A Case of Catch-22

When you think about it, depression is a most peculiar disorder. Most people know very well what it takes to get better; the same treatments and activities everyone recommends.

But the things a person needs to do to get well are the very things the illness makes it difficult for any person to do. Resistance is intrinsic to the condition, making recovery an extraordinary challenge that typically takes a long time.

And that, says psychologist Jon G. Allen, Ph.D., senior staff psychologist at the Menninger Clinic, makes depression the Catch-22 of illnesses. Further, it makes the plight of depressed persons subject to endless misunderstanding—not just by those around them but by themselves as well.

Perhaps nothing gets closer to the conundrum that depression is than the phrase "If you'd just...[eat right, get out and exercise, have more fun, stop isolating yourself, quit wallowing, or do X], you'd snap out of it." It's something depressed people hear many times from well-meaning people around them.

But it fails to recognize the serious illness that depression is. "I've come to think of 'just' as a fighting word," says Dr. Allen. "It's inflammatory to persons who have lived with depression and have tried to fight their way out of it with limited success. There's no single simple solution to persistent depression. It can be a long haul, even if you're able to put a lot of effort into it."

Outsiders misunderstand depression because they extrapolate from their own experience of down moods.

"Most people experience depressed mood at some point in their lives and so they come to believe that they understand depression," explains the Kansas psychologist. "They make generalizations from their own experience. But depression is a whole different beast from a depressed mood." There is a point at which depressed mood moves from a response to a state, when stress creates persistent adverse changes in brain functioning.

Even those who have it are not immune to belittling the seriousness of depression. On the one hand they believe they should be able to quickly overcome depression, that they can pop a pill and snap right out of it. At the same time their daily experience demonstrates the difficulty of doing what they need to do to get better.

A Rock and a Hard Place

Depression, Dr. Allen contends, puts those who have it between a rock and a hard place. The rock is the common belief that depression is not that serious, a relatively time-limited response to stressful events. The hard place is the reality that depression is a serious and stubborn mental-physical illness. There is a fundamental impairment in areas of the brain that support motivation, energy, hope. Not only does recovery usually take a long time, but even those who recover remain vulnerable to relapse and, like diabetics, must monitor their experience and exert continuous control over their lifestyle.

Minimizing the seriousness of depression leads to unrealistic expectations, enormous frustration, self-criticism and hopelessness—all of which exacerbate depression and complicate recovery. But acknowledging the seriousness of depression is a double-edged sword, contends Dr. Allen. It could lead people to conclude that they are destined to be severely depressed continuously. And it could also encourage people not to fight their way out of it.

There are enough reasons why someone might want to stay depressed. True, depression can be an excruciatingly painful state from which a person would do anything to escape-even including suicide. But there is another side; like any illness, depression confers the "sick role" on those who have it, involving exemption from everyday performance obligations. "Depression involves a retreat from problems that have become overwhelming," Dr. Allen points out. "And persons who have been depressed for long periods often find it familiar, even comfortable and safe in some sense."

Elbow Room

For all of depression's seriousness and persistence, patients really do have some choice and control over the illness, stresses Dr. Allen. And some responsibility. Of course, no one can recover by a mere act of will. "As an illness, depression puts significant constraints on freedom of choice, but it still leaves you with some elbow room, although, the more depressed you are, the less elbow room you have."

The catch is, while those who have depression are obligated to seek help and cooperate with treatment, depression makes it difficult to sustain an active effort in treatment. Still, those who are not profoundly depressed can choose to take actions that move them slowly along the path of recovery. "Most people work hard at recovering, and most recover—but not quickly," says Dr. Allen.

Recovery involves a series of hard choices over a long period of time—five months, on average. Choosing to get out of bed. Choosing to eat breakfast. Choosing to shift attention from negative thoughts to at least neutral ones. Choosing to stop ruminating.

It's difficult. But it's not impossible. "Making the distinction between difficult and impossible is crucial to recovery," observes Dr. Allen. "Understanding depression and what it takes to cope with it can provide a more hopeful view, based on more realistic expectations."

Patients have a little leverage and they need to exert it on many fronts. Their leverage isn't great—they can't just "snap out of it." They have some energy. They can take only small steps. As a result, success will be modest and slow—but real.

Little Steps, Many Fronts

There are many proven treatments for depression—medication, cognitive therapy, interpersonal therapy. Patients may need to draw from many of them—but not all at the same time.

Because there are many fronts on which to wage the battle against depression, there is a risk of getting confused about where to start getting leverage. Dr. Allen recommends that patients prioritize. "Think in terms of a hierarchy moving from the physical to the mental to the interpersonal. Start with sleeping and eating. Then add activity; start with a 10-minute walk. Tackle the cognitive and interpersonal stuff later."

He concedes that the physical aspects of depression—eating, sleeping, exercise—are commonly neglected in treatment. But he regards physical well-being as the third pillar of recovery, along with medicine and psychotherapy, and in fact a precondition for it. Sleep, for example, is basic to energy and thinking straight. Improving sleep may take a combination of medication and attention to schedules and routines.

"There's no magic to any of it," he says. Just understanding and persistence.