My experience of depression and its treatment

First written 25 Nov 2011

My psychiatrist Dr Kochar has asked me to write something about my personal experience of severe major depression, and what I have found to be useful over the years.

I first started seeing a psychiatrist  in 1995. The previous year my mood had been good. At the end of the year, I held a Christmas party for the clients of my business. The evening went really well, and everyone said how much they had enjoyed it. However, at the end of the evening, I felt a sense of disappointment. Warning bells! My emotions were not consistent with the objective facts. This was the first sign that my mood was slipping and I was becoming depressed. I started seeing my first psychiatrist in the early New Year. I was hoping to lift my mood by Easter, after a few sessions.

Clinical Depression

Clinical Depression (Photo credit: Alaina Abplanalp Photography)

Challenge your negative emotions

My first coping strategy was to question my own emotions, step back from them, and compare them to the evidence. We are often told “go with your gut; trust your feelings”. This is OK sometimes, but it does not work when you are depressed. One of the symptoms of depression is that your gut feelings and emotions are not a true reflection of reality. You have to learn some Cognitive Behavioural skills. This means using your intelligence to question and change your feelings and how you act on them. I am not saying that 6 sessions of Cognitive Behavioural Therapy (CBT) will fix any problem (which the Government funding bodies want us to believe). However, cognitive behavioural skills are very useful to manage depression. Sometimes your feelings are so overwhelming that you cannot believe the evidence.

Cognitive Behavioural Therapy Anxiety and Depr...

Cognitive Behavioural Therapy Anxiety and Depression 1 (Photo credit: DrJohnBullas)

For example my father became severely depressed. He had an overwhelming feeling of panic. Normally, people panic when they are faced with an extreme threat. But with mental illness, the feeling of panic arises even though there is no real threat. My father became psychotic and delusional. He believed that he was facing such an extreme threat that he tried to take his life. It was too hard for him to step back and say “I feel panicky, but the threat is not real.” My generation was more psychologically minded, and I was fortunate that I could develop these skills. I came to call it “the dredge”. This means that when I was depressed, my mind would dredge up all the negative thoughts, shit and bad stuff, and throw them to the surface of my consciousness. I thought of it as being like a dredge bringing up all the mud and garbage from the bottom of a river and bringing it to the surface.

Dredging on Buriganga River Bangladesh

Dredging on Buriganga River Bangladesh (Photo credit: Wikipedia)

So my first point is (paradoxically) “don’t trust your feelings – remember the dredge.”

My second point is “try to put a name on what you are experiencing”. Saying “the world is not all black – it’s just the dredge” will help to disempower those negative emotions. To give another example, when I had descended into severe depression, and I was falling apart, really disintegrating into bits and pieces that were all bad, I had a sudden insight. I said to myself “I know what this is. I’m just a whole universe of bad objects!” At that moment I felt becalmed, as if I had come through a storm and emerged the other side. Being a universe of bad objects may not sound very good, but putting a name on it, rather than being at the mercy of that feeling, really helped. I had emotions dating back to my pre-verbal years, and what I really needed to do was put a name to my feelings. This can take time and the help of a psychotherapist.

My third point is don’t be afraid to get help. I know that is the message of Beyond Blue. You’ve probably heard it before. I have often thought “that’s all very well, but what happens next?” Just as six sessions of CBT will not solve all your problems, three weeks on anti-depressants will not solve all your problems either. But it will probably help, and you need all the help you can get.

“Lassie Get Help1” by John Callahan.

Don’t worry about the attitude that some people have that medication is a cop-out, and you should be able to get better under your own steam. There should be no shame in taking medication. The only issue is whether it helps. When my father was sick, the medications he was given had a lot of side effects, and he was not able to take a high enough dose to do much good. Fortunately, things have improved, and I think today’s medications have less severe side effects and are more helpful.

I have found that it is necessary to experiment with different medications before you find one that suits you, so don’t be afraid to be assertive and discuss with your doctor the good and bad effects of your medication. It is not a “me doctor – you patient” relationship. It should be a collaboration. At one stage I was on a medication which made me severely sedated. It also helped me. The problem was, my doctor didn’t tell me that the sedation was a side effect. I thought it was part of my illness, and I didn’t know what was happening to me. I was worried sick, because I was losing my ability to function. If you have experienced that you will know how terrifying it is. My doctor could have saved me all that anguish by telling me what was going on. Ultimately it should have been my call – to weigh up the side effects against the good effects. It’s called “informed consent.” So don’t forget, you are the patient, but that doesn’t mean you have to be passive. Learn about your medication, and make a decision based on what helps. You have rights. Lack of co-operation is not always a bad thing. Once my doctor wrote in my file that I had refused medication. That made me look bad. What he didn’t say was that the reason I had refused that particular medication was that it caused weight gain, and being severely overweight, I couldn’t afford that. That sounds more reasonable.

On the other hand, try not to go off your medication. Psychiatrists hate it when a patient goes off their medication. I know. I’ve done it. Usually I did it when I was too disorganised to get to the pharmacy. You can get help there too. Many pharmacists will keep your prescription in stock and deliver your medication. If you’re too disorganised to get to the pharmacy, anything helps.

My fourth point is “don’t be a bear”. When we are depressed, many of us have an instinct to curl up in bed, pull the covers over our heads and forget about the world. I used to wish I could be a grizzly bear – fat, ugly, hairy, smelly, bad tempered and able to hibernate all winter.

Above, this is me in a former life

If it’s at all possible, try to resist this.  It is a very ancient biological response to illness, to crawl into a dark cave and wait until you get better. The problem is, for depression, it is exactly the wrong thing to do.Get outside and get some exercise and sunlight. It really helps, especially if you suffer from the “winter sads” (Seasonal Affective Disorder).

Fifthly, looking after yourself physically – this has been really important to my recovery. This has involved having a supportive GP, having weight loss surgery, and more recently, operations to have both hips replaced. I have had four to five years of very reduced physical mobility. In that time I have had to set up systems to look after myself or get someone else to look after me. Now that I am more mobile, I am dealing with a backlog of self-care needs – seeing the dentist, the optometrist, the podiatrist and so on. Depression typically means that self-care goes out the window. At my worst point, I couldn’t sleep in my bed, because there was a huge pile of clothes on it. I no longer knew which were clean and which were dirty. The laundry was so messy it had become a no-go area, and I was sleeping on the floor in my loungeroom, amidst a sea of empty chocolate wrappers and pizza boxes. If you are in this situation, you can get help. If you have an income you can hire a cleaner, have healthy cooked meals home-delivered and hire a young commerce student from the local university to come in and open your mail, pay your bills and do some basic filing. It only takes an hour or two a week to keep things under control. If you are too dysfunctional to organise help, your doctor can refer you to someone, such as a disability support worker, who can help you to organise these services. If you can’t afford to pay for help, you may be eligible for subsidised assistance from the local Council. I get carers to help me shower, and a cleaner who comes for an hour a week and does the basics.

Back to basics: a healthy diet, some exercise and sunlight are really important.

Point six: Avoid self-medication

Self-medication means using things like smoking, alcohol, coffee, chocolate, illicit drugs, sexual promiscuity, being a workaholic or even thrill-seeking to get an adrenalin rush in order to make yourself feel better. Most of us have done some of the above. It’s understandable, but in the long run it doesn’t work, and it creates other problems. These things can be hard to give up, but it has definitely been a part of my road to health.

People self-medicate with alcohol and tobacco

Point seven: Look for the good stuff

I know it is really irritating, when you are seriously depressed, to have people say to you “be positive”. It’s not easy. However, I have found some ways to do it, which I want to talk about. I was a professional dog trainer until I had to retire due to mobility problems. In dog training nowadays, we use positive reinforcement. This means rewarding good behaviour rather than punishing undesirable behaviour. It is very effective. You can learn to give yourself rewards for thinking positive thoughts or doing something useful.

The essential thing is to break the task down into small parts. It’s no good saying “Task 1. Turn my life around.” That’s far too big. It might be something like “today I will bring in the mail.” Or “tonight I will brush my teeth.” When you do it, you have to do two things. Firstly mark the behaviour. This means drawing attention to it or acknowledging it. If you were teaching your child you would say “wow! You just cleaned your teeth by yourself.” If you are reinforcing yourself, you have to say the same thing to yourself. Maybe put a big tick on your to-do list. Then, secondly, you have to give yourself a reward. Sometimes saying “that’s great” is enough of a reward. Sometimes, maybe after you have brushed your teeth for a whole week, give yourself a treat. What it is depends on you. It can be anything that you find rewarding. For my dog it would be a food treat or throwing her ball. For me it might be buying a music DVD on the internet.

If you find that you can’t bring the mail in, break the task down even further. For example, go out to the letter box. When I was very depressed and sedated, I couldn’t just say “Task 1. Get dressed.” I had to break it down. Put one sock on. Psych myself up for half an hour. Put the other sock on. Put one shoe on. Each task had to be acknowledged and rewarded. Now I don’t have any trouble getting dressed. I am starting to enjoy wearing nice clothes. People say I look good, which is a reward, and makes it likely that I will continue to care about my appearance. What tasks you choose, how you break them down and what rewards you give yourself depends on where you are at. The most important point is to make it achievable.

The other thing you can do is try to seek out people who reward you or give you good feedback. Try to avoid people who criticise and only point out your faults. You might think that praise and criticism are of equal weight. This is not true. Punishment far outweighs reward. Punishment has a lot of fallout. It is not a simple deterrent. It causes hostility, resentment, defensive aggression, lack of co-operation, emotional shutting down and if it is bad enough it destroys relationships between, say parent and child or teacher and student. I used to say to my clients, “if I reward you every day by saying ‘that’s good, you’re doing a good job’ then one day I slap you and say ‘you got it wrong, stupid’ would it help if I then said ‘what’s the problem? I’ve been rewarding you for a whole year, and I only punished you once.” People would say “of course not.” One punishment destroys a year of good work. If you are depressed, you have probably experienced punishment or bad feedback of some kind throughout your life. It casts a long shadow. Being depressed, you also have a tendency to punish yourself in your thoughts. Try to be kinder to yourself. Avoid people who put shit on you and try not to do it to yourself. When my father was admitted to hospital, he thought he was guilty and deserved punishment. He actually thought he was in jail. Try to resist thinking along these lines. You do not deserve punishment. It’s taken me a long time to really understand that I am not bad.

Point eight: monitor yourself

Monitoring you and your symptoms is your doctor’s job, but it helps if you can do it yourself as well.There are formal ways to do this – ask your doctor which checklist or depression scale to use. You can easily find a quick survey online or even as an iPhone app. But I think the best thing to do is become aware of your symptoms. I have become very attuned to mine. At the very first sign of a negative thought I can stomp on it at let Dr Kochar know. If you want some more information about what to look out for, the Wikipedia article is a very good summary.

It says “Depressed people may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, or restless. They may lose interest in activities that once were pleasurable; experience loss of appetite or overeating, have problems concentrating, remembering details, or making decisions; and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may be present.”

It’s interesting that it mentions some symptoms that are either “too much” or “too little”. It can go either way. For example, you might be sleeping too much, or not enough. You might lose your appetite, or gain weight. You might be very slowed-down, or less commonly, agitated. If you do a checklist, find one which covers both ends of the spectrum. If it just says “sleeping too much” you will not show up as having a problem if you are not sleeping enough.

Point nine: Psychotherapy – a long, hard road

My last point is that for me, and I think for many people who have emotional problems related to bad parenting or to being abused, a long period of psychotherapy was necessary. Like medication, psychotherapy can have positive benefits and it can also have toxic side effects. It is hard work, and it can be painful, but from my point of view, I have had a long journey, but it has been worthwhile. I said at the beginning that when I started seeing my first psychiatrist, I hoped to recover my good mood after a few sessions. What happened though was that he uncovered very traumatic issues relating to my father (amongst other issues) and the impact was that I fell apart. You need to have a therapist who will uncover your issues, revisit your traumas, but I believe the therapist should not retraumatise the patient. Some may disagree. I needed a therapist who I could be very attached to, so he could support me through the difficult process of dealing with my demons. I wanted a therapist who would listen to me, try to understand me, and give me support. However, support is not enough, because it doesn’t bring about change. Change requires some upheaval, so be prepared for that. We all make use of what therapists call “defences”. These are usually ways of thinking, feeling or behaving that protect us from harm. The problem is, you may be using defences that are doing you more harm than good. You have to be able to let them go, in a safe environment, created by your therapist. I said to my first psychiatrist “you have dismantled all my defences”, I felt very vulnerable. He pointed to the corner of the room, where they were, figuratively speaking, stacked up and available if I needed them. As time went on, I could do without some of them. He also said I could replace them with “top-shelf defences” such as humour and anticipation. It’s taken a long time, but I have made a lot of progress. I hope you do too.

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