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Managing the Depression Puzzle

Book cover: Managing the Depression Puzzle, 2nd edition, by Ashley L. Peterson

Managing the Depression Puzzle by Ashley L. Peterson explores a broad range of strategies for managing depression.

It’s available from:

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

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

Downloadable Depression Worksheets

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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, but I quickly returned to school to get a Bachelor of Science in Nursing. During my 15-year nursing career, I specialized in the field of mental health, working primarily with people with serious and persistent mental illness in both hospital and community settings.

Two years into my nursing career, I was hospitalized and diagnosed with major depressive disorder. Since then, I’ve been passionate about sharing my own experiences to challenge stigma and generate open conversations about mental health and illness.

For my Master of Psychiatric Nursing thesis work, I used a research method called autoethnography to situate my own experiences with mental illness within the context of nursing culture, addressing issues like stigma. I published several papers in peer-reviewed nursing journals based on this work.

Since illness-related disability has brought my nursing career to a close, I’ve shifted my focus to writing and advocacy efforts online.

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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.

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
  • Flat affect, i.e. lack of facial expressiveness
  • Decreased eye contact and fixed gaze

  1. 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.


  2. Is psychomotor retardation 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.


  3. What causes it?

    It's not entirely clear, although dopamine and the basal ganglia region of the brain appear to be involved. Other possibilities include changes in the hypothalamic-pituitary-adrenal (HPA) axis, which regulates inflammation in the body, changes in blood flow in the brain, and changes in circuits connecting the thalamus and the brain's cortex.


  4. 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 a variety 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 injected in the frown line area
  • Ketamine/esketamine: ketamine infusions or esketamine via nasal spray have a different mechanism of action than standard antidepressants, and can work rapidly
  • Somatic treatments: ECT is particularly effective

More MH@H Posts on Depression