Managing the Depression Puzzle

book cover: Managing the Depression Puzzle, Second edition, by Ashley L. Peterson

Managing the Depression Puzzle by Ashley L. Peterson, a comprehensive guide to living with and managing depression, is now in its revised and expanded 2nd edition.

It’s available from:

The paperback version is also available from Book Depository and Powell Books.

Managing the Depression Puzzle

This page is also your go-to guide for all things depression on MH@H.

About Managing the Depression Puzzle (2nd Ed.)

Managing the Depression Puzzle provides a comprehensive look at how to manage depression. The goal is to provide a wide range of pieces that might fit in your own unique depression puzzle, so you can pick and choose what does fit for you. No one strategy (or set of strategies) is going to work for every individual, but having information about what the options are will put you in a better position to make choices about your mental health.

The book begins with an overview of depressive illnesses and subtypes. Strategies for dealing with depression are broken down into illness treatments and wellness promotion strategies. Illness treatment strategies like medication, ECT, and therapy, lift you from sick to less sick. Wellness promotion strategies, including mindfulness and self-care, help boost you up from less sick to well. Finally, the book looks at common issues faced by anyone living with a chronic mental illness.

Managing the Depression Puzzle draws on the author’s education and experience as a former mental health nurse and pharmacist, as well as personal experience living with treatment-resistant major depressive disorder. The approach is pragmatic, candid, and realistic, with the recognition that depression doesn’t happen just one way; it is as unique as you are.

Chapter List
  1. Introduction
    1. 1) What is depression?
    2. 2) Why do we get depressed?
  1. Part I: Illness treatment strategies
    1. 3) Medications
    2. 4) Somatic treatments
    3. 5) Psychotherapy
    4. 6) Complementary & alternative therapies
  1. Part II: Wellness promotion strategies
    1. 7) Activation
    2. 8) Mindfulness
    3. 9) Self-care
  1. Part III: Putting the pieces together
    1. 10) Understanding your illness
    2. 11) Suicide
    3. 12) Living with a chronic illness


Downloadable depression worksheets:

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Readers’ Responses to Managing the Depression Puzzle

Ashley presents everything like pieces of a puzzle. Each piece is for the reader to choose. The reader can pick those that fit their plan and leave the other pieces. Just in case you are not sure what the pieces are, Ashley ends each chapter with: “This Chapter’s Potential Pieces of The Puzzle”. I found this very helpful, it is a way to refer back to at a later time.

rts of Facing the Challenges of Mental Health (2nd edition)

I believe that this book will be a great resource for those struggling with depression and those who care for someone with depression. I would not hesitate to suggest this book to my therapy clients, as it is both clinically sound and user-friendly.

Johnzelle Anderson of Panoramic Counseling (1st edition)
More Readers’ Responses

Knowledge is power and that power is provided in this book. I would recommend it for everyone who is interested in depression, is with living the illness themselves, knows somebody struggling with depression or who wants to have a better understanding of the condition.

– Five star review from Kacha of Food.for.Thoughts (1st edition)

The most important thing I wanted to mention to you is that right from the start I love the tone of this book. I felt as if Ashley was an experienced guide and was holding my hand and reassuring me, as she explained all sorts of facets of a mental health diagnosis and the array of potential treatments to aid recovery. 

Caramel (Learner at Love) (1st edition)
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About Ashley L. Peterson

Ashley L. Peterson, author and creator of Mental Health @ Home

I began my career in health care as a pharmacist in 2002, and quickly returned to school to become a nurse two years later. I specialized in the field of mental health for my entire 15-year career, working with people with serious mental illness in both hospital and community settings.

Two years into my nursing career, I was hospitalized with a diagnosis of major depressive disorder. Since then, I’ve been passionate about challenging the stigma around mental illness. I completed a Master of Psychiatric Nursing degree in 2015, despite two hospitalizations while in grad school. My thesis work and several related academic journal publications focused on my experience of mental illness within the context of nursing culture. I’m no longer working due to my illness, but I continue my education and advocacy efforts online.

More About Depression on MH@H

Depression is the illness I live with, and I write about it a lot here on MH@H. Managing the Depression Puzzle draws on many of the topics covered in these blog posts.

Depression is a broad umbrella that encompasses a lot of unique blends of symptoms, history, and responsiveness to treatment. Depression can have many faces.

Several types of depression have been identified that involve particular patterns, including:

Depression Symptoms - graphic of person sitting under rain clouds

Symptoms of Depression

Appetite: Appetite can either significantly increase (more common with atypical depression) or decrease (more common with melancholic depression), with corresponding weight gain or loss.

Cognition: Depression can cause cognitive symptoms, including impaired concentration and memory. It can also promote negative thinking patterns and cognitive distortions.

Emotions: For a diagnosis of depression, someone must have either depressed mood or decreased interest/pleasure in almost all activities, nearly all of the time and nearly every day, for at least two weeks. Depressed mood can also manifest as hopelessness or irritability. Excessive guilt is another possible symptom of depression.

Fatigue: When taking a shower is like climbing a mountain

Isolation: This isn’t technically a symptom of depression, but depression often puts significant strain on social relationships.

Movement: Besides decreasing energy, depression can cause leaden paralysis, a sense of extreme fatigue that involves the limbs feeling weighed down. This tends to happen in atypical depression. Depression can also affect movement by causing psychomotor retardation (described below) or agitation (e.g. pacing, hand-wringing). This is most common in the melancholic subtype.

Sleep: Depression can involve either insomnia or sleeping excessively. Insomnia, especially with early morning awakening, is more common, but atypical depression is associated with hypersomnia. The Sleep Better mini-ebook has more info on managing insomnia.

Suicidality: Depression can cause both passive and active thoughts of suicide (suicidal ideation). The Straight Talk on Suicide page has more information on this topic.

Psychomotor Retardation

Psychomotor retardaXtion (PMR) is a slowing of movement and thoughts (literally, mind-movement-slowing). The slowed movement is objectively visible, not just a subjective sense of slowness. While it’s long been recognized in the medical field, the general public tends to be unaware of this particular cluster of symptoms in depression.

effects of psychomotor retardation in depression

It can involve:

  • Slowed movements, particularly in the trunk; this includes slowed walking and changes in gait
  • Slumped posture
  • Delayed verbal responses
  • Speech is soft, slow, and monotone, with increased pauses (read more about speech impairment here)
  • Flat affect, i.e. lack of facial expressiveness
  • Decreased eye contact and fixed gaze
  • What does psychomotor retardation look like?

    PMR can affect the whole body, but tends to be most prominent closer to the core of the body. Walking can be difficult; steps become smaller, and the gait becomes awkward.

    There's also flattening of affect, meaning a lack of any facial expressiveness.
    I find that walking is affected first, and then speech when it gets more severe. Speech gets slow and quiet, and it becomes difficult to initiate. Subjectively, it feels like my brain is slow to fetch the motor scripts that go along with words. Written communication is easier because I just have to fetch the word cognitively, without the motor script.

    My Youtube channel has videos of psychomotor retardation and speech impairment.

  • Is PMR due to low energy?

    PMR can be hard to conceptualize if you haven't experienced it, and it may sound like it's the result of fatigue. However, with PMR, it feels like even if you had more energy, you'd be physically incapable of moving faster. If anything, I find the reverse is true; moving that slowly makes me feel tired.

  • What causes it?

    It's not entirely clear, although dopamine and the basal ganglia region of the brain appear to be involved. This post explores its possible biological basis.

  • How is it treated?

    There's no specific treatment for PMR, aside from the regular treatments that would be used for depression. Stimulant medications may be a helpful add-on. The research would say the benefit only lasts for a few months, but for me, dextroamphetamine has given a sustained benefit. There's some research to suggest that the Parkinson's medication pramipexole can help, but I tried it and didn't get a significant benefit.

What Causes Depression?

Science doesn’t know yet what causes depression, but that doesn’t stop people from coming up with ideas.

Treatment Options

For most people, effectively managing depression is going to require more than one tool. It might require 5, or it might require 10. What’s essential is meeting your own unique needs. Chances are that mix of tools is going to have a balance of illness treatment & wellness promotion strategies, and Managing the Depression Puzzle has plenty of options for both.

  • Psychotherapy alphabet soup gives a very brief overview of different forms of psychotherapy. Cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) have the strongest evidence base for depression.
  • Supplements: certain supplements, like S-adenosyl methionine (SAMe), L-methylfolate, and omega-3 fatty acids have shown benefits in clinical trials
  • Somatic treatments: these involve brain stimulation, including:
    • DBS: deep brain stimulation
    • ECT: electroconvulsive therapy – read about my own experience in This one flew over the cuckoo’s nest
    • tDCS: transcranial direct current stimulation
    • TMS: transcranial magnetic stimulation
    • VNS: vagus nerve stimulation

Treatment-Resistant Depression

What makes depression treatment-resistant? There are a few different definitions, but generally, depression is considered treatment-resistant if there have been failed trials of two or more antidepressants of adequate dose and duration.

My own illness has always been challenging to treat, but it was at about 10 years post-diagnosis that the treatments that had worked before stopped working the same way. They do still help with some symptoms, but I’m continuously symptomatic, and psychomotor retardation is a major issue.

Some of the options are:

  • Anti-inflammatories: there appears to be an inflammatory component to some people’s depression; not much has been identified medication-wise, but an anti-inflammatory diet may help somewhat
  • Botox: Botox injected in the frown line area may help with depression
  • Ketamine/esketamine: ketamine infusions or esketamine via nasal spray have a different mechanism of action than standard antidepressants, and can work rapidly

Making Sense of Psychiatric Diagnosis is also on:

Mental Health @ Home Books by Ashley L. Peterson - book covers
Mental Health @ Home Books by Ashley L. Peterson –
You can find them on my Amazon author page.