Coping With the Catch 22s of Depression

Jon G. Allen, PhD
The Menninger Clinic

The plight of the depressed person is not fully appreciated, even by many persons who are depressed. We tend to think of depression as an acute illness—something bad happens, you become depressed, then you recover fairly quickly. True, depression can be a relatively time-limited response to stressful events, and some persons respond fairly quickly and fully to treatment. But that's not the norm.

Severely depressed persons are between a rock and a hard place. Let's first consider the rock: Depression is an acute illness, like the flu, from which you recover quickly. Many persons who have struggled for a long time to overcome depression have been urged by others, "If you'd just (eat right, go out and exercise, have more fun, stop isolating, etc.) you'd feel better." I've come to think of "just" as a fighting word—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. You must work on several fronts. It can be a long haul, even if you're able to put a lot of effort into it.

Here's the hard place: Depression is a serious, persistent, mental-physical illness. I think the hard place is a more realistic place to be than the rock. Depression is a serious illness, recovery may take a lot of time, and you remain vulnerable to recurrence. This is a hard place indeed, but sitting on the rock is potentially crazy-making—you should be able to snap out of it, but you cannot. Therefore you conclude that you are crazy, lazy, or some other depressing idea.

There are good reasons to think of depression as a physical illness:

1. Depression can stem partly from genetic (inherited) vulnerability.
2. It is associated with changes in patterns of brain functioning.
3. It is often accompanied by physical ill health.
4. It is responsive to medications and electroconvulsive therapy.

But we should not lose sight of the mental aspects of depression. Psychological stress can lead to persistent adverse changes in brain functioning. The meaning of events in your life—recent or remote—can produce physiological stress that alters the way your brain functions. For example, losing your job (event) may lead you to fear that you can no longer support your children (meaning), which in turn leads to persistent stress-related changes in your brain and the rest of your body.

Depression is a hard problem. Why does it take so long to recover? Why is it so difficult and painful? Here's the rub: All the things you need to do to recover from depression are made difficult by the symptoms of depression! For example, if you're depressed, it's likely that you've been severely stressed and feel exhausted. Therefore, you must rest. But consider one of the most common symptoms of depression: insomnia. A Catch 22. There are many others. You should eat well, but depression decreases your appetite. You should be active—even exercise!—but depression robs you of energy. You should participate in enjoyable activities, but depression erodes your capacity for pleasure. You should think realistically, but depression brings negative thinking. You should spend time with family and friends, but depression prompts you to withdraw and isolate. Above all, you should stay hopeful, but depression may bring hopelessness.

Contemplating the Catch 22s of depression is risky—potentially adding to your discouragement. Keep in mind that it is not impossible to recover from depression, despite the Catch 22s. We know this, because people do recover. Recovery is difficult, but not impossible. Making the distinction between difficult and impossible is crucial to recovery. Recognizing the difficulty may be discouraging, but failing to recognize it can be even more demoralizing. Minimizing the seriousness of depression leads to unrealistic expectations, enormous frustration, self-criticism, and hopelessness—all of which add further fuel to depression.

You may criticize yourself—or be criticized by others—for wallowing in depression. But you did not choose to be depressed, and you cannot simply choose to be depressed no longer. You cannot just make up your mind to be well and heal yourself by some act of will. But, if you're not profoundly depressed, you can choose to take actions that will take you slowly along the path of recovery. Recovering from depression involves a series of hard choices over a long period. It can be a hard choice to get out of bed, to take a shower, to get dressed, to go for a walk, or to call a friend. You cannot choose to recover from depression at one moment, once and for all. Recovering from depression requires making hard choices continually, one after another, day after day, month after month. It's like climbing a mountain, with ups and downs, gains and setbacks along the way. The more depressed you are, the harder the choices, the harder the climb. As you respond to treatment, the choices become easier, and you have more strength and ability to climb.

I believe that understanding depression and accepting the seriousness of the condition puts you in the best position to cope with it. Understanding depression can provide a more hopeful view, based on more realistic expectations. Ideally, you might see depression as a challenge, a hard fight or struggle. But this is not an easy stance to take when you're depressed. You might need to set your sights on small steps and goals that you can achieve.

Within each of the Catch 22 areas, you have some leverage over depression. The leverage is not great—you can't just "snap out of it" no matter how much you would wish to do so. Fortunately, however, we are not dealing with black and white, but rather shades of gray. You need to be motivated to recover. You need energy to be motivated. If you're depressed, you may have little energy. But you're likely to have some energy and some motivation. It's these shades of gray—however dark—that make the Catch-22 problems very difficult rather than utterly impossible. You have a little leverage in many areas.

Recovery takes a long time and the risk of recurrence is high, but active engagement in treatment can facilitate recovery and reduce the risk of recurrence. For many depressed persons, a combination of somatic treatment (e.g., medication and electroconvulsive therapy) and psychotherapy is best. Treatment helps give you more leverage over the Catch 22s. Medication can help not only with problems with mood, sleep, and appetite, but also with the full range of symptoms of depression. Behavior therapy helps improve your activity level and increase your involvement in pleasurable activities. Cognitive therapy helps interrupt the automatic negative thoughts (e.g., "I'm worthless") that keep your mood in the pits. And interpersonal therapy helps with relationship problems and stressors that trigger and maintain depression. Thus, there are many potential avenues of help.

To sum up, there are many good treatments, but the road to health is often long and hard. Fully appreciating the challenges depression poses might help you be less self-critical and more compassionate toward yourself. Caring for yourself is the foundation for recovering and remaining well.

Note: This article is excerpted from The Menninger Clinic's Professionals in Crisis program patient education material, "Coping With the Catch 22s of Depression," and is based in part on the chapter on posttraumatic depression in Dr. Allen's book, Traumatic Relationships and Serious Mental Disorders, published by John Wiley & Sons, 2001.

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