This post addresses general considerations for managing one of mental health’s most common maladies: depression.  According to the World Health Organization approximately 264 million people are affected globally by depression.  Suicide is the second leading cause of death in 15-29 year-olds, with almost 800,000 people dying of suicide every year.  We will examine the vicious cycles created by the disease in order to understand how to prevent progressive deterioration.  We will also identify central focal points to learn how to generate positive, virtuous cycles through which we can cultivate psychological endurance and resilience.  

The first step in attending to potential depression is diagnostic assessment.  To make things simple there are 10 cardinal symptoms of depression.  If 5 or more of the symptoms are present for over a two-week period, then that is clinically defined as a Major Depressive Episode.  The diagnostic criteria are listed in the DSM-5 (the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders).

1. Persistently depressed or irritable mood.
2. Uncontrollable crying spells or angry outbursts.
3. Anhedonia, or the inability to enjoy activities that might usually be considered pleasurable, including disturbance of libido and social isolation.
4. Significant weight gain or weight loss; e.g., a change of more than 5% of body weight in a month.
5. Sleep disturbance: either not being able to sleep or sleeping way too much.  7-8 hours of sleep per night is considered ideal.
6. Anergia, or feelings of fatigue or loss of energy.
7. Feelings of inappropriate guilt or worthlessness.
8. Decreased ability to think or concentrate.
9. Psychomotor agitation or retardation; being observed to be highly restless or lethargic.
10. Recurrent thoughts of death or suicide.

Depending on how many symptoms are present we can conveniently use this as a rough measure of how severe someone’s condition might be on a scale from 1 to 10, with 10 being the worst and most severe.  In cases with 8-10 symptoms present or if recurrent thoughts of death or suicide are present, individuals should immediately seek professional assistance and would be recommended to begin supervised treatment with talk therapy and antidepressant medication as soon as possible.  The danger is that if left untreated, depression can be rapidly progressive and escalate quickly to an adverse outcome.  

Once we have identified the presence of depression and evaluated the need for acute intervention, the next step is to focus our attention on what I refer to as the Five Keys to Recovery.  

Key #1

To begin with I always try to remember the medical principle of Primum Non Nocere, or First, Do No Harm.  The first key is to make certain we do no harm to ourselves, especially in times of crisis.  It is easy to fall into a trap by desperately reaching for something that we hope will make us feel better even though we know it will ultimately make things worse.  Using drugs or alcohol to help us sleep or make us feel happier can lead to dependence and addiction.  Other self-indulgent activities like eating unhealthy foods, promiscuity, compulsive gambling, and excessive spending are also popular standbys.  I have some experience with all of them and can personally attest to their lack of efficacy as antidepressants.  I consider all of these traps because when we reach for things that feel good in the short term but are inevitably bad for us in the long term we start off with one problem but end up with many.  The pitfall of mindless behavior must be avoided at all costs to prevent depression from metastasizing. 

Key #2

The second key is to make a commitment to our physical health because as Norman Maclean wrote, “The body fuels the mind.”  This is closely related to the first key because devoting ourselves to a healthy path will naturally steer us away from those things that might feel good now but will be bad for us later.  Attending to our physical health ensures that we won’t do anything to make things worse.  If we can marshal our focus in times of distress and prioritize our physical health we will always make certain that we are containing the situation and preventing further escalation of the problem.  

I find nothing to be more emotionally and mentally therapeutic than sports and physical exercise.  When I am emotionally upset or feeling mentally disturbed I have learned to immediately lace up my running shoes and head outside for a run, or hop on the treadmill and crank it up.  The more upset I am the faster I run.  With consistent practice I’ve discovered a few interesting things.  One is that when running hard it is extremely difficult to think about anything other than breathing and turning over your feet.  During times of sadness or stress I often feel tortured by my own thoughts and emotions; during my worst periods of despair I found that 1-2 hours of hiking or running would quiet my mind and at least provide me with some brief respite.  The other thing I found was that it is very difficult to be angry or upset about anything after a long, hard run.  Usually I am just tired and happy that I am not running anymore.  

By rechanneling emotional pain into physical activity we can sublimate the adversity into a positive gain.  We’re effectively taking life’s lemons and making lemon bars.  If we choose to deal with our distress by focusing on physical fitness we not only contain the situation but are ultimately rewarded with improved physical health, which is invaluable.  The net effect is that as my stress grows, my running distances increase, my pace quickens, and my waistline shrinks.  That sense of accomplishment now gives me something to feel good about and is the first step towards turning the tide.  

Key #3

The third key addresses insomnia as one of the most common and problematic symptoms of depression.  Insomnia is particularly troublesome as it creates a vicious cycle that can cause precipitous deterioration.  Sufficient sound sleep is a cornerstone of physical, emotional, and mental health.  We require deep, restful sleep to reset all of our neurotransmitters, activate our immune systems, rebuild our bodies, and heal ourselves.  When depression strikes it often disrupts our sleep patterns first; whether it is the inability to fall asleep, early awakening with inability to return to sleep, or lying in bed for 12 or more hours per day but still not feeling rested and energized.  The vicious cycle is born when someone starts feeling depressed and begins struggling with insomnia, which then makes them feel worse.  The worsening depression makes them sleep less which further aggravates their depression, which then makes them sleep even less which again further worsens their depression, and so on until they are not sleeping at all and the depression becomes severely debilitating.  Therefore the third key to recovery is to make sure that we are getting enough good quality sleep.  

I recognize that is definitely much easier said than done.  Even as a child I have always suffered from poor sleep, and when I become depressed or anxious, insomnia is consistently the first symptom to rear its ugly head.  When I’m upset I find it nearly impossible to fall asleep and stay asleep.  I’ve tried everything you can imagine to address the problem, all with limited success and each with their own accompanying side effects.  What I’ve found is that the combination of physical exercise and yoga is the best tonic for my chronic insomnia, and this discovery has truly changed my life.  A nice long run or spirited weightlifting session followed by a hot shower and 30 minutes of restorative yoga often knocks me out before my head hits the pillow.  

Physical exertion and yoga can be very helpful but are often not enough.  Good sleep hygiene is also critically important and frequently neglected.  Start by setting, and sticking to, a bedtime that ensures sufficient rest.  In addition, I try to stay away from the phone, tablet, computer, and TV for at least an hour before bedtime to help my overstimulated mind slow down and prepare for sleep.     

If the insomnia persists there are some over-the-counter options.  Using melatonin regularly has helped me tremendously in times of need.  Melatonin is a naturally occurring hormone that helps control sleep/ wake cycles; it is non-addictive and has few side effects beyond drowsiness.  Sleep is a vital ally and making sleep a point of focus is essential during periods of depression.  Cultivating good sleep habits will prevent negative cycling and provide a solid foundation for psychological recovery.  If what I’ve offered is not effective there are many other options available via prescription.  Please contact your physician or consult with a psychiatrist to discuss what might be the best fit for you.

Anhedonia, or the inability to find pleasure in activities that might otherwise be considered enjoyable, is the other primary symptom of depression that drives everything into a downward spiral.  The problem is that when depression starts to manifest as anhedonia it discourages us from doing the very things that we most need to be doing.  Specifically, anhedonia targets our relationships and our passions that are so crucial to nourishing ourselves emotionally.  Social occasions start to feel more like chores or obligations, so we stop attending.  Because our hobbies and pastimes don’t feel as enjoyable as they used to, we stop engaging in them.  The net result is we wind up starving ourselves emotionally during our time of greatest need; withdrawal, isolation, lethargy and sloth soon follow.  If we succumb and cease pursuing what gives us joy, this triggers yet another vicious cycle.   As we become increasingly depressed, we isolate ourselves and spend less time doing the things we love which worsens our depression–so we isolate more and stop doing the things we love which makes us feel even worse, and so forth until we are totally alone, living an utterly joyless existence, and depression completely consumes us.  

Key #4

We all require healthy interpersonal relationships and attachments.  Humans are inherently social creatures who need a sense of acceptance and belonging to feel emotionally secure.  The joy we get from spending time with people we care about, and who genuinely care for us provides us with emotional sustenance.  That leads us to the fourth key to recovery: make sure to spend time with friends and family.  

Like any wounded creature, when we are in pain the reflexive instinct is to hide and lick our wounds.  When depressed we can become unusually sensitive or irritable and prone to outbursts of emotion.  In this state socializing is arduous.  But no matter how difficult it may be, we must concentrate our resources on pushing past the urge to isolate ourselves because we know that social withdrawal will only lead to greater despair.  The joy and emotional comfort we derive from our social support system is the salve necessary to heal our emotional injuries.  Socializing might feel acutely unpleasant at times.  But just as applying any topical treatment to a wound might cause some pain or discomfort, it is also a crucial part of the recovery process.  

On the game show Who Wants To Be A Millionaire? contestants are given 3 “lifelines” or calls they can make to friends or family to aid them with difficult questions.  If you are reading this and can’t think of 3 friends or family members that you can call, this is a red flag.  We need lifelines in life, just like in game shows.  I recognize that I am extraordinarily blessed with a tight-knit family and great friends, and I realize that many others are not so fortunate.  People can be selfish, insensitive, and unbelievably malicious.  But it is important to know that people can also be giving, empathetic, and incredibly kind.  It may take a while as the former tend to outnumber the latter but investing time in finding and building healthy relationships with quality people will yield invaluable returns.  Go to your local church, mosque, temple, or community center.  Join a gym or a book club, find a softball league, take an art class or some music classes.  These are just a few ideas to get you started.  Whatever it is that you like to do, try to find other like-minded people and connect with them.  I cannot recommend anything more strongly, as I can testify that we only get by with a little help from our friends.   

Additionally, there are a host of people who have dedicated their lives to educating and training themselves on how to help those in need; professional lifelines!  I cannot state it more emphatically, we must absolutely resist the urge to go it alone.  No one is an island.  There are therapists and counselors available, often covered by insurance or accessible through non-profit organizations.  Don’t hesitate to call and accept the help that is being offered.  In times of need I have participated in both individual and group therapy, so I can definitely understand how uncomfortable and vulnerable it feels exposing yourself emotionally to complete strangers.  But I can also attest to the healing power of being understood, validated, and accepted without judgment. 

Key #5

As previously discussed, anhedonia not only affects our relationships but also our hobbies and pastimes.  As depression sets in, these activities don’t feel as enjoyable as they used to, so we stop engaging in them which can trigger yet another vicious cycle.  Just as we need a strong social support network, we also need to have activities that we look forward to and get excited about doing.  That leads us to the fifth key to recovery: make time to do the things that bring you joy.

The most emotionally stable people I’ve met all have hobbies and pastimes that they are passionate about.  They derive great pleasure from their sport, art, music, or craft.  I am obsessed with snowboarding.  Having something like that is essential and provides us with emotional nourishment to sustain us in difficult times.  We all need at least one thing we can be passionate about that makes life fun and worth living.  Without it the converse is that life gets pretty bleak and starts to feel like maybe it is not worth living.

If you are reading this and lack healthy outlets please make it a point to go out and find at least one.  Ideally this should be an activity that is productive or constructive without costing too much money.  Not sure where to start?  I suggest thinking about people you admire or things which have always had some allure to you.  Go back to your childhood and remember the things you dreamt about doing when you were a kid.  I have always admired musicians and been drawn to the sound of drums.  As long as I can remember I’ve also been fascinated by sculptures.  If the occasion were to arise I know that I’d immediately buy a pair of sticks to start banging around with or head to my local community college to see if they’re offering any classes on sculpting.  Try one on for size.  If you find it doesn’t suit you, move on until you find one that’s a better fit.  It will be one of the best investments of time and energy you can ever make.  

I have gone through several episodes of depression in my life.  Around Christmas of 2011, while working on this project, I lost one of my best friends quite suddenly: Patrick George Monroe.  I was just getting back on my feet following a bad breakup and I took his passing very hard.  I fell into the deepest depression that I’ve ever experienced.  The anhedonia hit me like an avalanche.  I was living in Truckee, California near Lake Tahoe, surrounded by beautiful snow-covered mountains in the middle of ski and snowboard season and had completely lost the desire to ride.  Pat was a surfer and had been very influential to my discovery of snowboarding as a passion.  He was supposed to visit me that February and after he died, every time I tried to get dressed to go to the resort I would break down in tears as I remembered our plan that never came to be and thought about how much I missed him.  

Having some awareness of what I was dealing with, I made sure to focus on the things that would help.  During the winter after his passing I am grateful for the company of my brother, Bradley, and my friends and family who saw me through my depression.  All I wanted to do was dig a hole, climb into it, and disappear.  But again, having some perspective on my situation I pressed forward.  I made a commitment to myself that no matter how poorly I felt I would accept my friends’ invitations, get out, and spend time with my loved ones.  I told myself that I could either remain fixated on the dear friend I’d lost, or I could try to appreciate the wonderful friends and family I still have.  I am certain I was not the best company during those days and that only makes me more thankful for my friends and family who stood by me, for I would have been lost without them.

I stayed focused on fighting through the anhedonia to make sure I did not miss a day on the hill that season.  I told myself that Pat would want to see me riding my snowboard.  I told myself that Pat’s spirit would always be closest to the things that he loved the most: the ocean, the forests, and the mountains.  If I wanted to be close to him then I would have to go there to see him.  It was one of the most challenging things I’ve ever encountered but I knew that if I succumbed to the anhedonia, my condition would surely worsen quickly.  I forced myself to go no matter how hard it was.  I can report that with time things got easier and fortunately I started to feel better.  No matter how difficult it was to get up and go in the morning I always felt better at the end of the day; if only because I could console myself knowing that Patrick would be happy that I went.  Thankfully, day by day and little by little my spirits lifted and eventually the depression abated.  It has been over ten years now but I still think of my friend whenever I am in the mountains.

Life invariably hits us with punches we don’t see coming.  Adversity and misfortune must be accepted as givens in the equation.  The first step is recognizing and being aware of the situation.  Knowing the signs and symptoms will allow us to identify the problem and address things before they have a chance to snowball.  The good news is that there is a formula for developing emotional endurance and cultivating mental fortitude.  We can learn how to manage stressful situations and prevent them from becoming severe cases of depression.  Understanding the way depression creates vicious cycles through insomnia and anhedonia helps us to formulate our strategy.  The Five Keys to Recovery will help to guide us:  

1-  Stay away from things that might feel good but are ultimately bad for you; they will only make things worse.  The principle of Primum Non Nocere or First, Do No Harm applies most importantly to ourselves.  

2-  Focus on your physical health.  The body fuels the mind.  Sublimating our emotional pain into physical fitness provides a strong foundation to build from and helps steer us away from any potential pitfalls.

3-  Get good sleep.  We must focus on stabilizing our sleep patterns since we know good sleep is essential to physical, emotional, and mental health.  Uncontrolled insomnia will undermine our efforts.  Depression will strike here first so we must be prepared. 

4-  Spend time with friends and family.  Focus on our relationships, the ones that matter most, the people you trust the most.  They will be our closest allies in the fight.

5-  Make time to do the things that bring you joy.  The last step is to be conscious of the onset of anhedonia and lean on our hobbies, pastimes, and passions as our primary lines of defense.   

As emotional storms build we start to lose our mental clarity and our thinking becomes clouded.  Look to these principles as beacons to help us find our way.  If the tempest rages too strong and we become overwhelmed, we must reach out for professional help immediately or risk being swept away.  Know that there is always help available, we must be willing to accept the assistance that is offered.  And most importantly, never lose faith, never lose hope, and always remember that the storm will pass.