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.
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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)
Ms. Peterson’s book about managing depression is her best book yet. It flows nicely and provides relevant information about medications and wellness methods for dealing with the depression beast. I appreciate the author’s inclusion of various types of depression including PMDD. I also like the way she presents the whole concept as a puzzle and how various pieces of care and treatment are individual pieces of that puzzle; i.e. if something is missing don’t give up, just keep looking for the solution until you find a fit that works better. Good book, I recommend it.– ZeroSpace05 on Amazon (2nd edition)
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About Ashley L. Peterson
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. Several types of depression have been identified that involve particular patterns, including:
- Double depression: a major depressive episode superimposed on dysthymia
- Melancholic features
- Premenstrual dysphoric disorder (PMDD)
- Seasonal features, also known as seasonal affective disorder (SAD)
Symptoms of Depression
- Compensating for Depression Brain
- Mashed Potato Brains: what depression brain feels like for me
- Rumination is a common thinking pattern in depression that chews over past problems
- The THINC-it Test in Depression: THINC-it is a research tool that measures common cognitive effects of depression
- What Speed Does Your Mental Illness Mind Move At?: depression can cause slow brain or busy brain
- ↓ positive & ↑ negative affect: depression can involve the loss of positive feelings (as in anhedonia) and/or increased negative feelings
- Anhedonia and motivation / apathy
- Depression Without the Depressed Part?: anhedonia is enough to meet the mood criterion
- Mood rating: why I hate the 1-10 scale
Movement: Depression’s effects on movement: decreased energy, psychomotor retardation and leaden paralysis
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: The straight talk on suicide has more information on this topic.
Psychomotor retardation (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.
- What does psychomotor retardation look like?
It 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 initiating it is difficult. 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.
There's a video displaying PMR on my Youtube channel.
- Is PMR due to low energy?
PMR can be hard to conceptualize if you haven't experienced, and may sound like it's the result of fatigue. However, PMR 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 appears 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 guessing.
- Is depression anger turned inward?: Freud’s theory
- Is there ever only one explanation for mental illness?
- Learned helplessness: Seligman’s theory
- Should we be looking for a root cause?
- The Role of Heredity in Mental Illness
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.
- Psych Meds 101: Antidepressants are a basic building block of treatment, but the mood stabilizer lithium and atypical antipsychotics may be added on as part of the treatment regimen
- Learn why antidepressants cause more side effects early on and don’t start to really work for several weeks
- Psychotherapy alphabet soup gives a quick overview of different forms of psychotherapy. Cognitive behavioural therapy (CBT) and interpersonal therapy (IPT) have the strongest evidence base for depression. There are workbooks on acceptance and commitment therapy (ACT) and CBT, and a mini e-book on dialectical behaviour therapy, available from the MH@H Download Centre.
- Supplements (evidence-based): certain supplements, like S-adenosyl methionine (SAMe), L-methylfolate, and omega-3 fatty acids have shown benefits in clinical trials.
- Somatic treatments for depression: 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
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. I’ve developed various compensatory strategies to maintain as much functioning as I can.
Some of the options that may be considered (there’s more info in this post on TRD):
- 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
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