Once known as “the common cold of mental illness,” depression has been recognized throughout history. Dovid was summoned to the court of Shaul to alleviate the king’s depression with music. The Rambam, himself a physician, provides an explicit treatment for depression. In his writings, Rav Nachman of Bratzlav offers support and encouragement to anyone suffering from the low self-esteem – “falling in one’s own eyes,” in his words – and the despair that so many of us experience during depressive episodes. In the U.S., an estimated 5–12% of men and twice as many women will experience a diagnosable depression during their lifetime. In any given month, an estimated 5% of all Americans meet the criteria for a Major Depressive Disorder, a severe form of the condition. In short, depression is likely to touch our lives through our own struggles, or by affecting those close to us.

Depression is considered a mood disorder. Indeed, depressed people often feel sad, unhappy, apathetic, irritable, hopeless, desperate, and/or resigned. But depression involves many aspects of our lives: It affects our physical selves, often causing a loss of appetite or overeating, insomnia or sleeping too much, fatigue and low energy. It can change our thinking, interfering with normal memory and concentration as it increases negativity, guilt, worthlessness, and pessimism. Motivation plummets, and functioning is impaired; even simple tasks may seem overwhelming. Depression costs us dearly in terms of human misery, troubled relationships, lost productivity, and even suicidal thinking and behavior. This painful and widespread problem demands a thoughtful response.

Is depression an illness? The American Psychiatric Association says so. New York City’s Department of Health and Mental Hygiene says so. Pharmaceutical companies say so. But not everyone agrees. Experts concur that there are certain advantages to a medical model of depression: It reduces self-blame, and increases the likelihood that those suffering will seek appropriate help. (If I have a sore throat, I don’t think of it as a sign of personal weakness or failure. I call my doctor for a throat culture, and take the antibiotics he prescribes.)

However, the disease model may not be completely accurate. While biological predispositions, hormonal influences, and other physiological factors clearly play a role in some cases of depression; no simple, clear causal relationship has been proven. While certain levels of neurotransmitters, naturally occurring chemical messengers in the brain, tend to be abnormally low in depressed individuals; we don’t know whether the low levels cause the depression, or whether depression lowers the levels: It’s the old “chicken and egg” question. The best predictor of depression is a stressful life event, such as the death of a loved one or job loss. What does that have to do with biochemistry? And certain forms of psychotherapy have been demonstrated to produce the same changes in neurotransmitter levels that antidepressant medications do. A realistic picture of depression, then, seems to be more complex. Perhaps depression is best understood as an interactive process involving many aspects of our experience – our environments, our bodies, our feelings, our behaviors, our thoughts, and our relationships. This more sophisticated view of depression makes sense to many mental health professionals, and opens up a number of possibilities for effective intervention.

So what’s the good news about depression? In three letters, it’s EBT: Evidence-based treatment. The growing trend in mental health is to help people using proven methods. Scientific research demonstrates that these treatments work well and work better than standard (or nonspecific) approaches. Most EBT’s work on a short-term basis. Participants often make significant progress and are sometimes able to successfully complete therapy after 10 to 16 sessions. Here’s what research tells us works to undo depression:

Behavioral Activation

This approach sees the basic problem with depression as “shutting down.” In a misguided attempt to feel better, or with the mistaken belief that they shouldn’t or can’t do what they don’t feel like doing, depressed people often avoid activity, including social activity. They avoid the very behaviors that might give them a sense of pleasure, accomplishment, mastery, or problem-solving. The key to behavioral activation is to help depressed people re-engage with life. Participants collect information on the behaviors they choose in response to their moods, and how these behaviors, in turn, affect their moods. They focus on experimenting and discovering what behaviors bring them closer to the results they want.

Rochel* was strongly affected by her husband’s death. While she went back to work right after shivah and maintained relationships with family and friends, months afterwards she was clearly depressed. Fortunately, she became aware of her condition, and put a behavioral activation approach in place. She made only two changes: She took a walk for exercise at least five days a week, and did something enjoyable (or something that she thought might be enjoyable, or that she would have enjoyed before she felt depressed) once a week. She continued to mourn her husband, but her depression lifted within two to three months.  

Behavioral activation has been proven to be effective in both overcoming depression and preventing future relapse. An excellent self-help book on this method is Addis and Martell’s Overcoming Depression One Step at a Time.  

Cognitive Therapy

Cognitive therapy emphasizes that humans are meaning makers: We always interpret our experience. I learned this from my Tanach teacher, the great Nechama Leibowitz, z’l, who defined parshanut as attributing meaning to sensory data. What does it mean, for example, if I lift my hand? How you feel and what you do in response both depend on how you interpret it. You may decide that I’m waving in greeting, or that I’m motioning you to come over. You may decide that I’m simply stretching my arm to get out the kinks. You may think that I’m indicating that you should stop, slow down, or lower your voice. Maybe you think that I’m about to shake your hand. Maybe you think I’m about to hit you. Do you see how the meaning you give it changes your experience? According to most cognitive therapists, except on a level of reflex, we humans rarely react directly to our environment. Instead, our reactions are mediated by our cognitions – our thoughts, beliefs, and interpretations of the world. Al regel achat, the idea behind cognitive therapy is that you feel the way you think. Your thinking causes you to feel the way you do. And when you’re depressed, your thinking tends to be negativistic and distorted.   The focus of cognitive therapy is on identifying and changing distorted thinking.

Adina* struggled with severe depression since her divorce. She once described a heated exchange she’d had with her daughter, and said that she’d be better off dead. “She said: ‘You have no friends! You have no life!’ and it’s true. I don’t.” We examined the beliefs that fueled Adina’s painful feelings: I pointed out that Adina was alive, so, by definition, she had a life. “Oh, you know what I mean!” she argued. We considered her specific experience. Taking a more comprehensive view, we agreed that there were some aspects of her life, such as being a mother and earning a living by holding down a steady job, that pleased her, while others, such as her depression, anxiety, and being divorced that were painful. Adina also acknowledged that she was doing something about these problems – getting therapy, going to the gym, and working with shadchanim – and that she could possibly do more to enjoy a richer, fuller, more joyful life. I also pointed out that Adina had mentioned a number of friends, and asked how that fit with her belief of having none. As many depressed people do, Adina disqualified the positive. She told me that she hadn’t had much contact with one friend in quite a while, and that she thinks another only gets in touch when she wants something from her. She said that other people have more and better friends, and are more active cultivating those friendships. (The unofficial term for this is “comparisonitis,” and it’s a shortcut to depression!) We agreed that a more accurate idea was that she had some measure of enjoyment and support in her friendships, although they weren’t all she’d like them to be, and that she could choose to work on developing more and better connections with others. By challenging her perfectionistic, all-or-nothing thinking and recognizing “shades of grey,” Adina arrived at a more realistic, useful, and compassionate view of herself and her situation. Her mood improved, and hope replaced her suicidal thinking.

Cognitive therapy takes a while to learn, but is well worth the effort. It has been proven to treat depression and to prevent relapse. Greenberger and Padesky’s Mind Over Mood is an excellent self-help manual on this approach and the book that I recommend to my clients more than any other.

Interpersonal Psychotherapy

As the name implies, IPT emphasizes the importance of interpersonal relationships on our wellbeing and focuses on improving a depressed person’s relationships with significant others. IPT recognizes how relational difficulties can contribute to depression and how depression, in turn, frequently characterized by social withdrawal and low levels of functioning, often leads to further relational problems. Specifically, IPT focuses on one or more of the following problem areas: Role disputes (conflicting expectations about role behavior in a particular relationship,) role transitions (changing roles when, for example, we get married or divorced, have a child, move to a new community, enter or retire from the workforce, get a promotion, or go back to school,) unresolved mourning, and deficits in social skills. Research suggests that since women’s self-concepts tend to be inextricably linked to their important relationships, the IPT approach may be particularly useful for them.       

Debbie* stated that her husband, Yehudah*, caused her depression. When I met with the two of them, I noticed that almost all of their communication took the form of quoting rules to each other, and criticizing each other for not following them. “You’re the husband! You’re supposed to support me financially!” Debbie would say. “You’re the wife! You’re supposed to have a home-made meal ready for me when I come home every day!” Yehudah would respond. Their conflict, a classic case of role disputes, was making them both very unhappy. As they focused on improving their relationship, they developed alternative ways of communicating – actively listening, expressing appreciation, asking for what they wanted instead of demanding or blaming, negotiating their differences – and they grew closer. Debbie was pleased with her improved mood, and surprised by her increase in energy. “Our marriage is not problem-free,” she said, “but we catch ourselves when we get into destructive patterns. We know what doesn’t work, we know how to do what does work, and, most of all, we’re working as partners: Now we’re on the same team.”

IPT is demonstrated not only to reduce depression, but also to improve social functioning.  

Acceptance and Commitment Therapy

Given how much they suffer, depressed people often struggle long and hard to eliminate or at least reduce their symptoms. They also frequently also avoid situations and activities that they believe may trigger depression. From the perspective of Acceptance and Commitment Therapy (ACT), this attempted “solution,” while understandable, is a big part of the problem. We all experience a range of inner experiences, including painful feelings, troubling thoughts, uncomfortable physical sensations and reactions, unwanted, intrusive memories, and problematic urges. That’s part of being human. To a large degree, this is inevitable, and beyond our control. Not only can we not win the struggle, but the struggle – or the avoidance – takes our focus, attention, energy, and investment away from what really matters: the life we want to lead. ACT promotes a dual approach to reducing depressive suffering: Accept the inner experience: You don’t have to want it or like it, and you also don’t have to involve yourself with it, identify with it, fight it, or push it away. Then clarify your values and commit to acting on them. Use your resources to move toward a rich, full, meaningful life.

Karen* struggled with depression for years, and it worsened after she relocated to a new community following a painful break-up. She criticized herself for her weight and her single status, as well as for not having met her vocational and financial goals. She wanted to help herself, and eventually identified some coping strategies that decreased her symptoms, but found that they did not do so consistently over time. When they didn’t work or when she didn’t use them, she’d blame herself and feel more depressed. ACT proved to be revolutionary for Karen. She concluded that she might never extricate herself from depressive thoughts and feelings, but that she need not entangle herself in them, either. Instead of revolving her life around managing or controlling her depression, she made a conscious and deliberate choice to focus on what was truly important to her. She appreciated and nurtured mutually supportive friendships. She started a job search for a position that offered more creativity and reward. She consulted with a nutritionist and developed an eating plan that left her feeling more satisfied and energized. She rediscovered her interest in art and resumed painting. She acknowledged her deep and genuine spirituality and sought and found a shul to whose rav and members she related. She spent more time outdoors appreciating nature. She realized her value of chesed through volunteer work. Her depression became less impactful as she cultivated her expanding and increasingly fulfilling life.

ACT has been proven to be an effective treatment for depression that sometimes produces additional benefits after therapy is completed. The Mindfulness and Acceptance Workbook for Depression by the husband-and-wife team of Strosahl and Robinson is an excellent resource on this approach.

Medication

There are a number of safe, effective medication options for many depressed individuals. As a non-prescribing psychotherapist, I strongly urge anyone considering antidepressant medication to consult with an expert in psychopharmacology – a psychiatrist or a specialized nurse practitioner – and to openly share their symptoms and questions. Many people deny themselves effective medical treatment because of unfounded fears of side effects and/or addiction. A responsible practitioner will discuss the benefits and risks of medication with you, and address your concerns clearly and honestly. A good clinician will include you as an important member of your treatment team. Because medication affects body chemistry, it may be just as important to communicate with your provider about stopping medication as starting it; it is not safe to abruptly stop taking certain medications.

Both Adina and Debbie, in the examples above, benefited from a combination of medication and evidence-based psychotherapy.    

Exercise

Aerobic exercise has been demonstrated to be an effective antidepressant. (There was once a psychiatrist who was so impressed with the research findings on aerobic exercise in decreasing both depression and anxiety, that he started conducting all of his sessions while running with his patients! Of course, aerobic exercise has other important benefits as well, especially in enhancing cardiovascular health.) There is some research that suggests that other forms of exercise, including strength training, also decrease depression. (Again, there are many physical advantages of strength training, especially for women over age 35.)

Do all cases of depression require professional help? I believe that depression requires intervention. Some people, like Rochel in the example above, are able to undo depression by implementing their own self-help strategies. However, this can be hard to do because of the nature of depression: It decreases motivation, energy, and hopefulness. It increases pessimism, discouragement, and helplessness. It interferes with thinking and creative problem-solving. It causes people to withdraw from their support network instead of engaging it. Also, in cases where depression leads to suicidal risk or severely impaired daily functioning, self-help may simply not suffice, or may not work quickly enough, and more intensive treatment may be needed. For these and other reasons, professional help may be the best option. To get the most out of therapy, you may wish to read Preson, Varzos, and Liebert’s short, practical book, Make Every Session Count: Getting the Most Out of Your Brief Therapy.

* All identifying information has been altered, and case examples are composites of a number of different individuals.

Sararivka Liberman, LCSW-R, has been a psychotherapist for 30 years. For the past 20 years, she has provided supervision and training to mental health professionals. She currently serves as a Master Trainer in Evidence-Based Practice at the Jewish Board of Family and Children’s Services and an Administrative Supervisor at the agency’s Boro Park counseling center. She also maintains a private practice for adults in Flatbush. Contact information: (718) 393-7750; [email protected].