Although it's been 26 years since I left my psychiatry residency, psychiatric journals continue to follow me wherever I go. The drug companies just won't give up on their advertising if there's a chance I might still be prescribing. I even received journals when I lived in Mexico (without ever informing the publishers of my whereabouts). I do read them from time to time, though usually not in depth, but when I run across a useful article I'm glad to share. And in this month's Journal of Clinical Psychiatry there's a useful article (with the usual insufferably long title, "Psychological Characteristics of Chronic Depression: A Longitudinal Cohort Study").
Scientifically (and I won't bore you with the research methods), three traits stood out that differentiate the healthy from the chronically depressed: extraversion, rumination, and external locus of control. Introversion marks the depressive while extraversion (an outgoing personality more deeply involved in activities external to the self) marks the healthy. Rumination, the mind-numbing circular contemplations of the self and its shortcomings, also marks the depressive, as does a perceived external locus of control--or feeling more a victim of life than its engineer, beholden to gods or bosses or limitations imposed by society.
Other traits of the healthy, suggested by the study but not rigorously affirmed by science, include agreeableness and conscientiousness (this is not to say the depressed aren't conscientious, even overly so). So our picture of the healthy individual portrays an easygoing, outgoing personality with a sense of personal control over his life.
More traits of the depressive, again not rigorously confirmed by this study but only suggested, include higher levels of neuroticism, hopelessness, aggression, and risk aversion. It might be instructive to list these for the record:
Characteristics of the Chronically Depressed:
1) Neuroticism (behaviors associated with anxiety, fear of others' opinions, indecision and inhibitions that do not serve the self).
3) Aggression (Freud famously argued that depression was aggression turned against the self).
4) Risk Aversion
6) External Locus of Control
Characteristics of the Undepressed:
Now what do we make of this? How can this be applied to therapy for the depressed? Conscientiousness may possibly be taught, but how does one come by extraversion and agreeableness? Are these learned traits or inborn? How much can they be promoted by therapy? Aye, there's the rub.
As medical intervention has recently failed me, in a 45-day stay at a university hospital with maximum medications, group therapy and 12 ECT treatments, I have turned to psychotherapy out of necessity, though I have little faith in the method, as twice before "depth" psychotherapy has actually made me worse. This time I have at least selected a cognitive-behavioral therapist, whose method is most endorsed by research. And what does this method involve? No less than re-programming of old, self-defeating tapes and the substitution of new behaviors. Or simplistically, "Act as if you are not depressed and feelings should follow." Try to identify what thoughts are associated with negative feelings and endeavor to combat them--catch yourself in mid-dip and argue with yourself, trying to put a rational perspective on things. Do not give in to your irrational inner child, fixated in early development, self-indulgent, afraid and non-functional (as an adult).
I can see from this inner landscape, as my therapist has also advised me, that it is hard work crawling out of the hole. And I have never been impressed by how much people change over time, in fact the opposite seems true: people don't change very much. But if I am to have a hope of being delivered from the depressive side of my manic-depressive disease, the side that unfortunately dominates, I need to take my psychology in hand and do something about the way I think, feel and behave. This may seem obvious to some but in my experience it is novel, as it seems to me that when the proper cocktail of medications has been discovered in the past, I became well and did not feel a need for therapy. In fact, I may have become agreeable and extraverted, though I have always been conscientious--if not financially then at least interpersonally, , especially in keeping my word.
The wisdom of this article I may have compressed long ago in my own capsulized advice about depression:
1) It is better to do something than nothing.
2) It is better to do something active than passive.
3) It is better to be with or around people than alone.
4) Try to set an achievable goal each day, however small.
Still when one is seriously depressed, following this advice or even more daunting, trying to achieve agreeableness and a sense of personal control are almost unimaginable. But courage, my friends, courage. "Never give up, never ever give up" quoth a famous depressive, Winston Churchill. I need this kind of courage if I am to save myself.
If psychotherapy doesn't help, what do I have left? Voodoo? I'd much rather sacrifice a chicken than work hard to reverse my dysfunctional,ingrained mental processes. But to what do I owe them? A genetically inherited disease beyond my control, a malady of the brain? (Studies have confirmed that depression changes the very structure of the brain, up to a 20% decrease in the volume of the amygdala, for instance.) How can psychology affect this?
Obviously it is not one or the other. It is both nature and nurture. Talking oneself out of the pits must be of some utility or it would not be so firmly in practice.
The etymological root of therapy is "correction." Can I be "corrected" at this late date, at age 56, when my brain has already been changed by my disease? I have to hope so. And hope is so essential to surviving depression. I can't think of anything more valuable. Despite past experience, I must imbue the psychotherapeutic process with hope. Then again, how can one hour a week compete with the other 167? One hopes that the patient can apply the lessons of therapy during the hours away from the therapist, else all is in vain. But ideally we need some kind of boot camp for depressives, as modeling is the best form of teaching, and in these camps there should be more healthy individuals than sick ones.
One of the great disadvantages of a mental hospital, one I recently experienced, is that all the sick people are thrown together. Who are they to help each other? The staff is not powerful enough to successfully model new behaviors. They are too often lost in paperwork anyway. It would be so much better to place a mentally ill person in a healthy family for a time than subject them to the idiosyncrasies of other patients. But health is at a premium, and would fetch a premium price, and besides, this approach is not likely to ever be implemented while present models of disease and health predominate.
Still, if there is a family out there willing to adopt me for a time, I would seriously consider it--with my wife's permission, of course (is that too much an expression of an external locus of control?).
Thine as ever,