...... 8 hours later ......
You have to go to school tomorrow. Again. You are ready to do anything to avoid coming across those people who made it their business to turn your life into a hell. You can’t tell it to your parents because why should they know that you are the “weirdo” in the school and you are not “perfect” as they imagined you to be. Also, you are a grown-up now and you can’t run to your parents when you face a problem. And the last thing you would ask for would be a mother who asks you more “are you okay” type of questions. You rather fake sickness… You can even hurt yourself to avoid going to school and facing them! You just want to be left alone.
Your best friend is on the phone and he is inviting you to a party. “It will be so much fun,” he says and continues his overzealous rambling about the upcoming fun night. You are not impressed as you hide under your bed sheets with a phone in your hands, which you unwillingly answered just to prevent a relative or friend from calling the police because of not reaching you for days. You tell him you are sick just to hear him say “still?” because you’ve been using the same excuse for the last 15 days simply because you don’t want to leave your bed and especially don’t want to meet with friends and/or family. You don’t have the energy and you are not in the right mood… never.
You might have depression. Whether you are a 14-year-old female student or a 35-year-old businessman, depression can occur at any age and it is the hidden epidemic of our century.
What exactly is depression
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) is the most widely accepted nomenclature used by clinicians for the classification of mental disorders (1).
The DSM–5’s criteria for Major Depressive Episode is as followed:
A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
C. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). (American Psychiatric Association, 2013).
One of the most important points is that the symptoms must have been present during the same 2- week period and represent a change from previous functioning. This leads to another common question:
How to know whether you are just having a series of bad days or you are depressed?
First of all, if you are asking this question, probably you’ve been experiencing at least some of the symptoms above for more than a couple of days, maybe weeks. It is normal to feel sad after losing a loved one. Also okay to not being able to sleep properly some nights. Most people feel gloomy some days and show little to no interest in their usual activities. So, where to draw the line? Lee H. Coleman, Ph.D. answers this question, “Without oversimplifying things too much, I generally look at how much your symptoms are affecting your relationships, your daily activities, and how you think and feel,” (4). When you are feeling sad for some reason, do you sit in your room all day, skip your classes or call in sick? You used to love hiking and go for long hikes every Sunday but now can’t even remember the last time you went for a hike? Is it nearly impossible for you to sleep for days? Or do you find yourself sleeping all the time? This sort of behavior means that your symptoms are affecting your life. If you had at least five such symptoms at a level similar to that during the same 2-week period, it is time to seek help.
After you decide that you might need help, the first step in treatment is to find the right mental health professional. This can end up being harder than it sounds, unfortunately, especially when you feel like you do not have the energy to do anything. But you owe it to yourself! The important point is finding the mental health professional that will best suit your needs.
Most people get confused about the difference between different mental health professionals. “Should I go to a psychologist? Therapist? Psychiatrist? What is the difference anyway?” Let’s take a look…
Psychiatrist: A physician who specializes in the prevention, diagnosis, and treatment of mental illness. Psychiatrists can prescribe medication, which psychologists cannot do (3).
Psychologist, clinical: A professional specializing in diagnosing and treating diseases of the brain, emotional disturbance, and behavior problems. Psychologists can only use talk therapy as treatment; you must see a psychiatrist or other medical doctor to be treated with medication (4).
Licensed clinical social worker: A social worker trained in psychotherapy who helps individuals deal with a variety of mental health and daily living problems to improve overall functioning. Abbreviated L.C.S.W (5).
Licensed Professional Counselors: These counselors are required by state licensure laws to have at least a master's degree in counseling and 3,000 hours of post-master's experience (6).
Now you have some idea about the different kinds of mental health professionals, the next step is to choose one.
1- Get your managed care company’s list of providers.
2- Ask around! Ask your friends and family for a recommendation.
3- Call a large clinic and ask for recommendations.
4- Once you get a name (or more than one) do your research online. Check what the practitioner is specialized in. This is important!
5- When you choose a mental health professional, do not hesitate to ask them your questions about their background and policies. Continue the therapy only as long as it feels like you can trust your mental health professional.
Now you have a mental health provider by your side, let’s suppose that you are diagnosed with major depressive disorder. What to expect next?
First of all, “You are not crazy” or “weak” and you should not feel like this diagnosis is a curse. One of the most important steps in your treatment is accepting that you are facing an obstacle and you’ll get through that because you are capable. You are not alone. As mentioned before, depression is our century’s epidemic.
Depression treatment may only consist of talking therapy or talking therapy with medication. On or before the first day of your visit, you might be asked to complete some measures such as the Beck Depression Inventory, Symptom Checklist 90 revised, Burns Anxiety Inventory. After receiving your scores, a treatment plan which serves your needs will be made. During your treatment period, you might be asked to complete the above-mentioned forms before each and every session. This is to see whether you are getting better, in other words, whether the treatment is working.
The most commonly used therapy in the treatment of depression is Cognitive-Behavioral Therapy (CBT). CBT is a form of psychotherapy and it is based on reframing the way you think. Cognitive restructuring helps you to recognize your distorted thoughts and replace them with healthier, realistic ones. The main tool to do that in the therapy is “thought records”.
As you can see above in the Thought Record Sheet, you will start by writing what triggered the situation (something that happened in your life which caused you distress), how you felt, what you thought, and the facts about those thoughts. Then you will follow by writing the alternative facts a.k.a facts that provide evidence against your thoughts and more balanced and realistic perspectives about the situation, and outcomes (re-rating your emotions). This is a way for you to see the situation from unique perspectives. Your therapist will assist you in this process.
According to 269 meta-analytic studies, CBT has shown a higher response rate compared to other treatments and control conditions (8).
In addition to the thought records, you might be asked to write your treatment goals and be guided to make an activity schedule to use your time more efficiently.
Here is an educational video to give you an idea about CBT.
Antidepressants, such as SSRIs, are the most commonly used medications in the treatment of depression. However, medication treats the symptoms, while therapy has the potential to change the thought and behavior patterns which cause the symptoms. According to a research conducted by Andrews, an assistant professor in the Department of Psychology, Neuroscience & Behaviour at McMaster University, relapse rates are higher in patients who use anti-depressants than those who use no medication at all (9).
Depression can be treated. It is not something you have to live with and it is not who you are. It is a disorder, it is an episode. As the name suggests, it simply drags you away from your usual self--from your “order”. You might usually love hanging out with your friends but not anymore. You might usually love going to live shows every Friday but not anymore. You might usually love reading but not anymore. This, unfortunately, leads to a vicious circle; the more you pull yourself away from the things that make you happy, the more you fall into the trap. But the good news is that with some help and effort, you can and you will get out of that vicious circle. This too shall pass. I guarantee you that. However, it is your choice to make whether you want to be in charge of time or let the time drag you along. I’d say, time is so precious to waste and you should not waste your tomorrows hiding under the covers in your room.
So let’s make the first activity schedule for tomorrow...
1- Get your managed care company’s list of providers. Call a large clinic and ask for recommendations for a mental health professional.
2- Do one thing, just one thing, that used to make you happy (or still makes you happy). When did you last go to a county fair and get on a roller coaster? It always works its charm. Whatever works for you... Call your best friend whom you haven’t called for a long time. Or call a relative--whoever, you feel close to, whoever you used to love spending time with. If they can’t make it, go alone! Just send an email to yourself, get a date from yourself (yes, for tomorrow!), and don’t miss that date. But most importantly, have fun and don't feel ashamed to ask for help when it is needed!
(1) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
(2) http://psychcentral.com/blog/archives/2014/03/01/telltale-signs-its-time-to-treat-your-depression/
(3) Psychiatrist. (2012). Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=5107
(4) Psychologist, clinical (2012). Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=5109
(5) Licensed clinical social worker (2012). Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=15160
(6) Feature, J. (n.d.). How to Find a Therapist. Retrieved May 8, 2015, from http://www.webmd.com/anxiety-panic/guide/how-to-find-therapist
(7) Fisher, M. (2009). Depression rates [map]. Retrieved from http://www.washingtonpost.com/blogs/worldviews/files/2013/11/depression-rates.jpg
(8) Hofmann S. G., Asnaani A., Vonk I. J. J., Sawyer A. T., Fang A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cogn. Ther. Res. 36 427–440.
