If you walk into a bookstore these days, there is an ever expanding self-help section, all claiming to have the secret answer to help you to overcome your Depression. But do these titles even teach us anything new, and do they actually help individuals to improve?
What is Depression?
Although it is considered normal to experience short episodes of sadness or depressed mood, Depression, formally known as Major Depressive Disorder (MDD), is a psychological disorder of pervasively lowered mood that is accompanied by several physiological, cognitive and behavioural changes. These changes include:
- lack of interest or pleasure in most activities
- loss of energy
- insomnia or hypersomnia
- psychomotor agitation or retardation
- increased or decreased appetite
- substantial weight gain or loss without intending to do so
- feelings of worthlessness
- excessive or inappropriate guilt
- concentration difficulties, and
- recurrent thoughts, plans or intentions towards death or suicide.
In order to meet criteria for MDD, an individual must have at least five of these symptoms most of the day, nearly every day for two consecutive weeks, and it must result in significant distress or functional impairment (American Psychiatric Association, 2013).
Depression is a highly prevalent and debilitating condition:
- Depression is the leading cause of non-fatal disability in Australia, accounting for 3.7% of the total disease burden (Access Economics Pty Ltd, 2005).
- Around 1,160,000 Australians live with Depression each year, and up to 1-in-5 females and 1-in-8 males will experience an episode of MDD in their lifetime (Australian Bureau of Statistics, 2008).
- In the US, the cost of Depression through direct medical costs and lost productivity was estimated to be between $30 to $50 billion per year (Rice & Miller, 1998).
Educational programs such as Beyond Blue have raised awareness of Depression in Australia and increased the percentage of males and females seeking help. However, many indirect costs still remain, such as lower employment rates and lost productivity, plus an increased risk of physical illness, substance abuse problems and suicide (Judd, Paulus, Wells, & Rapaport, 1996). Furthermore, relapse rates remain high (Ramana et al., 1995) and optimal treatment is often not sought or given (Halfin, 2007; Mathew & Charney, 2009).
Potential Treatments for Depression
1. Antidepressant Medications:
Various antidepressants have been developed and prescribed over the years, including monoamine oxidase inhibitors (MAOIs), tricyclics antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and more recently norepinephrine (SNRIs) and dopamine reuptake inhibitors and melatonin-based antidepressants. The most commonly prescribed antidepressants are SSRIs, due to their improved side- effect profile in comparison to MAOIs and TCAs (McManus et al., 2003). Two SSRIs in particular, Escitalopram and Sertraline, have been found to significantly reduce depressive symptoms in adults (Cipriani et al., 2009). Because of their efficacy and improved safety, SSRIs and SNRIs have been considered the pharmacological treatment of choice for moderate to severe MDD.
In Australia, antidepressant prescriptions are often given for milder forms of Depression, which is currently not recommended and should not be subsidized under the National Pharmaceutical Benefits Scheme (McManus et al., 2003). As a result of this overprescribing, antidepressant consumption in Australia has nearly doubled from 45 per 1000 people per day in 2000 to 89 per 1000 people per day in 2011 (OECD, 2013). This latest figure now ranks Australia second to only Iceland out of the 24 nations who had this data collected for the Organisation of Economic Co- operation and Development’s 2013 health report (OECD, 2013). Moreover, millions of prescriptions are still given for TCAs, which can have worse side effects than SSRIs, and these TCAs are often prescribed at sub-optimal doses or for different durations than are therapeutically recommended (McManus et al., 2003). Consequently, antidepressants in Australia are often prescribed both incorrectly and inefficiently.
Even if antidepressants are being correctly prescribed, a large proportion of individuals with Depression are unlikely to improve through this treatment. A meta-analysis that reviewed all English language studies on SSRI treatment of MDD between 1981 and 2000 found that the mean response rate was only 50.1% (Walsh, Seidman, Sysko, & Gould, 2002). Although the response rate improved with each year of study, the response rate to a sugar-pill placebo also increased with each year of study (Walsh et al., 2002).
Additionally, 57% of antidepressant trials reviewed failed to find a significant difference between the active pharmacological intervention and the placebo, despite many having large sample sizes (Kirsch, 2002). As expectancy effects accounted for a larger proportion of improvement than the SSRIs themselves, belief in the efficacy of antidepressant treatment may promote more helpful cognitions and behaviours, which then play a major role in whether Depression severity improves through antidepressant treatment (Rutherford, Sneed, Devanand, Eisenstadt, & Roose, 2010b). Similar improvements could therefore occur through non-pharmacological treatments for Depression, especially if individuals had similar expectations about the efficacy of the treatment.
2. Psychological Treatments:
Cognitive Behavioural Therapy (CBT) for Depression is a non-pharmacological treatment that focuses on improving cognitive (including expectations) and behavioural factors associated with depression. CBT for Depression has many studies supporting its efficacy, with meta-analyses showing comparable or greater efficacy than pharmacological interventions for Depression, especially with milder forms of Depression (Butler et al., 2006).
Furthermore, antidepressants in combination with CBT have been found to have additional benefits over either CBT or SSRIs alone for severe Depression (Thase et al., 1997). Thus, effective treatment for Depression, especially for moderate to severe cases, would benefit by incorporating both pharmacological and psychological interventions.
3. Self-Help Strategies:
Although Psychological therapy is recommended for mild Depression, and Psychological therapy in combination with antidepressants is recommended for moderate to severe Depression, there are a lot of individuals who are still impacted by depressive symptoms without meeting the full criteria for MDD (sub-threshold Depression). There are also various instances where individuals are unable to access or do not want to use any of the traditional treatments for Depression. This is where self-help strategies can potentially assist.
In 2009, Morgan and Jorm asked several Depression experts which strategies (out of 282 possible strategies) they thought would be most likely to be effective for individuals with sub-threshold Depression.
They then recruited 1326 adult participants with sub-threshold Depression (between two and four depressive symptoms for more than half of the time over a 2-week period), aged between 18 and 78, and asked them to rate how frequently they used 25 of these self-help strategies for Depression, and if they used them, how helpful they perceived these strategies to be (Morgan, Jorm & McKinnon, 2012).
Of these 25 strategies, 14 strategies were rated by Depression experts (Morgan & Jorm, 2009) as most likely to be effective (depicted in green), 7 strategies were rated as less helpful but not harmful (orange), and 4 strategies were rated as potentially harmful (red). See the differences between what the experts say, what the participants think, and what the participants actually do in the table below:
|What Experts Say Are Helpful Self-Help Strategies for Sub-Threshold Depression||Perceived Helpfulness of Strategies by Individuals with 2-4 Depressive Symptoms||Most Frequently Used Strategies by Individuals with 2-4 Depressive Symptoms|
|1. Make sure that you get out of the house for at least a short-time each day
2. Eat a healthy, balanced diet
3. Do something you enjoy
4. Try to remain involved in purposeful activities for at least a small part of each day
5. Engage in exercise or physical activity
6. Make sure you get enough sleep at night and have a bed time and rise time that varies little from day to day
7. Engage in an activity that gives you a feeling of achievement
8. Talk over problems or feelings with someone who is supportive and caring
9. Let family and friends know how you are feeling so they are aware of what you are going through
10. Try methods to improve your sleep, such as not napping during the day, avoid caffeine and alcohol before bedtime, and make your bedroom as restful as possible
11. Enlist a trusted friend or relative to help you get out and about or do activities
12. Reward yourself for achieving a small goal
13. Learn relaxation methods
14. Make a list of strategies that have worked in the past for depression and use them
15. Take a nap
16. Have a warm bath
17. Take omega 3 fatty acids (fish oils)
18. Get a massage
19. Do yoga
20. Take St John’s Wort
21. Take SSRI’s (antidepressants)
22. Spend more time alone
23. Drink alcohol
24. Do something risky and exciting, such as driving a car too fast
25. Use illicit drugs, such as marijuana
|1. Engage in exercise or physical activity
2. Engage in an activity that gives you a feeling of achievement
3. Do something you enjoy
4. Make sure that you get out of the house for at least a short-time each day
5. Talk over problems or feelings with someone who is supportive and caring
6. Do yoga
7. Get a massage
8. Try to remain involved in purposeful activities for at least a small part of each day
9. Enlist a trusted friend or relative to help you get out and about or do activities
10. Have a warm bath
11. Learn relaxation methods
12. Make sure you get enough sleep at night and have a bed time and rise time that varies little from day to day
13. Eat a healthy, balanced diet
14. Reward yourself for achieving a small goal
15. Let family and friends know how you are feeling so they are aware of what you are going through
16. Make a list of strategies that have worked in the past for depression and use them
17. Take St john’s Wort
18. Try methods to improve your sleep, such as not napping during the day, avoid caffeine and alcohol before bedtime, and make your bedroom as restful as possible
19. Take a nap
20. Take SSRI’s (antidepressants)
21. Take omega 3 fatty acids (fish oils)
22. Use illicit drugs, such as marijuana
23. Drink alcohol
24. Do something risky and exciting, such as driving a car too fast
25. Spend more time alone
|1. Spend more time alone
2. Make sure that you get out of the house for at least a short-time each day
3. Eat a healthy, balanced diet
4. Do something you enjoy
5. Try to remain involved in purposeful activities for at least a small part of each day
6. Engage in exercise or physical activity
7. Make sure you get enough sleep at night and have a bed time and rise time that varies little from day to day
8. Take a nap
9. Drink alcohol
10. Engage in an activity that gives you a feeling of achievement
11. Talk over problems or feelings with someone who is supportive and caring
12. Let family and friends know how you are feeling so they are aware of what you are going through
13. Try methods to improve your sleep, such as not napping during the day, avoid caffeine and alcohol before bedtime, and make your bedroom as restful as possible
14. Enlist a trusted friend or relative to help you get out and about or do activities
15. Have a warm bath
16. Reward yourself for achieving a small goal
17. Take omega 3 fatty acids (fish oils)
18. Learn relaxation methods
19. Do something risky and exciting, such as driving a car too fast
20. Make a list of strategies that have worked in the past for depression and use them
21. Get a massage
22. Do yoga
23. Use illicit drugs, such as marijuana
24. Take St John’s Wort
25. Take SSRI’s (antidepressants)
To answer the title question, it does seem that some of the recommended strategies by experts are both used frequently and thought to be helpful by individuals with depressive symptoms. However, the higher the participant’s Depression severity rating was, the less effective they rated the self-help strategies that were said to be likely to be helpful by the Depression experts (Morgan, Jorm & McKinnon, 2012). But does this mean that these strategies don’t work for them, or does it mean that they engage in these strategies less and therefore have a higher rating of depression severity? The direction of this relationship is unknown.
What is known from this data is that individuals with depressive symptoms are fairly good at being able to understand which strategies are likely to be helpful for them, and which strategies are likely to be harmful. Therefore, reading more self-help books might not teach them anything they don’t already know. When it comes to their behaviour however, individuals with depressive symptoms tend to isolate themselves way more than experts recommend, and more than they know is helpful, drink more than is helpful, and struggle to exercise, achieve things, talk to others, ask for help, and relax as much as they would like to. This is why extra support from qualified professionals is needed, especially when Depression becomes more severe and more debilitating.
Why Psychological Therapy is Often Better Than Self-Help Strategies for Depression?
Feedback is essential for better overall outcomes in the treatment of Depression (Miller, et al., 2008). It promotes more effective behavioural change, through ensuring that the specific strategies and techniques are implemented appropriately and effectively. Control theory suggests that feedback is most likely to result in behavioural change when a behavioural target is provided as a comparison, and an action plan is suggested to help the individual reach this behavioural target in the future (Gardner, Whittington, McAteer, Eccles, & Michie, 2010). Without a behavioural target or an action plan, as would usually be the case with individuals trying to implement self-help strategies for Depression, they are unlikely to achieve sustainable behavioural changes.
Without professional feedback, individuals trying to implement self-help strategies may also give too much attention to unimportant factors whilst giving little attention to the most important perpetuating factors for their Depression (Bergsma, 2008). These errors occur due to several common cognitive biases, which Kahneman (2003) has highlighted in his research:
- Humans are poor at thinking statistically, and struggle to distinguish between high quality information and low quality information.
- Cognitive ease can be mistaken for accuracy, because the human brain tries to conserve energy and draw causal links where possible. This means that change is usually attributed to the easiest, most salient cause, even when this is not correct.
- Humans are predisposed to avoid losses rather than search for gains, and will stick to the safe option rather than take a risk, even though they may not improve as much as they would otherwise.
- Humans also tend to frame things narrowly rather than broadly, and think of what will benefit them in the immediate moment or the short-term rather than the long-term.
But with regular feedback and collaborative problem-solving with a Psychologist that is knowledgeable in treatment for Depression, it is easier to overcome these cognitive biases, adhere to counter-intuitive interventions, and achieve larger and longer-term improvements.
Although self-help interventions may not always assist with Depression as much as we would like them to, you do not have to suffer alone. If you know anyone who is suffering from Depression, please share this article with them. If you are currently suffering from Depression, please seek help today.
Dr Damon Ashworth