins: Vitamin deficiencies, particularly Vitamin D and B deficiencies may contribute to depression. Some individuals may not properly process folate (vitamin b-9). This is important as proper folate conversion is necessary for the brain to produce neurotransmitters appropriately and correcting this with l-methylfolate or other supplementation (often as an adjunct or additional/secondary treatment) may help alleviate depression. While those with significant vitamin deficiencies may experience significant results when deficiencies are corrected, supplementation for those without deficiencies will likely yield no significant result and using excess amounts or “megadosing” may not just be ineffective but will likely be harmful and dangerous, particularly with fat soluble vitamins.

Bright Light Therapy: This is used most commonly for seasonal affective disorder (SAD) but may also be useful for those with other forms of unipolar depression, particularly if they experience seasonal exacerbation. Bright light therapy involves the use of a specialized lamp intended to safely mimic the beneficial aspects of sunlight. Obtaining natural sunlight (in moderation and with proper use of sunscreen) can boost serotonin and vitamin D levels to improve mood.

“Mood Diets”: Good nutrition is absolutely essential for optimal brain functioning and a balanced mood. However, diets centered around the idea of eating foods high in serotonin or tryptophan (an amino acid precursor used to make serotonin) are flawed. Serotonin may be found in a limited number of foods but will not cross the blood-brain barrier if ingested. Foods high in tryptophan are typically high in other amino acids. Tryptophan typically exists in smaller amounts than other more abundant amino acids, which will be transported first (these amino acids compete for transport to the brain). While there may be some tricks to temporarily boost serotonin levels with food they are likely counterproductive and unhealthy. A healthy well balanced diet is fundamentally important to our moods, but diets focused on boosting neurotransmitter levels with certain food items, at least at this point in time, is something that is not yet practical. This is an area that certainly merits more research and holds potential, but we have not figured it out yet. On the other hand eating healthy foods, avoiding refined sugars and processed foods, and drinking water can be very beneficial.

Transcranial Magnetic Stimulation (TMS): This is the use of magnetic fields to stimulate or activate regions of the brain that may have become hypoactive during depression. This procedure is now at least partially covered by many insurance policies. The treatments are usually conducted over the course of several weeks with in-person sessions being required nearly every day, although this seems to be evolving over time. TMS is often recommended for those who have not had success with traditional therapy and medications. The side effect profile of TMS is low but the time and financial commitment can be extensive. While TMS may be effective, it has also become big business and the marketing hyperbole may not always match real-world results. In our opinion, more research is needed on its long-term efficacy but it may be a viable treatment option for some individuals.

Electroconvulsive Therapy (ECT): This procedure is considered to be quite effective but carries considerable risk and is usually a late consideration and/or for severe forms of depression that have not responded to other treatments. Under anesthesia a seizure is induced and this may reactivate regions of the brain that have become dormant. Treatments last only a few minutes and are usually conducted several times over the course of a month. Although this procedure has become safer over time it still carries very serious medical risks, and significant memory loss or impairment is not uncommon.

Part V: Lifestyle Modifications

Often times our lifestyle habits contribute to depression and anxiety. Modifying some of these behaviors can have a dramatic impact on our mood. As mentioned previously, depression and anxiety snowball and perpetuate themselves when not actively managed. Throughout the day many of our individual thoughts and actions dictate whether our moods will head in a negative or positive direction. By making a concerted conscious effort to initially modify our behaviors and thoughts this snowball of positivity will eventually require little effort to maintain. On the other hand, by giving in to negative thoughts and reinforcing negative behavior patterns, the snowball of negativity becomes much and much more difficult to reverse.

For those with more serious disorders, or just starting in treatment, the idea of incorporating some of these modifications may seem unrealistic. You may be thinking, “I can barely get out of bed to get to work most days and you want me to start exercising or focus on eating healthy?” Or “I am so depressed I can’t help napping throughout the day.” If this is the case, simply try to incorporate any aspects you can and keep the rest in mind for the future. As medications and/or therapy begin to improve your mood you can begin incorporating the rest. These are intended to be additional steps or treatments to incorporate once someone is able to, as part of a thorough treatment plan. They are not intended to replace traditional medications or therapy.

Sleep “Hygiene”

Most of us realize how critical good sleep is to our overall health and mood. Mental health disorders often impact one’s ability to get adequate, good quality (deep) sleep. Then without adequate sleep, mood deteriorates further setting up a perpetual cycle. Sleep “Hygiene” is a set of tips and strategies focused on obtaining more sleep and better quality sleep without the need for medications. In many cases these strategies are going to be even more effective than medications and can be incorporated anywhere.

Harvard has a great article on “sleep hygiene”: 12 Simple Tips to Improve Your Sleep

One thing they do not mention is that if you currently have irregular sleep patterns or are sleeping at odd hours of the day, switching back to normal patterns and hours can often make one feel worse temporarily while their internal clock readjusts. Additionally, if you take steps to decrease the level of light in your room, even small decreases may be beneficial. However, for a truly powerful effect you need to make the room extremely dark, which can take significant effort to initially set up.

Nutrition and Diet Quick Tips

Proper nutrition is paramount for good mood. The brain is like a finely tuned orchestra and needs to have a variety of adequate nutrients to function optimally.

 

  • Before starting any weight loss diet or making any significant dietary changes, speak to your healthcare provider.
  • Avoid or at least minimize processed foods.
  • Avoid skipping meals. Eat 3 meals per day with healthy snacks in between. Hunger and large blood sugar fluctuations are not good for your mood.
  • Listen to your body: If you feel bad or overly tired after eating something and this was not due to overeating, avoid this food in the future.
  • Drink lots of water! You can never go wrong with water, especially filtered water. Soda is liquid candy and empty calories. Eating fruit can be healthy, but fruit juice has minimal health value even when it is real fruit juice and not a substitute.

If your normal diet consists of processed junk foods and refined sugars and you change to a healthier diet you may temporarily feel worse. Many unhealthy food items and refined sugars can be addicting and sudden cessation can make individuals temporarily moody. In the long run the reverse will become true and many report less interest in, and less enjoyment from, eating unhealthy food. If your diet is very poor and you struggle to change it you may need to make slower incremental changes.

 

If you are overweight, feel that some of your depression is related to this, and are trying to lose weight:

 

  • As always speak with your personal healthcare provider before beginning any regimen.
  • Set a realistic weight loss goal in coordination with your healthcare provider. Do not be overzealous and strict about dieting. Our brains have evolved over thousands of years to ensure our survival above all else. If you make large abrupt changes to your intake your brain will think you are starving. When this happens you will naturally begin to experience powerful food cravings. These cravings will often be for more calorie dense foods as the brain prioritizes high calorie foods to fend off starvation. You will likely feel miserable during this process and begin to “hate” dieting. The more extreme the diet, the higher chances of failure. When the diet ultimately fails and you remember how “terrible” the process was it reinforces the idea that dieting has to be some horrible period of time. Therefore, any future diets may be avoided and pushed out further and further and the process ultimately reinforces and repeats itself. You may psychologically beat yourself up about “failing” to diet and become even more depressed.
  • Avoid fad diets: Carbs and fats are not evil, they are vital nutrients and just need to be balanced and consumed in moderation.
  • Exercise is enormously beneficial for physical and mental health. However, it will not have a major impact on weight loss for most individuals as the body quickly adapts to the changes. Most weight loss will come from food intake.

Plan well, take your time, go slow, and dieting does not have to be an unpleasant experience.

 

Exercise

Exercise is enormously beneficial for both your physical and mental health. The fact that it has such major benefits, costs nothing, and can be performed nearly anywhere make it an absolute must for mental health. It helps reduce depression, stress (see the next section below!) and anxiety. It leads to feelings of relaxation, well-being, and sometimes even euphoria such as the “the runners high.”

If the idea of “exercise” conjures negative thoughts, take a moment to reframe your thoughts and change your attitude about exercise! Exercise can be achieved in so many different ways it does not have to be the activities that you may dread. It can be a simple walk, using a treadmill, skiing, biking, hiking, swimming, weight lifting, and so many different activities. Try to incorporate something you enjoy into the activity and the exercise won’t feel like such a chore. Maybe this means watching a television show while on a treadmill or biking through a scenic area with an amazing view.

As always get cleared by your primary healthcare provider before beginning any exercise regimen. Any new exercise program should be started slowly. Ease into any serious program or you will make yourself feel worse instead of better during the transition period.

Stress

Stress is the king of depression and anxiety.

The importance of reducing stress cannot be overstated. Both chronic and acute stress contribute to and exacerbate mental health disorders. They can cause real damage to brain cells and brain functioning. Stressful events and trauma often precede severe mental health episodes. Trauma and stress may potentially even activate new, life-long mental health disorders that would remain dormant or be much less severe under less stressful circumstances. While some stressors and trauma are unavoidable and unpredictable, by taking steps to minimize chronic stress and avoid known acute stressors when possible, one will be better able to manage severe stressors when they do arise.

Exercise is great for stress reduction as is engaging in meaningful activities and hobbies with individuals whose company you enjoy. Stress reduction can involve carefully making life decisions about partners, friends, careers, and whether or not accept that (stressful) promotion at work so as to avoid those which are going to make us more stressed and unhappy.

Caffeine

Coffee, tea, soda, energy drinks, even decaf coffee and chocolate contain caffeine. Caffeine may be an effective though short-lived antidepressant when used in moderation in a healthy adult. While it appears generally safe it is a psychoactive, addictive drug and can make depression and anxiety worse as well.

If you indulge, limit caffeine use to mornings. Large amounts of caffeine and caffeine use later in the day interfere with one’s ability to obtain sleep, particularly deep, restorative levels of sleep. Caffeine is a stimulant. It sends out stress signals and reduces one’s ability to relax. It can cause or aggravate anxiety. If you have bouts of panic or severe anxiety, caffeine use should ideally be eliminated completely.

Those drinking large, excessive amounts of caffeine as an antidepressant may be making the depression worse. While small and moderate amounts of caffeine are thought to be relatively safe, excess amounts are probably detrimental to physical health as well. If it is determined that caffeine use should be reduced: except in severe cases it is usually better to reduce caffeine intake very slowly to avoid withdrawal symptoms.

Underlying drug and alcohol abuse (including prescription drug abuse) or addiction

In many instances where patients have not responded to extensive medication trials and therapy it is often discovered they have an underlying substance use disorder that was not shared with their treatment team. This may have started as a self-medicating attempt but over time made things worse and created additional problems. Just know that it is nearly impossible for a provider to effectively treat any patient if they do not have a comprehensive understanding of your case. While many patients may be reluctant to share this information out of fear of being stigmatized, they will likely receive little to no benefit in treatment until this is addressed and explored. Additionally, mixing medications with alcohol or other drugs can be extremely dangerous. If you occasionally use alcohol or drugs this too should be shared so it can be taken into consideration in the context of the symptoms you are experiencing.

Final Words

While medication, therapy, and lifestyle modifications often have a profound and dramatic effect, some individuals struggle with some degree of depression or anxiety long-term. Minimizing the severity of the depression and anxiety often takes ongoing effort. Unfortunately, some become overly preoccupied with finding an instant solution or a miracle medication that will quickly alleviate all of their symptoms, when they should be implementing various small lifestyle changes and strategies in addition to engaging in therapy and medication trials. Effective management of depression or anxiety often takes the incorporation of many little steps. Practicing sleep hygiene, eating properly, attending therapy and taking medications, minimizing stress and making time to engage in activities one enjoys and that give them a sense of purpose and meaning, exercising, and actively attempting to change negative thinking patterns (and so on) as a whole can have a profound and dramatic effect.

Due in part to the unfortunate history and treatment of mental health disorders in our country, the psychiatric specialty has lagged behind other areas of medicine significantly. No doubt as time progresses and we begin to understand the brain more thoroughly, newer and more effective medications with less side effects will eventually hit the market. For those who feel like they have tried everything, maintain hope because new medications will be produced. If several medication and or therapy trials have been unhelpful for you, try to view treatment as piecing together a large puzzle step by step and piece by piece instead of focusing on finding an instant solution. With time, effort, and a commitment to participating in treatment, the vast majority of patients do significantly improve.

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