The Happiness Guide to Self-Management of Depression

Depression affects more than 350 million people worldwide and is the fourth leading cause of disability. Depression is also the most common reason why people see me in my practice. When I see patients seeking help for depression, more often than not, their primary reason for seeing me is, “Doc, I want to be happy,” or “I want to be able to enjoy life,” or “I want to be my old self.” Being trained as a physician, I practice what is called the medical model, which emphasizes finding what is not working and fixing it. Thus, when my patients ask me on how they can feel happy again, I find myself redirecting the conversation to if and why they are feeling depressed. Regrettably, the focus of traditional psychotherapies has been on deficits, disorders, symptoms, syndromes, weaknesses, and vulnerabilities. This is not surprising given the fact that negatives are more pervasive and potent than positives and for one positive emotional term, there are 10 negatives. However, this deficit-based medical model has three major shortcomings:

1. It incorrectly assumes that only “symptoms” need to be treated and any positives are by-products of treating the negatives.

2. It fosters labeling of psychological distress into discrete disorders, which in itself is not undesirable, but robs an individual of their rich complexity.

3. It does not necessarily enhance well-being or happiness. Research has shown that absence of psychological distress is not equivalent to presence of well-being.

I have myself faced these shortcomings of the medical model when helping individuals with depression. I use medications and evidence-based psychotherapies such as cognitive-behavioral therapy to treat depression. These treatments are successful in ameliorating depression in a majority of my patients. However, I still grapple with the question, “Are these individuals happy or, as one would say in the positive psychology lingo, flourishing?” Put in real-life terms, not having clinical depression doesn’t automatically guarantee that one is having a meaningful life along with the ability to enjoy things and having positive relationships. I have found interventions based on positive psychology, also called positive psychology interventions or happiness interventions in layman’s terms, a useful adjunct to traditional treatments. Positive psychology is the scientific study of positive experiences and positive individual traits. It is not a self-help movement or repackaging of the “power of positive thinking.” The purpose of positive psychology is to supplement the traditional “fix-what’s-wrong” approach with “build-what’s-strong” approach.

The purpose of this book is to highlight practical evidence-based positive psychology interventions that have been shown to reduce depressive symptoms. These are not pop psychology “five easy ways to feel happy” interventions that sound encouraging but are empty promises of arm-chair self-help gurus. These are empirically established practices tested in randomized controlled studies. These approaches are not meant to substitute established evidence-based treatments but to complement them. Evidence suggests that positive psychology interventions, besides boosting well-being and decreasing depressive symptoms, also lead to decreased recurrences of depression and are effective in preventing depression. They also benefit individuals who have not fully responded to antidepressants and/or psychotherapy and continue to experience residual depressive symptoms.

Let’s put the above statements in perspective. The response rate of antidepressants (i.e., 50% decrease in depressive symptoms compared to baseline) is around 54% and that for a placebo is around 37%. The remission rate, which is now considered the goal for antidepressants, also presents a sobering picture with only 37% individuals with depression remitting after the first trial of an antidepressant and subsequent rates of remission being lower with later treatment steps. Evidence-based psychotherapies for depression such as cognitive therapy are as efficacious as medications for treating depression, but this efficacy also depends on the adequacy of therapy implementation and the competence of the therapist. This is not to suggest that antidepressants or cognitive therapy are not an effective way to treat depression and that people quit taking antidepressants or stop seeing their therapist. It does, however, indicate that antidepressants and existing depression-focused psychotherapies are far from being the optimal treatment for depression. In addition, depression presents in a myriad of ways and there is no treatment modality, which will work for everyone. This is where positive psychology interventions complement the existing approaches to treat depression by boosting an individual’s sense of well-being.

Compared to medications, positive psychology interventions are easy to use, are less expensive, carry no stigma, and have no side-effects! Wellbeing is postulated to be determined 50% by genes, 10% by circumstances, and 40% by positive cognitive, behavioral, and goal-based activities. While you cannot change your genetic make-up and sometimes circumstances may not be amenable to change (e.g., job, relationships, geographic location, marital status, etc.), but the one thing that is certainly under your control is the amount of positive activities you engage in. This the crux of this book.

The goal of this book is not to eliminate negative emotions altogether. Rather, this book offers a compendium of positive activities to serve as “daily emotional maintenance” which you can call upon if feeling down or depressed. This is the pro-active approach to self-managing depression compared to the “passive-receptive” approach wherein you wait for the troubles to become manifest and then figure out how to contain or repair the malfunction. Self-management is increasingly becoming the standard of care in people with long-standing medical conditions. Self-management puts one in the driver’s seat with regards to making choices to treat depression. People with diabetes, heart disease, emphysema, asthma, and other long-standing medical conditions have successfully used self-management to live a healthy life. However, treatment of depression has lagged behind in incorporating the concept of self-management with most popular self-help books on depression focusing mostly on cognitive-behavioral approaches. Other self-help books on depression do talk about positive life style changes but are not evidence-based. This book, a product of thorough research, attempts to fill this void by consolidating evidence-based positive psychology approaches for treatment of depression and presenting this information in a practical and easy-to-use format that can be incorporated into day-to-day self-management of depression.