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Expert Q&A

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How can Ikeep my depression from recurring?

Asked by Gina, New York

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It is known that people who have had a depressive episode have a high chance of experiencing a second depressive episode. It seems that people are more "sensitive" to stress/life events (kindling hypothesis). What options are available for people who had a depressive episode in the past, to avoid having a recurrence or at least lower the chances of a recurrence in the future?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Gina: You know your stuff. Everything you say is, unfortunately, quite correct. Before giving my thoughts about your question, let me get our readers up to speed on the sad natural history of depression.

Our best official data suggest that about 15 percent of American adults will experience a major depressive episode during their lifetimes. However, if you have one episode of depression, the chance of having a second episode increases to 50 percent. That is a 300 percent increase in risk, and it shows the tremendous effect that depression has on the brain and the body. If you've had two episodes of depression, your chances of having a third episode increase to 75 percent. Once you've had three or more episodes of depression, your chances of becoming depressed again approach 100 percent.

As dismal as these figures are, recent studies suggest that they are overly optimistic because they are based on people retrospectively reporting their experiences. I don't need to tell you how much people forget about their own pasts. Studies that have followed normal people prospectively find much higher rates of depression. For example, one very well-designed study from New Zealand that has followed 1,000 people from birth onward has reported that almost half of all people experience a major depression by age 30 (which doesn't surprise me at all, thinking back on my own lonely college experience). A long-running study conducted by the National Institute of Mental Health has observed that 100 percent of patients who entered the study with a depressive episode in the late 1970s have had at least one depressive relapse in the intervening years.

You mentioned the word "kindling," which deserves a comment. Technically, kindling is a phenomenon related to seizures, in which an electrical stimulus that does not produce a seizure when initially applied to the brain begins to produce seizures if it is repeated often enough. Eventually, animals subjected to repeated bouts of the stimulus will begin to have seizures spontaneously, even in the absence of the electrical stimulus.

Although there is no evidence that depression is routinely the result of seizure activity, the notion of kindling has been taken up as a metaphor to describe the fact that people usually need something bad to happen to have a first episode of depression, but that over time, the depressive episodes seem to just happen spontaneously. The idea here is that depression damages the brain in ways that make it easier and easier for people to fall back into depression the more often they experience a depressive episode. Thus although the old cliché says "that which doesn't kill me makes me stronger," for most people, it is truer to say "that which doesn't kill me makes me depressed." Sadly, for most people, stress doesn't lead to strength, it leads to brain damage.

So what to do? Here, the data are very clear. Many studies have now shown that the best way to forestall a recurrence of depression is to make a commitment to remain in treatment indefinitely. I say "in treatment" rather than on medications, because evidence suggests that both medications and psychotherapy can reduce the risk of a depressive relapse. Some data (but not all) suggest that psychotherapy might actually be better than antidepressants in this regard. So if someone is really serious about never being depressed again, the best course of action is to find an antidepressant that works and has tolerable side effects and stay on it chronically. In addition, one should have access to a competent psychotherapist so that life issues can be faced early on, before they lead to depression.

In addition to these concrete actions, there is something deeper that can be done, although it is more difficult. Overwhelming data suggest that the best way to avoid depression (other than being born in a family with no genetic risk!) is to live the best life we can manage. By "best," I mean one supported by loving friends and family, with minimal conflict and maximal focus on helping other people as opposed to a fixation on one's own problems.

Of course, this is much easier said than done, which is probably why psychiatrists don't say this kind of thing very often. But we can all make a commitment to making steps in this direction, and even small gains can have huge payoffs in terms of our peace of mind and sense of contentment, both of which are powerfully predictive against depression.

To say it more practically, in addition to staying on an antidepressant and utilizing psychotherapy when times get tough, your desire to be free of depression should be a clarion call to reduce the stress in your life to manageable levels by making choices that will foster good interpersonal relationships and that will give your life a sense of purpose.

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