COMMENTARY

A Guide to Treating Depression

Matt A. Goldenberg, DO

Disclosures

December 08, 2014

In This Article

Lifestyle Change and Behavioral Activation

Depression is associated with behavioral changes, as noted in my recent Medscape article on the signs of depression. In brief, depression tends to lead to social isolation and a decreased interest in hobbies, nutrition, exercise, and other enjoyable activities.

Therefore, as difficult as it may be, I always encourage my patients with depression to take an inventory of their current behaviors. These include attention to diet/nutrition, exercise/physical activity, recreational activities/hobbies, chores/bill paying, and personal hygiene. More often than not, when patients evaluate these areas, they find that they have significant deficits compared with their predepression behavior and levels of activity.

Trying to change all of these areas of behavior at once is overwhelming, frustrating, and counterproductive. Therefore, I work with my patients to develop a personalized plan that is tailored to their current motivation, functioning, and abilities. This may involve picking a single area of deficit and highlighting one goal for each day. This could include walking around the block, showering each morning, or picking a book or magazine and reading a chapter or single page. Even small victories and accomplishments can lift a patient's mood when depression has caused so much pain and struggle.

The important part is successfully completing a task that is enjoyable or has been proven to improve depression. Exercise increases endorphins, raises vitamin D levels (from the sun), and can improve sleep and energy. All of these benefits are known to improve depression. Better nutrition can directly improve energy, health, and mood as well. Unfortunately, depression can keep our patients from having the motivation to do the very things that will help them to feel better.

I encourage you to explore the behavioral changes that your patients with depression have experienced. It does not take long to uncover areas of deficit and provide education regarding the benefits of increasing their activity level. The most important factors to focus on are their current level of motivation, the duration of the behavioral deficits, and their baseline activity levels before the depression episode. You can then advise your patients on what changes can help their mood recover and try to point out how their current behavior and activity level have decreased from before they became depressed.

Work with your patients to develop a personalized plan to activate their behavior. However, if they are uninterested or unwilling, pushing a patient to do something before they are ready can be detrimental to the therapeutic alliance and counterproductive.

It is also important to recognize what behavior changes are due to the depression episode and which are not. If someone has never had a healthy diet, gotten regular exercise, been social with friends, or paid bills on time, then these behaviors are very unlikely to be due to their current depression. That is not to say that making a positive impact on these behaviors would not be helpful. On the contrary: Exercise, for example, can help anyone, regardless of their athletic prowess or history, feel better. However, when working with a patient who has never engaged in a certain behavior, it is important to "start low and go slow."

Accordingly, I advise slower and smaller changes the longer my patient has been depressed. For example, if it has been a year since a once-avid gym-goer has worked out, I advise easing back into a routine more slowly than if it has only been a month or two.

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