Wednesday, December 21, 2016

The Truth About Social Comparisons and Depression


We live in a society where it is impossible to escape comparisons. Growing up, your parents probably compared you with other siblings and in school you compared yourself with other students. As an adult, you continue to compare yourself with your peers at work, your neighbors, your friends and relatives, and people you come across on social network sites or other media outlets. There are two kinds of social comparisons (Taylor & Lobel, 1989): 

1. Upward social comparison: You compare yourself with others whose performance and abilities are better than yours.

2.  Downward social comparison: You compare yourself with others who are less fortunate than you are in the attributes you are comparing.


People compare themselves to others when they need an external standard against which to judge their abilities or opinions (Festinger, 1954). Comparison helps you manage your negative mood, especially with downward comparison, which makes you feel better realizing that there are people who may be faring much worse than you are. Upward comparison may help you by providing you with role models for improvement (Taylor & Lobel, 1989). The above is true when people are not feeling depressed and have a healthy self-image. However, in people with depression, especially with concurrent low self-esteem, social comparisons get distorted. People with depression are more likely to engage in not only more frequent social comparisons (Swallow & Kuiper, 1992), but also more downward social comparisons (Gibbons, 1986). It is hypothesized that people with depression make frequent comparisons because they may have low self-respect or lack of stable sense of self-worth or feel insecure or may base their self-worth on the results of comparisons with others (White et al., 2006).  However, frequent social comparisons come with a price. Research shows that people indulging in frequent social comparisons are more likely to experience negative emotions such as envy, guilt, and regret and also display behaviors such as defensiveness, lying to protect one’s self, lying to protect others’ feelings, and having unmet cravings (White et al., 2006).

When you compare yourself to those that appear to be doing less well than you, there is a temporary improvement in your mood as you feel that you are not so bad off yourself. However, this is a short term relief and offers you no experience or knowledge to help you cope better or learn new skills to deal with what you are going through. Comparing yourself to someone doing better than you can produce more hope, especially if you have high self-esteem (Aspinwall & Taylor, 1993). However, this upward comparison can backfire and make you feel more frustrated if you had a recent setback or faced a threat to your sense of self (Aspinwall & Taylor, 1993). For example, if you were recently reprimanded by your supervisor, then comparing yourself to your friend who just got a raise will only make you experience more negative emotions. However, this comparison would have been helpful if you were not faced with any setbacks or threats and had a more positive image about yourself.
 
Depression makes people feel trapped between a desire for praise and a conviction that they don’t deserve it (Swann, Jr. et al., 1992). Thus, when people with depression compare themselves with others who are less better off, then instead of feeling better, they may discount such comparisons as it doesn’t conform to their self-concept – “I don’t deserve to feel better when someone else is suffering.” Moreover, if a comparison turns out unfavorable for them, people with depression tend to dwell on such a comparison (Gilbert, 2001). The irrational thought processes of mind reading and labeling in depression may trigger a person to view an unfavorable comparison as to mean that others may also feel about them this way and that they actually are “inferior.”

While you cannot avoid social comparison, some strategies to guide you to be careful about social comparisons are below (Dyer, 1978; Gilbert, 2001, 2009; Lieberman, 1997):
  • Ask yourself why you are comparing yourself in the first place? Are you making the comparison to make yourself feel better or worse?
  • If you are comparing yourself to someone worse off to make yourself feel better, is it because then you don’t have to work hard on yourself to improve your situation?
  • Is irrational depressive thinking making you compare to people who are better off than you so that you can self-verify your existing situation?
  • Is envy or jealousy driving your comparison? If so, then don’t compare as these negative emotions will only perpetuate your depression.
  • If comparing yourself with others always makes you feel bad, then is there any advantage of comparing yourself with others?
  • Are you even making a reasonable comparison? Are you comparing yourself to someone who is not going through depression?
  • Compare to get inspiration and not to foster competition. Life is not a big contest and don’t let your own insecurities make you believe that somebody’s failure is your success.
  • Recognize that you are a unique individual who thinks and acts in their own unique way and comparisons are an exercise in futility as other people are unique in their own ways. You can emulate values and character of another person, but you cannot be another person.
  • Avoid doing upward social comparison when you are going through tough times yourself as this will only increase your depression.
  • Don’t be a victim of comparison trap thrown by others when they use statements such as, “Why can’t you be more like…?”
  • If a comparison brought on by you or by others on you turns out to be unfavorable, then recognize and be compassionate about your own strengths and qualities. Frame a more balanced response to the comparison highlighting your strengths and adding the statement “…and what I feel good about myself is that…” to the comparison. For example, “My friend has a higher paying job than me and what I feel good about myself is that I like the work I do and people like me for my work ethic.” When you identify your strengths, you challenge the irrational thinking pattern of disqualifying the positive brought on by your depression.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.


HARPREET S. DUGGAL, MD, FAPA


REFERENCES

Aspinwall, L. G., & Taylor, S. E. (1993). Effects of social comparison direction, threat, and self-esteem on affect, self-evaluation, and expected success. Journal of Personality and Social Psychology, 64(5), 708-722.

Dyer, W. W. (1978). Pulling your own strings. New York, NY: Harper Paperbacks.

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7, 117-140.

Gibbons, F. X. (1986). Social comparison and depression: company’s effect on misery. Journal of Personality and Social Psychology, 51(1), 140-148.

Gilbert, P. (2001). Overcoming depression: A step-by-step approach to gaining control over depression (2nd ed.). New York, NY: Oxford University Press, Inc.

Gilbert, P. (2009). Overcoming depression: A self-help guide to using cognitive behavioral techniques. New York, NY: Basic Books.

Lieberman, D. J. (1997). Instant analysis: How to understand and change the 100 most common, annoying, puzzling, self-defeating behaviors and habits. New York, NY: St. Martin’s Griffin.

Swallow, S. R., & Kuiper, N. A. (1992). Mild depression and frequency of social comparison behavior. Journal of Social and Clinical Psychology, 11, 167-180.

Swann, Jr., W. B., Wenzlaff, R. M., & Tafarodi, R. W. (1992). Depression and the search for negative evaluations: more evidence of the role of self-verification strivings. Journal of Abnormal Psychology, 101(2), 314-317.

Taylor, S. E., & Lobel, M. (1989). Social comparison activity under threat: downward evaluation and upward contacts. Psychological Review, 96(4), 569-575.

White, J. B., Langer, E. J., Yariv, L., & Welch IV, J. C. (2006). Frequent social comparisons and destructive emotions and behaviors: the dark side of social comparisons. Journal of Adult Development, 13(1), 36-44.



Tuesday, November 8, 2016

11 Ways on How the Most Comprehensive Book on Depression is Changing the Concept of Self-Help

You probably have heard or read a few self-help books on depression. Here's a new book The Complete Guide to Self-Management of Depressionwhich to date is the most comprehensive self-help book on depression, and will change how depression is treated in the future. What makes this book different from others is highlighted by the following features unique to this book:

1. Depression is a complex illness, which presents in a myriad of ways and almost 60-70% people treated with antidepressants fail to achieve a symptom-free state when first treated with these medications. The treatment of depression cannot be pigeon-holed into one or two kinds of treatment modalities. This book offers the reader a broad menu of options for self-management of depression above and beyond medications.

2. Self-management is increasingly becoming the standard of care in people with long-standing medical conditions. Self-management puts one in the driver's seat with regards to making choices regarding one's health. People with diabetes, heart disease, emphysema, asthma, and other long-standing medical conditions have successfully used self-management to live a healthy life. However, treatment of depression has lagged behind in incorporating the concept of self-management with most popular self-help books on depression focusing mostly on cognitive-behavioral approaches. This book serves to fill this void.

3. This book broadens the narrow perspective of self-help beyond the traditional treatment of symptoms to self-management of depression. Self-management, besides a focus on treating symptoms, also addresses life style changes, social relationships, communication, problem-solving, and also includes elements of wellness and recovery.

4. This book also presents evidence-based approaches for complementary and alternative treatments of depression, including herbs, dietary supplements, exercise, mindfulness, and light therapy.

5. Treatments that work for anxiety, substance use, and grief, which may commonly co-occur with depression, are discussed in separate chapters in the book.

6. The book discusses the role of internet-based treatments for depression, what to look for in these treatments and also the treatments that are more likely to work.

7. Treatment-resistant depression and chronic depression, rarely discussed in self-help books, are discussed in separate chapters.

8. The book elaborates on recognition and treatment of cognitive symptoms (memory problems, poor concentration, etc.) as research now suggests that these symptoms influence functional outcomes in depression.

9. The book highlights the concept of measurement-based care, which emphasizes the role of periodic monitoring of symptoms using self-assessment tools to make treatment-related decisions.

10. While the highlight of this book is to make the reader aware of the proven strategies that work for depression based on research, where applicable, caveats or situations when a particular strategy may not work, are also discussed. This approach differs from the traditional self-help books on depression that sometimes tend to convey the "one-size-fits-all" paradigm.

11. In contrast to the traditional paternalistic model of healthcare, consumer-defined wellness and recovery are now becoming the norm for healthcare delivery in mental health settings. In line with the modern practice of behavioral medicine, this book highlights the role of wellness and recovery in self-management of depression.

Self-Management is a key component in the treatment of longstanding medical and psychiatric conditions. Learn more about this book and how to self-manage depression at 
The Complete Guide to Self-Management of Depression. 

Tuesday, October 11, 2016

11 Types of Irrational Thoughts that Fuel Depression


People with depression often have negative or irrational beliefs, which continue to fuel their depressive thinking. According to the cognitive model of depression, the emotions in depression such as sadness, guilt, hopelessness, worthlessness, helplessness, anger, frustration, and anxiety are triggered by a dysfunctional thought process. This dysfunction involves misinterpretation or misattribution of situations, past events, memories, and even feelings leading to irrational thoughts – also called cognitive distortions – that in turn perpetuate depressive symptoms. These irrational thought patterns are described below:

1. All-or-None Thinking: This type of irrational thinking is also called black-and-white thinking or dichotomous thinking. This is thinking in extremes or absolutes with no consideration for any alternatives in between the extremes. For example, if you get a below-average performance evaluation and feel that you will never get a good performance evaluation in the future, you are indulging in black-and-white thinking. The same is true if you were rejected by someone who you were hoping to have a relationship with and your thoughts were, “I am a total failure in relationships.” All-or-none thinking defies the universal truth that people’s abilities and their character exists on a continuum and can never be pigeon-holed into an either/or category. Pay attention to words like “total,” “complete,” “always,” and “never” when you describe something that didn’t happen the way you expected it to. Most likely, in these circumstances, your mind has been hijacked into an all-or-nothing thinking mode. You will be successful in some areas of your life and not so much in others. Your failure in one aspect of your life doesn’t negate your successes or accomplishments in other areas; however, it does so when you are going through depression. This is because of selective abstraction, another type of irrational thinking, described next.

2. Selective abstraction:  You focus on one particular detail of a situation or thought, take it out of context, and ignore other important and positive aspects of the situation. People with depression focus on the negative aspects of a situation and ignore the positives, thus perceiving the entire situation as being negative. Also called “mental filter,” this type of irrational thinking is common in depression, especially in people with a pessimistic outlook. For example, a student who got a “B” in one subject and “As” in all the other subjects may dwell on the “B” ignoring their excellent performance in other subjects, thus feeling dejected. Selective abstraction can make you undermine your strengths and underestimate your self-efficacy. Some people with depression take this distorted thinking to even a greater level and start disqualifying the positives as described next.

3. Disqualifying the positives: Depression can cloud your thinking into not just ignoring the positives, but also making you actively negate the positives. This is particularly true when depression lowers your self-esteem, which then makes you feel that you don’t deserve positive things in your life. You can recognize this type of irrational thought when you use the “yes, but” language to discount positive changes. An often cited example for this distorted thinking is when upon being complimented, you find an excuse to justify why you are not worthy of the compliment – “they said this just to make me feel better.” Another variant is when you don’t give credit to yourself and either shift the credit to others or use justifications like, “I just got lucky.” When carried to an extreme, this type of thinking can make you loathe in self-pity to the extent that anything positive seems foreign to you.

4. Arbitrary interpretation: You wrongly assume that others are thinking in bad terms about you without any factual evidence to support your notion. This irrational thought pattern is also referred to as jumping to conclusion or mind reading. Typically, this type of misinterpretation occurs when the cues are ambiguous. For example, if you say “Hi” to your coworker when you walk into the office and they don’t reply back because they are too engrossed in their own thoughts, you may think they are ignoring you and feel bad about the situation.

5. Overgeneralization: You lose perspective of the situation as a whole and allow one problem or perceived deficit to color your perception to negatively interpret the entire situation. An example is when you fail to make a good impression at a meeting and start believing that you don’t have any people skills.

6. Labeling: You use negative labels to describe yourself or others. Labeling is an exaggerated form of overgeneralization and is usually recognized in sentences starting with “I am a ….” Examples include, “I am a loser,” or “He is good for nothing.” In labeling, the emotional reaction to an event is out of proportion to the actual intensity of the event.

7. Magnification/minimization: You inflate your problems or faults and underestimate your strengths and abilities. For example, you are involved in a minor fender-bender and your first reaction is, “This is going to cost a fortune to repair.”

8. Catastrophizing: Magnification taken to an extreme is catastrophizing. You predict the worst-case scenario for a future situation ignoring all the evidence to the contrary. Also called fortune-telling, this type of irrational thought pattern is more common in anxiety. You can recognize this pattern of thinking if you are using statements starting with, “What if…” and ending with a bad outcome. For example, a person who is afraid of heights may think, “What if I feel dizzy and fall over the balcony?” A person afraid of flying may think, “What if I have a panic attack in the plane and no one can help me?” Catastrophic thinking evokes your sense of vulnerability and takes it to an extreme level overriding your rational mind to come up with other more plausible alternatives.

9. Personalization: You take personal responsibility and blame yourself for a situation gone bad or other problems. You even take blame for what others may have done. For example, a woman going through divorce may believe that she is a disappointment to her children and family because she couldn’t save her marriage. As evident, personalization evokes the feelings of irrational guilt, which perpetuate depression.

10. “Should” and “must” statements: You have impractical, often absurd, expectations and you use these expectations as a yardstick to evaluate yourself, others, or a situation. For example, “I should always do my best,” “He should have tried harder,” or “I must win every time.”

11. Emotional reasoning: Your strong emotions make you believe that the feeling-state you are in is actually true without considering evidence to the contrary. For example, “I am feeling guilty, and, therefore, I should deserve to feel bad.”  

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA



Saturday, September 24, 2016

7 Questions That Will Help You Overcome Anxiety, Fear and Panic


Anxiety, fear and panic are associated with irrational thoughts involving themes of threat or danger. These irrational thoughts take the form of “if” or “what if” beliefs. For example, a person who is afraid of heights may think, “If I am on the elevator alone and it gets stuck, no one will be able to save me,” or a person with panic disorder may believe, “If my heart beats too fast, it means that I am probably having a heart attack.” The “if” and “what if” thinking in anxiety disorders is a byproduct of your irrational thought patterns, including magnification, catastrophizing, overgeneralizing, and “should” and “must statements.” Sometimes anxiety is a result of genuine problems or situations that have no solutions. The seven questions that you ask yourself to overcome anxiety are as below:

  1. What is the likelihood of this happening?
  2. What is the evidence supporting my prediction?
  3. What are some other ways to look at this based on facts?
  4. Based on facts, what can happen most realistically?
  5. Can I cope with the most realistic outcome?
  6. If this is a genuine problem, can I problem-solve?
  7. Is it time to accept?
What is the likelihood of this happening?
Individuals with anxiety or panic overestimate the probability of a threat or a bad outcome in a particular situation. Overestimating the probability involves irrational thought patterns of overgeneralizing (e.g., if it has happened one time over past several hundreds of times, it can happen again), jumping to conclusion (e.g., it will happen despite no evidence to support it or evidence to the contrary), or “should”/“must” statements (e.g., it will happen because you have a rigid rule about it). For example, a person with panic disorder may feel that they will faint, if they feel dizzy. However, they may have never fainted before during a panic attack, but their irrational thinking makes them overestimate the probability of fainting. Another common irrational thought in people with panic disorder is that they will have a heart attack if their heart is beating quickly, even though they may not have any history or risk factors of heart disease and their faster heart rate could be explained by several alternative explanations such as doing physical work, drinking coffee, or just being excited.

Other questions you can ask yourself to challenge this faulty overestimation are as below:

  • “What are the odds of this happening?”
  • “Realistically, how likely is this situation going to happen?”
  • “How often has this happened to me in the past?”
  • “How often have I seen this happen to others?”
  • “Am I overestimating the likelihood of this situation to happen?”
What is the evidence supporting my prediction?
This question is particularly helpful to quell your catastrophic thinking about the severity of consequences of a situation. In catastrophic thinking, you believe that a particular outcome will be unmanageable and at the same time underestimate your ability to manage the outcome. Related irrational thought processes are “awfulizing” and “I-can’t-stand-it-it is.” Examples of catastrophic statements include the following:
  • “If I have a panic attack in a movie theater, it would be a disaster.”
  • “It would be absolutely terrible to faint.”
  • “I couldn’t manage if I were to panic on an airplane.”
  • “If I lose my job, it would be a complete disaster.”
  • “I must do everything I can to avoid experiencing a panic attack or else something horrible will happen.”
  • “I would not be able to manage if I were to have a panic attack at work.”
  • “If I have a panic attack, I would not be able to cope.”
One of the most important ways to challenge your catastrophic thinking is to look for evidence to support your worst-case scenario prediction. It is easier to identify irrational thoughts if you change the “what if” statement to a definite statement. For example, “What if the elevator runs out of air?” would be reframed as, “The elevator is going to run out of air.” Then ask yourself, “What is the evidence supporting my prediction?” 

Other questions that you can ask yourself are as below:

  • “Am I predicting that a particular situation will be more catastrophic or unmanageable than it actually is?”
  • “Do I know for sure if my prediction will come true?”
  • “If I have made similar predictions in the past, how often have they come true?”
  • “Do I have any proof that this situation is as dangerous as it appears?”
  • “Will I still think about this situation a month, 6 months, year, or five years from now?”
  • “When I think that I would not be able to cope, what does ‘not be able to cope’ mean?”
  • “Have I ever actually lost control before?”
  • “Based on my past experience, what is the worst thing that will happen?”
  • “What does my past experience tell me about the likelihood of this happening? 
  • “Am I underestimating my ability to cope with this situation?”

What are some other ways to look at this based on facts?
Another strategy that complements the previous approaches to challenge your underlying irrational anxious thoughts is to find more plausible explanations for the situation, thought, body sensations, or image that is causing you to feel anxious or fearful. For example, increase in heart rate may be due to several other factors such as climbing up a flight of stairs. A person who is anxious about making a presentation may arrive at another way to look at this if they tell themselves that people don’t care about how one appears during a presentation. Similarly, a person worrying about their spouse being half-hour late coming home from work can alternatively interpret this as their spouse either leaving work late or being stuck in traffic. It is not unusual for individuals with anxiety to jump to conclusions and arrive at the most fearful scenarios to explain an uncomfortable situation while ignoring the most common possibilities that may explain that situation.  


Based on facts, what can happen most realistically?
The next step in your effort to change your irrational anxious thinking is to pause, assimilate all the information you have gathered so far, and come up with the most realistic outcome for the situation that you predicted as dangerous or awful. Ask yourself, “Given the information I have now, what is the most realistic outcome in this situation?” If you are still convinced that the worst-case scenario is the only plausible outcome, then either you may have to dig deeper to challenge the anxious thoughts or you may have some underlying rigid assumptions or negative core beliefs (e.g., all dogs are dangerous or no one likes me). In addition, it takes practice and repetition to be able to successfully identify, challenge, and change irrational thoughts. You have had these thoughts for years and they are not going to change overnight. 

Can I cope with the most realistic outcome?
Once you have arrived at the most realistic outcome, ask yourself if you are able to cope with it. Most people with anxiety disorders underestimate their ability to manage an anxiety-provoking situation. Coping not only involves your internal resources, but also external resources such as getting help from friends, family, or support group members, and seeking advice from healthcare professionals. Ask yourself:
  • “How have I coped with this before?” 
  • "What other resources are available to me to cope with this situation?" 

If this a genuine problem, can I problem-solve?

Genuine problems such as not being able to pay your bills on time or not knowing how to go about furthering your education can also lead to anxiety and are best addressed by problem-solving and not by cognitive techniques such as challenging your irrational thoughts. The problem-solving steps are described next:

  • Define the problem in clear and specific behavioral terms, i.e., what specific behavior needs to be addressed or changed. You will be able to generate better solutions for a specific problem such as, “I have been postponing paying my bills for last two weeks and feel overwhelmed whenever I try to do that” versus the vague problem, “I can’t get anything done.” To get the specifics of a problem, describe it in terms of: Who? What? When? Where? Why? and How?
  • Define your goals in addressing the problem – what is your desired outcome? Goals are often stated beginning with the phrase, “How can I …?”
  • Brainstorm possible solutions to the problem. When brainstorming solutions, generate as many solutions as possible, don’t analyze or judge the possible solutions at this stage.
  • Weigh pros and cons for each solution.
  • Pick one solution and implement it. Sometimes a combination of solutions may work better as they complement each other.
  • Evaluate the effectiveness and make changes to your approach, if needed.

Is it time to accept?

At other times, there may not be a solution to your problem that is contributing to your anxiety and you may have to switch to an acceptance mode. For example, a person who finds out that their loved one has a terminal illness. Mindfulness-based strategies offer a way of acceptance to manage anxiety related to such unfortunate situations.  

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.



HARPREET S. DUGGAL, MD, FAPA

Saturday, September 3, 2016

Internet-Based Psychotherapy for Depression: Does it Work and What to Look For?


There are several internet-based psychological treatments available for treating depression. Most of the commercially available treatments are based on the principles of cognitive-behavioral therapy (Titov et al., 2014). Studies comparing internet-based therapy with face-to-face therapy demonstrate that internet-based treatments are as effective as face-to-face therapy (Andrews et al., 2010).
Similar to other evidence-based therapies for depression, internet-based cognitive-behavioral therapy is a structured program divided into modules with assigned reading, worksheets, self-assessments, and homework. This may not be suitable for individuals who prefer a less structured therapy. In addition, like traditional face-to-face therapy, internet-based approaches may take time to be effective. If you don’t see any effect within 3 to 4 weeks after starting an internet-based depression intervention, it may be time to discuss potential barriers to using the program or other treatment options with the therapist or clinician assigned to you through the program. Internet-based self-guided programs are not geared for crisis situations and shouldn’t be undertaken if one is at risk for harming self or others.

What to look for in an internet-based psychological treatment?


Internet-based psychological treatments come in various formats and some are freely accessible while others require a fee or an activation code. Some programs are self-guided while others are therapist-guided. Below are few questions that may help you evaluate these programs (Renton et al., 2014):

  • Is there a fee or physician referral required to access the program?

  • Has the program been evaluated for efficacy with at least one randomized controlled trial? Go to the research section of the program and look for the words “randomized” and “controlled” in the cited research as randomized controlled trials afford the highest level of evidence to support the effectiveness of an intervention.

  • What therapies/treatment approach(es) does the program offer? Research mostly supports cognitive-behavioral therapy approaches as being effective for depression with some evidence to support the efficacy of behavioral activation, interpersonal psychotherapy, and acceptance-based treatment (Carlbring et al., 2013; Titov et al., 2014).  

  • Who is the program designed for? The program should be designed for individuals with depression with or without anxiety.

  • Is the program interactive or only provides education about depression? Although education about depression may increase your knowledge about this condition, it is not a substitute for therapy-based interventions that interactive programs offer.

  • Does the program allow users to monitor their progress/modules completion and mood over time? A key ingredient for self-management of depression is monitoring your symptoms to gauge if the treatment is effective.

  • Does the program offer linking with a clinician or therapist (either your own clinician or a program-specific clinician)? What is the type of linkage (e.g., telephone, secure email, text message, etc.)? Research shows that clinician-guided programs have better outcomes and retention.

  • Does the program offer worksheets, either printable for offline use or integrated throughout the program? Are these worksheets mandatory or optional?

  • Does the program offer crisis or emergency contacts?

  • Does the program offer an assessment at the beginning?

  • Does the program offer additional features such as e-mail or text reminders?

  • Does the program offer peer-support (e.g., forum, personal story sharing, or blogs)?

  • Is the program available in the language of your choice?

  • How is the content delivered: size of text, audio or video inputs, use of character examples, and case scenarios?

  • What kind of personal or mental health information is required by the program and how is it kept confidential?

These questions will help you find a program that tailors to your needs in terms of accessibility, affordability, type of intervention being sought, and the extent of support desired. You may find answers to majority of these questions in the “Frequently Asked Questions” section on the program website. Besides affordability and accessibility, the other key factor in choosing the right program for yourself is that it needs to be evidence-based and documents the research supporting its beneficial effects. Don’t waste your time on programs that don’t cite any research to support their effectiveness.


To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.




HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE, 5(10), e13196. doi:10.1371/journal.pone.0013196

Carlbring, P., Hägglund, M., Luthström, A., Dahlin, M., Kadowaki, A., Vernmark, K., & Andersson, G. (2013). Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. Journal of Affective Disorders, 148, 331-337.

Renton, T., Tang, H., Ennis, N., Cusimano, M. D., Bhalerao, S., Schweizer, T. A., & Topolovec-Vranic, J. (2014). Web-based intervention programs for depression: a scoping review and evaluation. Journal of Medical Internet Research, 16(9), e209. Doi:10.2196/jmir.3147.

Titov, N., Dear, B. F., & Andersson, G. (2014). Internet-delivered psychotherapy for anxiety disorders and depression. FOCUS, XII(3), 299-308.




Saturday, August 13, 2016

"How Do I Know If I Have Depression?" The Role of Self-Assessment

What is Self Assessment?

Unlike other fields of medicine where illnesses can be diagnosed using laboratory tests or imaging techniques, psychiatry heavily relies on an individual’s account of their current and past symptoms. This is also true for depression. However, recounting one’s depressive symptoms without using an objective self-assessment tool is fraught with inaccuracies. People overemphasize symptoms that need urgent attention and miss some, especially if they are unaware of the full spectrum of depressive symptoms.

What are the Available Tools for Self-Assessment?

The internet is flooded with the so-called "depression tests" with questionable validity. The following self-assessment tools have been extensively used in research and/or clinical settings and can be downloaded for no charge from the internet. 

Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16): This is a 16-item self-rating scale used for screening depression or assessing its severity (Lamoureux et al., 2010; Rush et al., 2003). The scale comprises of domains of depression as covered in DSM-IV and has been validated for use in trials on depression. QIDS-SR16, along with its scoring instruction, is available online (www.ids-qids.org/).The total score ranges from 0-27 and if you score above 13 or 14, the chances of you being correctly identified as having depression is above 80% (Lamoureux et al., 2010). If you have been diagnosed with depression, then you can assess the severity of depression using the following guidelines: 0-5 (no depression), 6-10 (mild depression), 11-15 (moderate depression), 16-20 (severe depression), and ≥21 (very severe depression).

The Patient Health Questionniare-9 (PHQ-9): The PHQ-9 is a self-reporting scale, which is extensively used in primary care and other medical settings for screening depression. It has nine items which parallel the DSM-IV criteria for major depressive disorder with a total score ranging from 0-27 (Kroenke al., 2001). A copy of the scale can be downloaded from a website (http://www.phqscreeners.com/). On this scale, the cut-off scores of 5, 10, and 15 represent mild, moderate, and severe depressive symptoms, respectively (Kroenke et al., 2010). If you score 10 or higher on PHQ-9, then you have an above 82% chance of being correctly identified as having clinical depression (Haddad et al., 2013).

If you screen above the cut-off score for depression in one of the above rating scales, it is prudent to consult your primary care provider. They will either assess you in depth for depression or refer you to a mental health provider to do the same. Once diagnosed with depression, you can continue to use these self-assessment tools to monitor the progress of your symptoms and also the impact of treatment as described next.

What are the Advantages of Self-Assessment?

  • Self-assessment tools provide you with an objective measure on whether or not you have depression.
  • Once diagnosed with depression, periodic self-assessments help you monitor your progress with treatment and change course if needed.  
  • Sharing information from the self-assessment tools with your provider ensures that you don’t forget to report any important symptoms. 
  • Repeated self-assessments broaden your understanding of depression and help you recognize early symptoms in case of a relapse or recurrence. 
  • Self-assessments, if tracked along with interventions, will help you figure out the kind of interventions that have worked for particular symptoms and to put them to use if these symptoms return.
To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Haddad, M., Walters, P., Phillips, R., Tsakok, J., Williams, P., Mann, A., & Tylee, A. (2013). Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study. PLoS One, 8(10), doi: 10.1371/journal.pone.0078493.  

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.

Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptoms scale: a systematic review. General Hospital Psychiatry, 32(4), 349-359.

Lamoureux, B. E., Linardatos, E., Fresco, D. M., Bartko, D., Logue, E., & Milo, L. (2010). Using the QIDS-SR16 to identify major depressive disorder in primary care medical patients. Behavior Therapy, 41, 423-431. 

Rush, A. J., Trivedi, M. H., Ibrahim, H. M., Carmody, T. J., Arnow, B., Klein, D. N., Markowitz, J. C., Ninan, P. T., Kornstein, S., Manber, R., Thase, M. E., Kocsis, J. H., & Keller, M. B. (2003). The 16-item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biological Psychiatry, 54, 573-583.

Tuesday, August 2, 2016

11 Ways on How the Most Comprehensive Book on Depression is Changing the Concept of Self-Help

You probably have heard or read a few self-help books on depression. Here's a new book The Complete Guide to Self-Management of Depression: Practical and Proven Methods, which to date is the most comprehensive self-help book on depression, and will change how depression is treated in the future. What makes this book different from others is highlighted by the following features unique to this book:

1. Depression is a complex illness, which presents in a myriad of ways and almost 60-70% people treated with antidepressants fail to achieve a symptom-free state when first treated with these medications. The treatment of depression cannot be pigeon-holed into one or two kinds of treatment modalities. This book offers the reader a broad menu of options for self-management of depression above and beyond medications.

2. Self-management is increasingly becoming the standard of care in people with long-standing medical conditions. Self-management puts one in the driver's seat with regards to making choices regarding one's health. People with diabetes, heart disease, emphysema, asthma, and other long-standing medical conditions have successfully used self-management to live a healthy life. However, treatment of depression has lagged behind in incorporating the concept of self-management with most popular self-help books on depression focusing mostly on cognitive-behavioral approaches. This book serves to fill this void.

3. This book broadens the narrow perspective of self-help beyond the traditional treatment of symptoms to self-management of depression. Self-management, besides a focus on treating symptoms, also addresses life style changes, social relationships, communication, problem-solving, and also includes elements of wellness and recovery.

4. This book also presents evidence-based approaches for complementary and alternative treatments of depression, including herbs, dietary supplements, exercise, mindfulness, and light therapy.

5. Treatments that work for anxiety, substance use, and grief, which may commonly co-occur with depression, are discussed in separate chapters in the book.

6. The book discusses the role of internet-based treatments for depression, what to look for in these treatments and also the treatments that are more likely to work.

7. Treatment-resistant depression and chronic depression, rarely discussed in self-help books, are discussed in separate chapters.

8. The book elaborates on recognition and treatment of cognitive symptoms (memory problems, poor concentration, etc.) as research now suggests that these symptoms influence functional outcomes in depression.

9. The book highlights the concept of measurement-based care, which emphasizes the role of periodic monitoring of symptoms using self-assessment tools to make treatment-related decisions.

10. While the highlight of this book is to make the reader aware of the proven strategies that work for depression based on research, where applicable, caveats or situations when a particular strategy may not work, are also discussed. This approach differs from the traditional self-help books on depression that sometimes tend to convey the "one-size-fits-all" paradigm.

11. In contrast to the traditional paternalistic model of healthcare, consumer-defined wellness and recovery are now becoming the norm for healthcare delivery in mental health settings. In line with the modern practice of behavioral medicine, this book highlights the role of wellness and recovery in self-management of depression.

Self-Management is a key component in the treatment of longstanding medical and psychiatric conditions. Learn more about this book and how to self-manage depression at The Complete Guide to Self-Management of Depression: Practical and Proven Methods.


Tuesday, July 26, 2016

Is it Grief or Is it Depression?


Grief and depression may have some overlapping symptoms such as sadness, crying, fatigue, reduced concentration, and sleep and appetite disturbances. However, grief and depression are not the same. Grief is a normal reaction to a loss whereas depression is a clinical condition. Other distinguishing features between grief and depression are as under (American Psychiatric Association, 2013; Shear, 2012):  
  • Although in grief, individuals feel sad and are tearful, the predominant mood in grief is a feeling of emptiness and loss, whereas in depression, the depressed mood is persistent and there is an inability to anticipate happiness or pleasure.
  • Bereaved people feel sad because they miss a loved one, whereas individuals with depression feel sad because they see themselves and/or the world as inadequate, flawed or worthless.
  • Self-esteem is preserved in grief, whereas depression is usually characterized by feelings of worthlessness and self-loathing.
  • Feelings of guilt in grief are related to one’s perception of failing to say or do something before the person died (e.g., not seeing the deceased person more frequently or not being able to mend a relationship before the person died). In depression the feelings of guilt are associated with irrational thoughts of taking excessive personal responsibility or that one doesn’t deserve to fare better when others are suffering.
  • In grief positive emotions occur as frequently as negative emotions as early as a week after a loved one dies whereas in depression, these emotions are rare.
  • Depression biases one’s thinking in a negative direction, but grief does not.
  • Depression inhibits one’s capacity to relate to other people’s intention and to care about them. In grief, the desire to be with others and appreciation for the efforts of others is preserved.
  • In grief, suicidal thoughts about death or dying are related to the themes of “being with” or “joining” the deceased, whereas in depression these thoughts are triggered by underlying themes of worthlessness, hopelessness, feeling that one is undeserving of life, or inability to cope with the pain of depression.
If an individual has suffered a recent loss and they are not sure if their grief has evolved into depression, then using the above distinguishing pointers would be helpful. However, be mindful that depression can still occur in context of bereavement. The Diagnostic and Statistical Manual of Mental Disorders – fourth edition, text revision (DSM-IV TR) excluded depressive symptoms occurring up to a couple of months after a loss as being a sign of a major depressive episode (American Psychiatric Association, 2000). However, depression arising after a loss of a loved one is no different compared to that arising due to a job loss or recent divorce or “out of the blue” (Pies, 2014). Moreover, not diagnosing depression during grief can potentially divest such people from getting timely help; professionals may defer treatment until symptoms persist or become more severe. In tandem with these observations, the DSM-5 doesn’t consider bereavement as an exclusion for diagnosing depression.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: American Psychiatric Association.

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Pies, R. W. (2014). The bereavement exclusion and DSM-5: an update and commentary. Innovations in Clinical Neuroscience, 11(7-8), 19-22.

Shear, M. K. (2012). Grief and mourning gone awry: pathway and course of complicated grief. Dialogues in Clinical Neuroscience, 14, 119-128.


Tuesday, July 19, 2016

Problem Solving: A Proven and Simple Way to Treat Depression




If you are human, you will have problems. Having problems means that you are normal and solving them means you are a happy normal! Genuine problems such as not being able to pay your bills on time or not knowing how to go about furthering your education are best addressed by problem-solving and not by cognitive techniques such as challenging your irrational thoughts. Problem-solving therapy is an effective treatment for depression, but has received little attention as most popular books on self-help of depression heavily rely on cognitive-behavioral techniques (Kirkham et al., 2015). The problem-solving steps are described next (Martell et al., 2010; Nezu et al., 1989).
 

Problem-solving steps


1.     Define the problem in clear and specific behavioral terms, i.e., what specific behavior needs to be addressed or changed. You will be able to generate better solutions for a specific problem such as, “I have been postponing paying my bills for last two weeks and feel overwhelmed whenever I try to do that” versus the vague problem, “I can’t get anything done.” To get the specifics of a problem, describe it in terms of: Who? What? When? Where? Why? and How?

2.     Define your goals in addressing the problem – what is your desired outcome? Goals are often stated beginning with the phrase, “How can I …?”

3.     Brainstorm possible solutions to the problem. When brainstorming solutions, generate as many solutions as possible, don’t analyze or judge the possible solutions at this stage, and think in terms of both broad strategies and focused tactics. However, be aware that when you are feeling depressed, it is a challenge not to prematurely judge a solution negatively due to your underlying negative irrational thoughts (e.g., “This is never going to work,” or “Yes, but…” rejection of a solution). Also, a judgmental stance engendered by depression curbs creative thinking. If you are drawing a blank, then use the following strategies to stimulate your brain into thinking about more solutions:
  • Think about an individual you know personally who you admire and respect or someone from the world of movies, books, or current events. Next, ask yourself, “How would he or she approach this problem? What actions would this person take if faced with the same problem?”
  • Close your eyes and imagine yourself in the problematic situation. Imagine yourself successfully coping with the problem. Think of what you would say and do to deal effectively with the situation.

4.      Weigh pros and cons for each solution.
  • “How likely is it that this solution would help me reach my goal?”
  •  “What bad things could happen if I pick this solution?”
  •  “What is the likelihood that I can implement this solution in its optimal form?”

5.     Pick one solution and implement it. Sometimes a combination of solutions may work better as they complement each other.

6.     Evaluate the effectiveness and make changes to your approach, if needed.

7.     If the problem is not resolved, then do one of the following troubleshooting strategies:

  • Reset your goals as they may not be realistic.
  • Break the problem down into smaller chunks. 
  • Think of more possible solutions.

Becoming a master problem-solver comes with practice. You may want to write down the problem-solving steps on an index card as a reference to deal with minor or major problems. In addition, it is essential to integrate your new behaviors into a routine in order to have an enduring impact of the problem-solving exercise.


Tips to improve problem-solving skills

Following tips will enhance your problem-solving skills (Nezu et al., 1989):

·         Recognize that problems are part-and-parcel of life.

·         Many individuals have common types of problems and you are not alone.

·         Approach problem-solving with a rational, realistic, and positive attitude.

·         Don’t avoid facing a problem. Solving problems breaks the vicious cycle of problems leading to depression leading to more problems.

·         Work on smaller problems and build yourself up for the bigger ones.

·         There is no such thing as the perfect solution. Pick the best solution that works for you.

·         Stop and think before picking a solution – the first idea may not always be the best!

·         You have the ability to change your solution whenever you want.

·       If you cannot solve a problem after trying the troubleshooting strategies, then seek help from someone who is more knowledgeable or trained to deal with your situation. For instance, consult a financial advisor if you are not able to solve your financial problems after repeated problem-solving attempts.

To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

Kirkham, J. G., Choi, N., & Seitz, D. P. (2015). Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry, Oct 5. doi: 10.1002/gps.4358.

Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2010). Behavioral activation for depression: A clinician’s guide. New York, NY: The Guilford Press.

Nezu, A. M., Nezu, C., & Perri, M. G. (1989). Problem-solving in depression: Theory, research, and clinical guidelines. New York, NY: John Wiley & Sons, Inc.


Written by a board-certified psychiatrist and an international expert on self-management of depression, this blog focuses on proven scientific methods of treating depression that go beyond medications and traditional therapy. It discusses elements of healthy lifestyle, positive psychology, relationships, values, strengths, communication, and wellness. The content of the blog is not to be construed as treatment advice.

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