The Vicious Cycles of Depression

There are plenty of theories about what causes depression.  And many of them overlap with each other in some of their concepts. But here is another theory, one that is often in my mind as I am treating patients.  It is not necessarily different from other existing theories, but it has a somewhat different emphasis.

It seems to me that depression is an illness involving numerous vicious cycles.  Event A leads to Event B, which leads back to more of Event A, which leads to more of Event B, and so on.  There are a variety of these cycles in depression.  If there was just one, it would be easier to treat.  But there are several, and each keeps perpetuating itself. 

The theory doesn't really address the issue of what starts depression in the first place.  But it does help explain how a mild depression can turn into a severe one.

Here are some of the vicious cycles which I see in the depressions my patients struggle with:

Cycle #1--Withdrawing from the World.  Depression increases passivity and decreases social interaction.   This in turn isolates the person and deprives them of interpersonal stimulation. They don't get the social support and distraction from negative thoughts which they would otherwise get from interpersonal relationships.  They are increasingly left alone to deal with negative thought distortions on their own without any corrective input from non-depressed persons.  This in turn increase depression.  Which increases social isolation.  And so on.

Cycle #2--Negative Thinking.  Depression increases negative thinking about self, world, and future. The increase in negative thinking increases the depression level. The more depression a person has, the more negative thoughts are generated in the brain.  This is the basis of cognitive therapy. The cycle of negative thinking to depression and back to negative thinking has to be interrupted.

Cycle # 3--Possible Negative Effects on Nutrition.  Depression often decreases the appetite, which in turn may be depriving the person of important nutrients relevant to mood, well being, and health, thus increasing depression, and so on.  The depressed person may opt for a high carbohydrate (high sugar), junk food diet because they don't want to eat, or don't feel up to cooking a more balanced diet.  They seek out foods that will medicate their immediate feelings, not foods that will provide good nutrition for their brain.  Lacking good nutrition, the brain may be more susceptible to depression.  The link between nutrition and depression has not been proven, but there are some studies suggesting that there may be a connection.

Cycle #4--Decreasing Assertiveness.  Depression  makes people less assertive and less likely to use good problem solving techniques.  When people are less assertive, they don't get their needs met.  Aggravations in their environment can continue unabated.  Problems pile up.  And depressed persons generally do not follow well thought out problem solving approaches that would be needed to deal with the stresses they face.  The ongoing presence of stresses keeps them depressed.  The lack of assertiveness and/or problem solving allows stresses to get worse (such as by building up finance charges on credit cards), which can make the person more depressed.  And so on.

Cycle #5--Downward Spiral of Physical Activity.  Depression makes people less active, which means that some of the benefits of exercise (e.g., brain derived neurotrophic hormone and so on) are not obtained.  (Neurogrowth hormone is a naturally occurring substance in the brain which helps nerve cells grow.)  Theoretically, nerve cell growth or regrowth in the brain may be necessary to recover from depression.

The lack of activity also means that the depressed person is deprived of positive environmental stimulation (lights, sounds, tastes, etc.)  Even though these stimuli may be less interesting and less pleasurable than when the person was non-depressed, they may still give some pleasure, and these may be almost totally absent as the person withdraws into their house and/or room.

Cycle #6--The Cortisol Loop.  Psychological stress causes increases in cortisol.  Cortisol has a negative impact on brain function, although we are not sure all of the different ways this may affect it.  The impact of cortisol on the brain (or of other stress related chemicals)  may then cause the brain to go into deeper depression.  Which causes more negative thinking, less energy, and so on.  And so on.

Cycle #7--A Lowering Availability of Mental and Physical Energy to Cope with Stressors.  Let's say a person goes into a mild depression. This reduces their energy and likely increases their negative thinking about how much they have to do. A molehill starts to seem like a hill; a hill starts to seem like a mountain; a small mountain starts to seem like a big mountain.  There is a perceived difference between what they have to do and overcome on the one hand, and how many resources they have for the task.  The person may get an overwhelming feeling of, "I just can't do it all." This is not just a thought process. It is visceral--felt in the gut. They see their tasks as overwhelming, but they also feel it to be overwhelming because they are so fatigued due to the depression.

These vicious cycles all have the capacity of deepening depression to moderate or even severe levels.  For that reason, intervention can be needed to help someone recover. 

In other cases, depressed persons may succeed in eliminating the external source of stress.  That is, if they are without a job, they may succeed in getting another suitable position.  In still other cases, time may cause the external stress to seem less important.  If we lose a job today, it may feel overwhelming, but in two years, it may seem much less important.

Whatever the reason, the vicious cycles of depression fortunately do not go on forever for most people.  If, on the other hand, a person's depression does seem to be going on and on without any let up, then it would be logical to bring in an outside influence such as a psychotherapist, to help break up the cycle.

Don't Let Your Grief or Loss Turn into Depression

Very often, I work with people who have recently suffered some type of important loss in their life, usually a spouse or significant other.  The loss can be through death, divorce, or the break up of a relationship.

This process is almost always painful, but it is important in these situations to separate out the necessary pain from the unnecessary pain.  The necessary pain is the grieving.  Grieiving is the way that the mind detaches from someone with whom the grieving person has bonded.  Grieving hurts badly, and I wish that it was not necessary, but it is.

On the other hand, depression is not necessary.  Depression is more severe, more pervasive, more disabling, and to some degree has a different symptom picture.  "Uncomplicated grief" is different from grief that develops into depression:

• In grief, the negative thoughts tend to be more realistic, such as "I will miss them terribly," or "they were unique," rather than "I will always be alone" or "There is no one else that I can be happy with."
• Similarly, feelings of worthlessness are not part of grieiving.  To the degree that guilt is present, in grieving the feelings are limited to specific incidents regarding the deceased; in depression, it may be more pervasive or illogical.
• In grief, suicidal thoughts are usually not present.
• In grief, there is usually not the intense psychomotor slowing (slowed thoughts and movements).
• In grief, there is usually not too much work impairment.
• Depression tends to be more pervasive, and nothing may lead the person to feel much better, whereas in grieving, the support of friends and family is more likely to help the person.

There are probably at least four pathways by which grieving becomes depression.

Pathway #1.  Negative thinking.  In this pathway, the person doesn't simply miss the person that has died or left them; they attach very severe negative interpretations to it.  "I'm a loser; I will never find anyone else; I'm ugly; it is my fault that he left me; I'm being punished by God by Him taking my husband away."

Pathway #2.  Excessive withdrawal from life.  Many of us have a tendency to withdraw and "lick our wounds."  To some degree this is normal.  However, it is quite possible to withdraw so much that we interrupt the flow of our daily lives.  We pull back from life so far that we cannot recieve any social support.  We may pull back from pleasurable experiences in general.

Pathway #3.  Triggering an underlying genetic tendency towards depression.  For some people, the depression is not due to what they are doing or thinking but to the way their brain responds to stress.  They may have already experienced major depression in their life.  In this case both medication and therapy may be needed.

Pathway #4.  The triggering of old memories.  The loss of someone in adulthood may trigger painful, unresolved feelings from some event very early in life, such as the death of a parent.  Again, therapy might be helpful in this situation.

In general, when I am helping someone who is going through this process, I try to allow them to grieve in whatever way is comfortable to them, but within limits.  I try to keep them from falling into the trap of excessive negative thinking, or from pulling back so much from life that they have no enjoyable experiences.

Is It ADHD--Or Is It Anxiety--Or Is Depression?

In psychology and psychiatry, we are almost always presented with the issue referred to as differential diagnosis.  There is often more than one diagnosis which can explain a set of symptoms.

For example, with ADHD, there are deficits in attention and other aspects of executive functioning.  However, these deficits can be caused by many reasons.  Some of the most typical causes (besides ADHD) are depression and anxiety.

In depression, if it is severe enough, the brain is not working at maximum efficiency.  In fact, it is like a car trying to go up a hill when three out of six spark plugs are not working.  There just isn't the power to do what it needs to do.  Concentration and memory consolidation are affected.

For an example of a pet scan in depression, go to http://www.mayoclinic.com/health/medical/IM00356
(Pet scans are like an xray of the brain.  However, instead of revealing structure, they reveal activity levels.  They show the level of glucose utilization.  Red and orange areas show high levels of glucose utilization, hence indicating higher levels of brain activity.  Purples and blues indicate lower levels of brain activity.)  In the petscan at the Mayo Clinic link, you can see how the brain which has recovered from depression is more active than the brain in a state of depression.)

In anxiety, the person has a hard time concentrating.  They may feel fuzzy headed, or they may be distracted by their worries.  This interferes with attention, and when there is impaired attention, it is hard to learn.

Of course, it is quite possible that a person will have both depression and ADHD, or anxiety and ADHD.  Depression, at least in a mild form, is often a result of ADHD in children and teenagers because they are not doing well in school and perhaps not being accepted by their peers.  On the other hand, the more severe that the depression is, the less likely it is to be explained by depression, and the more we have to start looking at other causes.

The Myth of Christmas Depression?

Through my career, I have often been asked to speak on the topic of holiday depression. The problem is that research indicates that it may not exist--at least for our country as a whole.

There is no evidence that there is more depression around Christmas than at other times of the year. In fact, the suicide rate is highest in the spring, not at Christmas.  There is no apparent in suicide around Christmastime.

Most clinicians do find a rise in depression in late fall, for persons who are normally prone to depression. While this could be due to the approaching holidays, there is more evidence to support the idea that it is due to Seasonal Affective Disorder and the lessening sunlight of fall.

There is no doubt that Christmas is depressing for some people. We are bombarded by happy images on the TV, and if our family isn't/wasn't like that, then we may indeed feel down. However, for other people, Christmas is a time that lifts their spirits, and so there is an offsetting effect for people in general.

I don't want to make light of the problems that some people have with Christmas and Thanksgiving. For some, it may be really difficult. But the idea that there is more depression at Christmas is essentially an urban myth. There can be depression at any time of the year, and like any depression, if it goes on long enough, it might be wise to seek treatment.

Getting "Over the Hump"

Many times my depressed patients find themselves stuck. They are at home, fatigued, sad, and filled with negative thoughts. What is often needed at times like that is to get out of the house and get some new experiences. Staying at home and watching TV is not sufficient stimulation to distract them from their internal negative thoughts. However, getting out can be difficult. It requires energy, and that is something they often don't have.

But once they are out, they usually feel better than if they had stayed at home. It would seem like a paradox. Why don't we do what is good for us?

I think that one answer is to use the example of a lawnmower. It takes initial energy to get the process started. Then once it is started, it runs on its own. A scientist patient of mine compared it to the energy of activation of a chemical reaction. It takes an external input of energy to get the reaction started; after that it is self-sustaining.

So the depressed individual needs something to get them "over the hump," to get them going. Then once they are out of the house, they often feel better than they would have felt if they just stayed at home watching TV or sleeping.

What is the solution? In therapy, I find that it works best if there is a plan. Once the patient has a plan, they are more likely to follow through. One plan is to make a commitment to get together with other people. Another type of plan is to buy tickets. People often will follow through with a concert or event because they have already put money down on the tickets. Another type of plan is to have someone come by to pick up the person and go out. It is hard to turn someone down who has made the trip over. There are probably many other types of solutions to this, but these are a few.

I think that another important type of plan is to look objectively at the consequences of staying home. Does it make the person feel better? If not, then the next time they have a chance to get out, they need to remember that staying home may be the easiest thing to do for a few minutes or an hour, but it may lead to more depression over the next several hours than getting out would.

Stress, Cortisol, and Depression

What’s the evidence to think there’s a link between stress and depression?

There are 23,000 references in PubMed if you type in stress and depression.

The first type of evidence is epidemiological: People who have just had major stressful events are statistically more likely to fall into a depression.

Stressors are 2.5 times more likely in depressed patients compared to controls.

In community samples, 80% of depressed cases were preceded by major life events

Most episodes of major depression are preceded by stressful life events (although
most people do not become depressed even if they experience a negative life event).

It all seems so obvious that stress could lead people to be depressed. But actually it’s not.

For example, why doesn’t excessive stress cause something else? Why doesn’t it cause us to run amok, doing all sorts of wild and crazy things? Why depression?

Why doesn’t stress cause us to work harder? That would be logical–for our bodies to pump out more adrenalin and make us work harder to fix the problems we face.

The answer is we don’t know.

But to have any chance of understanding the human stress response and depression, we have to start with the basic nature of the human stress response.

We have a generalized response to a variety of stresses. Psychological stress and physical stress on the body generally lead to the same set of hormonal responses within the body, which is in itself unusual, or at least, counterintuitive.

We have one main stress response syndrome in our body:
Perception of threat
Hypothalamus activation
Pituitary activation
Adrenal gland activation
Adrenalin+Noradrenalin+Cortisol

During stress, a chain reaction of physical and chemical processes prepares the body for a fight or flight situation. After the logical, thinking part of the brain recognizes that danger is present, another part of the brain, the hypothalamus releases Corticotropin Hormone Releasing Factor (CRF). This in turn stimulates the pituitary (the “master gland”) to release Adrenocorticotrophic Hormone (ACTH). The release of ACTH triggers the secretion of cortisol from the adrenal cortex (the adrenals are located on the kidneys) to provide energy and to help suppress inflammation. Through a neural pathway (that is, via a nerve rather than chemical release in the blood stream), the adrenals are also stimulated to produce more chemicals called adrenaline and noradrenaline. These in turn serve to accelerate the pulse rate, elevate blood pressure, and stimulate the central nervous system.

The fight or flight response is a good thing. It has saved many of our forbears from saber tooth tigers and other dangers. But what is good for us in the short run is not necessarily good for us in the long run.

And cortisol is one of those things. I believe that our best bet at the current time to understand why stress would lead to depression is cortisol.

We do have some evidence that that may be true.

Cortisol like drugs, i.e., steroids, can cause depression as one of their side effects.
People who are given high levels of synthetic glucocorticoids for autoimmune disorders or inflammatory issues have greatly increased risk of going into a depression.

Secondly, we know that long term exposure to cortisol results in some really nasty effects on the brain, particularly the hippocampus. The hippocampus is the memory center of the brain. It also does something else. It modulates the release of cortisol. Long term exposure of the hippocampus to stress leads to loss of neural branches called dendrites. And it leads to problems with memory loss.

If cortisol has a damaging effect on the hippocampus, then it also might have a damaging effect on other parts of the brain. There is only one article I found on this , but it could be true. The negative effects of prolonged cortisol exposure occur throughout the body, so it is not a far stretch to believe that we have only begun to understand the negative effects of it on the brain.

Thirdly, about 50% of people with depression hypersecrete cortisol. Of course, by itself this proves nothing. But it would be consistent with the hypothesis that too much cortisol leads to – too much cortisol. In other words, stress leads to too much cortisol, which can lead to damage of the hippocampus, which unleashes more cortisol.

By the way, elevated cortisol levels occur in mania as well as depression.

Now, let’s transition from looking at depression as a biological disorder to looking at the psychological aspects of depression.

It is certainly possible that once we become depressed, the depression itself stresses us. It enhances our negative thoughts, which increase our perception of threat and stress, which increases our cortisol output, which in turn would further cause disorder of brain functioning.

There is some evidence that the anterior cingulate, a curved bundle of nerves around the corpus callosum between the limbic system and the prefrontal cortex is affected by or is causing depression. And there is a small amount of evidence that high cortisol levels can cause atrophy or smaller volume in the anterior cingulate.

And there, the physiological trail runs cold. We just don’t know the rest. But sometimes a bad theory is better than no theory at all.

So here is the theory in my head when I am working with patients.

Stress begins for most people as a psychological process, although there are also physical components. If my wife is in the hospital, I may sleep different hours, eat different meals, and so on. But also there is mainly psychological stress.

Then the HPA axis causes the release of cortisol. If this is on a sustained basis, the long term effects of cortisol affect the hippocampus and perhaps the anterior cingulate.

Since the hippocampus is supposed to help regulate the HPA axis, if it is impaired, then the HPA axis may get further out of control leading to more cortisol.

Ultimately, the anterior cingulate and the serotonin pathways are affected, leading the person to become depressed if this goes on for too long, and the person has certain genetics.

But even if the trail runs cold, we may know enough to inform our decision making. Stress, particularly prolonged and severe stress is not our friend. Combatting stress takes time and energy, and in some ways it is simply easier to let ourselves be stressed out, even if that is more painful. But it is not good for our brains and it is not good for us. And depending on our genetics, it is often a luxury that we just can’t afford.

Thinking about stress psychologically.

Stress is not just the result of a situation. It is the combination of the situation and our way of perceiving the situation.

We used to think of, or I used to think of, stress as something which could go away. And once it went away, then everything would return back to normal. This way of thinking clearly has gone out the window. Memory will sometimes return back to normal after exposure to chronic stress is over, but not always.

And multiple depressions leave us even more vulnerable to further depressions. Thus, we cannot conclude that we simply return back to normal.

I sometimes say to my patients that stress is a luxury that we can’t afford. What do I mean by that? Because oftentimes, there is little that we can do about stress. Either we are stressed or we aren’t.

But that’s not quite true. There are things we can do about stress.

Cognitive therapy, for example, is aimed at helping people to be less stressed by situations than they otherwise would be.

So there is some sense in saying that stress is a luxury that we can’t afford. To the degree that we do have any control at all over our stress, we cannot afford to let ourselves sink to the bottom of the pit, with the idea that we will eventually bounce out. For some of us, this undoubtedly triggers a genetic response of biological depression. For others of us, it may impair our hippocampus if this goes on for months or years. And for others of us, it may do both.

So if stress is a luxury that we cannot afford, what can we do about it?

This is where the panoply of typical depressive therapies comes in.

Cognitive therapy works to reduce irrational negative thoughts. Why is this important? Because without excessive negative thinking, our body just might turn off the stress response. Which could turn off the cortisol. Which would give our brains a chance to heal.

Behavior therapy sometimes works on assertiveness training. Why is this important? Because assertiveness often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Interpersonal therapy works on improving interpersonal relationships. Which again often fixes situations that we perceive as threatening, which means we don’t have to be stressed, which means that our bodies can turn off the cortisol, which lets our brains heal.

Therapy sometimes helps the person to gain control, or at least enhance their feeling of control, which etc etc.

Get the picture? We cannot afford the luxury of stress. If there is anything that we can do which can turn off the stress response, then we need to do it. If we can divert our attention for a few hours, so much the better. If we can fix the situation, so much the better. If we can find more adaptive ways of thinking about the problem so much the better.

The Triple Layer Cake

There is nothing like cake to get my attention. So maybe I have your attention, too.

This is the way I explain depression to my clients. It's like a triple layer cake.

Layer one is the original depression. Let's call it biological depression. Something has happened in the brain in response to stress. As a result, mild to moderate depression has set in. The person is having difficulty concentrating, less enthusiasm for doing things (anhedonia), and some fatigue. As a result, they aren't getting as much done. Their grades are going down in school. They are snapping at their children.

Now here is the kicker. Now they start to criticize themselves: "I am lazy." Or, they may think or say, "I am stupid." And so on. They are not able to deal with their decreased efficiency. They think that they "should" be totally in control of themselves, their symptoms, their behaviors, their lives, and if they are not, then they are defective. Now we have the second layer of the cake--being depressed about being depressed. This drives the person down deeper into depression--perhaps from being mildly to moderatly depressed all the way down to severely depressed.

Now for the third layer. The person stops doing the positive behaviors they used to do. They quit socializing. They quit doing their hobbies. They start developing the habit of thinking negatively. Old, good habits start to extinguish. New, bad habits are taking their place.

If the person is treated with an antidepressant, they may recover their appetite, their energy, their sex drive, etc. And this may well help layer two--their self blame, since they have less to blame themselves for.

However, the habits of negative thinking, avoidance, and withdrawal may remain even though many of their depressive symptoms are in remission. This is one of the tasks of psychotherapy--to make sure that the person fully returns back to their normal self.

Many of my clients find that this simple little model helps them understand how their depression became severe in the first place and also focuses them on what they need to be doing to recover. Namely, they need to quit blaming themselves for any remaining depression. They need to overcome their acquired habit of negative thinking (e.g., as in cognitive therapy), and they need to get back to their old positive habits of socializing and having pleasurable experiences.

The Dead End of Perfectionism

Many of the people consulting with psychologists have a problem with perfectionism. Some of them understand the problem and burden imposed by their own perfectionism. They are tired to having to do everything just right; they are worn out. Or they are depressed and they realize where the depression is coming from.

For others, doing things perfectly is a lifelong value, even a cherished value. They do not realize the full downside to the perfectionistic way of doing things. They may be depressed or anxious, and they may want to feel better, but they may want to feel better without giving up their quest for perfection.

There are multiple problems with perfectionism. These are discussed more fully in the chapter available on my website under "handouts."

Here are a few of the problems with perfection as a goal

• It leads to depression in some people
• It can alienate other people from us
• It leads to procrastination in some people
• It is ambiguous, that is it has unclear and confusing goals
• It can lead to focusing on minor details rather than the larger issues of life
• It is impossible to be perfect

Perfection may be a halfway possible goal for the child or teenager. Consider the sixth grader. What do they need to do to be perfect? Make straight A's, keep their room straight, and obey their parents. (Having "perfect" thoughts is more difficult, since sixth graders can have a lot of aggressive thoughts.) But with the coming of high school, it is much harder to make straight A's. And in the college years, almost impossible. Then, the person enters adulthood. They are a worker. What does it mean to be a perfect worker? If the job is straightforward enough, again it might be possible. But then they become a homeowner, and they have a house to keep up. And then they become a spouse. And then they become a parent. Now they have to be a perfect person, perfect worker, perfect homeowner, perfect spouse and perfect parent. Are there really enough hours in the day? No, there aren't. And something will suffer if they try to achieve perfection in one of these areas at the expense of another area.
Being perfect is ambiguous. As we have seen, it is relatively straightforward for a person to know what being perfect is in the sixth grade. But what does it mean at age 65 when we are retired? Does it mean keeping our lawn trimmed everyday and keeping the weeds out? Does it mean that we are volunteering? Does it mean that we are obeying all the rules? Or does it mean that we are learning which rules to break (as for example during the civil rights disobedience of the sixties). Does it mean that our house looks perfect to visitors or that we are being creative with our time? Does it mean that we keep outward appearances just right so that others will approve of us, or that we will use our time wisely so that we will approve of ourselves?
There are large issues in life, and these can rarely if ever be accomplished perfectly. Perfection is something we can accomplish when we vacuum the house. It is not likely to be accomplished in poetry, painting, volunteering, or even just helping out a friend. It is unlikely that we can write the perfect poem or be the perfect volunteer. The temptation for the perfectionist can be to do the smaller things which can be done more or less perfectly.
Perfectionism can alienate the people around us. When they do not live up to our perfectionistic standards, we may be magnanimous and forgiving--or we may be critical. And even when we attempt to be forgiving and "overlook" any mistake, our impatience with their lack of perfection may show through. This can put people off.
Perfectionism can lead to procrastination. We know that once we take on a project, we will have to do it pefectly. This can make it a daunting task, and we may find it easier to keep putting it off rather than doing it "just right."
Finally, studies have shown that perfectionism tends to lead to depression in many people. When the perfectionist falls short of their perfect goal, they may berate themselves, causing low self esteem and this may in turn lead to depression.
As an alternative to perfection, we can aim at doing things well. We can realize that it is better to be fully engaged in life and trying a lot of things rather than just doing a narrow range of activities where we can be assured of the outcome. There are times to be perfectionistic. Pilots are taught to be extremely thorough in checking over their airplane before taking off, for example. And if I ever have brain surgery, I would prefer my surgeon to be a perfectionist. However, in everyday life, perfectionism tends to detract from our productivity and feelings of well being.

Supporting the Depressed Person

Yesterday, I said that I would write something about how to best support the depressed person. I basically said what not to do. It can be difficult to be supportive when one sees the depression going on and on. But there are some things which I believe to be helpful.

First of all, there are different levels of depression. Even within the diagnosis of major depression, there are mild, moderate, and severe levels. A person with severe major depression will need more support than a person with mild major depression. And a person with milder forms of depression (dysthymic disorder, adjustment disorder, etc.) will not need the same kind of support. Persons with more severe depressions need practical as well as emotional support (such as filling out forms to be absent from work, setting up therapy sessions, making sure that the person takes their medication accurately, or driving them to therapy). Persons with milder levels of depression need more emotional support. For them, the practical support may be helpful, but it may have more of a symbolic helpfulness (showing that you care).

So, keeping in mind that it is difficult to give guidelines that would apply to all depressed persons, here are some suggestions:

First of all, support the person being in treatment. Don't criticize them being in treatment. If they are still depressed after being in treatment, that doesn't mean that they need to stop it and "buck up." It may mean, however, that some type of change is needed in their treatment strategy.

If you don't think that their current psychiatrist or therapist is helping, you can suggest that they seek a second opinion without criticizing their current doctor. Or alternatively, you could even ask if it would be okay for you to speak to their doctor and give feedback about your concern that they are not improving.

Realize that they don't want to be depressed. They most likely want desperately to feel good. They are trapped in a maze. They don't know how to get out. Communicate to them that you understand that they want to feel better and that you are there to help.

If they talk negatively, give them gentle feedback. For example, if they said "I'm just stupid," you could reply that you don't believe that and that there is no evidence for it. They may not accept your reassurance or believe you, but it is probably better to provide a gentle confrontation than to say nothing.

Help them to get out of the house. Staying at home allows them to ruminate over their negative thoughts more. They may not want to get out, but give them encouragement to do so. Make it easy. You do the footwork. Buy the tickets to the movie or make the babysitter arrangements.

Don't take their depression personally. It can be helpful to look to see if you are doing anything that is contributing to their depression. By all means. But oftentimes, you will have nothing to do with their depression. If you don't take it personally, you can be of more help because you won't be defensive. Support the person, but don't take responsibility for them getting well.

If on the other hand, your self-examination leads you to believe that you are part of the problem, then try some marital therapy sessions to work on those issues.

If the depressed person is also abusing substances of some sort, don't assume that this is their only problem. Oftentimes, there is depression behind their alcoholism or drug abuse. AA can be helpful for alcohol abuse, but it is not likely to be an effective treatment for depression.

Give the other person positive reinforcements. These can be in the form of positive verbal statements ("You did a good job cleaning house today," or "You look nice") or taking them out. Don't be surprised if they disqualify your positive statements (finding ways of saying that they are not true or don't deserve compliments).

Look for a local depression support group. Take them and or attend with them, if they wish it.

Educate yourself about depression. Very thick books have been written about depression. You don't need to know everything that is in them. But it is helpful for you to realize that depression is sometimes a severe, complex illness. It is not just a feeling. Educate yourself about some of the complexities of depression.

Help them manage their medications if necessary. Depressed people may not take their medications correctly because of a variety of reasons. They may forget to take them. They may become pessimistic about the medication helping and stop taking it. They may not believe that they can afford the medicine.

Take care of yourself. Make sure that you have a social support network, too. That way, you don't burn out, and you have something to give.

Be ready to deal with your own feelings of resentment. It can be difficult being the spouse of a depressed person. Don't feel guilty about feeling that way, but don't just stew in your resentment either. Find someone with whom you can talk through your feelings.

Don't Blame the Victim

Psychological research has documented that there is an unfortunate tendency in people to blame victims. Part of the reason for this appears to be the need to reassure ourselves that bad things are not going to happen to us. When we see someone who suffers misfortune, we may feel anxiety and want to believe that it could not happen to us. Or we may feel a twinge of guilt that our lives are so good. For example if we hear of someone being robbed or attacked at night, we might think that they shouldn't have been out at night by themselves--they should have known better.

Some of my patients experience the same type of blaming. Depressed persons often report to me that their families do not understand their depression and tell them to snap out of it. People imply that they could be well if they wanted to be, that they simply want to be sick. Or there may be the implication that the person is morally weak and bad for not choosing to be well. This is also blaming the victim.

There may be some people out there who want to use their psychiatric symptoms for some reason (disability, etc.). I rarely encounter them. In my practice, I find people want to get well. If they could get better on their own, they would. One of the ways they work on getting better is by coming to see me. It does no good to tell them to snap out of it. It does no good to blame them and imply they are weak. Even worse is when people imply that their depression or anxiety is because they are out of right relationship with God.

There are ways of encouraging a depressed person to get better, but blaming them is not one of those ways. In my next piece, I will talk about some positive ways of encouraging persons who are suffering through psychological symptoms.