This is the second in a series of articles on emotional intelligence for personal growth. The first part is here.

Mindfulness is a non-judgmental, present-centered awareness in which each thought, feeling, or sensation that arises is acknowledged and accepted as it is. It is a skill that is learned by committed practice. The object is to focus one's attention on thoughts, feelings and events in the present moment while remaining curious, open, and accepting whatever occurs.

The idea is to take on the role of an observer of your own mind. Notice everything that happens without holding onto anything, having a "Teflon Mind". An important part of observing is putting words to the experience. The effect of naming the experience effectively separates you from it. Thoughts are just thoughts, feelings just feelings, all transient experiences that are not necessarily a part of or define who we are.

True mindfulness involves immersing yourself in your experiences so that you actually forget yourself. The idea here is to stop the conversation you have with yourself, or as Eastern traditions put it, letting go of ego. This internal dialogue, while an important skill in the right circumstances, can become a major distraction. Imagine yourself walking through a beautiful park muttering to yourself. Would you remember what you saw in the park? You'd probably remember more about what you were muttering to yourself!

One way to do this is to focus on what is at hand. "See the job, do the job." The idea is NOT to always stay busy, ut to invest all of yourself in everything you do. "Smell the roses." Another thing to watch while doing things judging if this should have happened or whether it's fair, just, or right or wrong. It IS, the only value in questioning why is avoiding a problem in the future. Anything more than that is a waste time and emotional energy. See what you are doing, but don't evaluate it. Focus on the facts without evaluating it. Count on your intuitive self to react appropriately, changing the harmful situation or changing your harmful reaction to the situation.

Another distraction to your experiences is multi-tasking. Doing more than one thing at a time spreads your skills thin so that your product becomes sub-optimal, perhaps even mediocre. If you multi-task regularly, you actually train yourself to be easily distracted. There is some research that suggests that this subtle distraction training contributes significantly to attention deficits that impair your concentration. Research also suggests that training persons with Attention Deficit Disorder with mindfulness techniques can be an effective treatment!

The idea is to keep your mind's eye on the objectives until the task is done having faith that you will do the best job your can and react appropriately should something go wrong. Think about it, if you are preoccupied with what might go wrong while doing something, will your focus be on the job or the fear of what might happen? If you are distracted by fear, how good a job can you do?

Most of us, when not structured and focused on a task at hand, are thinking about past and future events. We either review previous experiences looking for new learnings we might have missed or planning our reactions to anticipated events. We focus on the moment only when there is something immediately presenting that requires a response. Our focus is often divided between what is happening in the moment and the thoughts on which we are focused.

For those of us that have more than our share of regrets and/or worries, being focused on the past or the future becomes a nearly full time job! This is not good. Without your full participation in the moment you are in, you are distracted, your reactions are primed with the emotions of the worry or regret. That means your judgment and decision making ability is impaired by emotionally distorted judgments! Have you ever been startled by someone while preoccupied with regrets or worries? Did you react with an emotion not meant for the other person? Most people have had that experience. It is likely we have all experienced spilling our internal emotion on an unintended other. And if that person was paying attention, he or she probably noticed your emotion and wondered if you were upset with them!

Few of us have the ability to be focused on the moment at will. It is a skill that takes a lot practice and a commitment to follow through. The eventual reward is an incredible feeling of peacefulness, acceptance, and centeredness combined with heightened concentration. You see, a mind uncluttered by regrets or worries has only the moment to focus on. Self-consciousness dissolves into the experience of the moment. Instead our focus is on our senses, our perceptions, punctuated by the thoughts and feelings flowing through our minds. The ultimate state of mindfulness is what is called flow.

Flow is the state in which the person is fully immersed in what he or she is doing with a feeling of energized focus, full involvement, and an expectation of success. Flow could be conceived of as being completely focused and motivated in a single-minded immersion. Emotions and thoughts are synchronized in the service of performing and learning. In flow, the emotions are not just contained and channeled, but positive, energized, and aligned with the task at hand. While in flow, we feel a clear sense of direction, confidence, intense concentration, and personal control. We feel a natural and continuous intrinsic reward. Time seems altered, slowed or moving quickly. Feedback for one's actions and focused redirection come easily and painlessly so that action and awareness seem to merge.

One does not have to reach the ultimate form of mindfulness to benefit. With each strengthening of the skill comes with incredible benefits in quality of life. There are many tools available to us that will help us learn. Check out the resources here.

Continued here.

Aaron Beck, considered the Father of Cognitive Therapy, is an American psychiatrist and a professor emeritus at the Department of Psychiatry at the University of Pennsylvania. He is President of the Beck Institute for Cognitive Therapy and Research that is directed by his daughter, Judith S. Beck, Ph.D.. He is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. At age 87, the man is still publishing, building on his pioneering work on the cognitive model of depression. In his latest article published in the American Journal of Psychiatry, he recalls his early work:

Caught up with the contagion of the times, I was prompted to start something on my own. I was particularly intrigued by the paradox of depression. This disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct, and the pleasure principle. All of these normal human yearnings were dulled or reversed. Even vital biological functions like eating or sleeping were attenuated. The leading causal theory of depression at the time was the notion of inverted hostility. This seemed a reasonable, logical explanation if translated into a need to suffer. The need to punish one's self could account for the loss of pleasure, loss of libido, self-criticism, and suicidal wishes and would be triggered by guilt. I was drawn to conducting clinical research in depression because the field was wide open--and besides, I had a testable hypothesis.

I decided at first to make a foray into the "deepest" level: the dreams of depressed patients. I expected to find signs of more hostility in the dream content of depressed patients than nondepressed patients, but they actually showed less hostility. I did observe, however, that the dreams of depressed patients contained the themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased. At first I assumed the idea that the negative themes in the dream content expressed the need to punish one's self (or "masochism"), but I was soon disabused of this notion. When encouraged to express hostility, my patients became more, not less, depressed. Further, in experiments, they reacted positively to success experiences and positive reinforcement when the "masochism" hypothesis predicted the opposite (summarized in Beck).

Some revealing observations helped to provide the basis for the subsequent cognitive model of depression. I noted that the dream content contained the same themes as the patients' conscious cognitions--their negative self-evaluations, expectancies, and memories--but in an exaggerated, more dramatic form. The depressive cognitions contained errors or distortions in the interpretations (or misinterpretations) of experience. What finally clinched the new model (for me) was our research finding that when the patients reappraised and corrected their misinterpretations, their depression started to lift and--in 10 or 12 sessions--would remit.

We owe a lot to Dr. Beck. His cognitive model of depression still dominates how I and most of my colleagues write treatment plans for persons suffering with depression. Our goal is to inspire and teach our clients to change their negative self-evaluations, correct distorted memories, and create an expectation of success. The only problem is depression is not that simple.

Try as they might, many clients are able to recognize what they need to do, understand how their thoughts about themselves and their world need to change, are able to state those changes, and diligently practice them. But when they really need to be able to master their fate, when ruminative thoughts spiral downward into the depths of depression, their efforts quickly collapse and they succumb.

So is the Cognitive Model of Depression wrong? No, I think it's incomplete. There is the biomedical model of depression involving errant neurotransmitter levels treated by various anti-depressants. That discussion is beyond this article's purpose. I'm more interested in what we as therapists can do differently in the counseling office. Of course we need to be sure a severely depressed client is referred for a medication review. But I want to know how we might better facilitate our clients attempts to master their mood. To this end, I will review my recent reading on the subject of emotion and argue to include emotion in a new Cognitive Theory.

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Hat tip to Psych Central for an report on a higher than expected prevalence of suicidal thoughts among college students. Researchers surveyed 26,000 students across 70 colleges and universities. Half reported having at least one episode of suicidal thinking at some point in their lives. Fifteen percent of students surveyed reported having seriously considered attempting suicide and more than 5 percent attempted at least once.

Presenting at the 116th Annual Convention of the American Psychological Association, psychologist David J. Drum, PhD, and co-authors at the University of Texas at Austin reported their findings from a Web-based survey conducted by the National Research Consortium of Counseling Centers in Higher Education. [..] Six percent of undergraduates and 4 percent of graduate students reported seriously considering suicide within the 12 months prior to answering the survey. Therefore, the researchers posit, at an average college with 18,000 undergraduate students, some 1,080 undergraduates will seriously contemplate taking their lives at least once within a single year. Approximately two-thirds of those who contemplate suicide will do so more than once in a 12-month period. The majority of students described their typical episode of suicidal thinking as intense and brief, with more than half the episodes lasting one day or less.

The researchers found that, for a variety of reasons, more than half of students who experienced a recent suicidal crisis did not seek professional help or tell anyone about their suicidal thoughts.
[..]
Both undergraduate and graduate students gave these reasons for their suicidal thinking, in the following order: (1) wanting relief from emotional or physical pain; (2) problems with romantic relationships; (3) the desire to end their life; and (4) problems with school or academics.

Fourteen percent of undergraduates and 8 percent of graduate students who seriously considered attempting suicide in the previous 12 months made a suicide attempt. Nineteen percent of undergraduate attempters and 28 percent of graduate student attempters required medical attention. Half of attempters reported overdosing on drugs as their method, said the authors.

From the survey, the authors found that suicidal thoughts are a frequently recurring experience akin to substance abuse, depression and eating disorders. They also found that relying solely upon the current treatment model, which identifies and helps students who are in crisis, is insufficient for addressing reducing all forms of suicide behavior on college campuses.

The authors suggest a new model for dealing with the problem of student suicidal tendencies in order to address the entire continuum of suicidal thoughts and behaviors. By focusing on suicidal thoughts and behaviors as the problem, rather than looking only at students in crisis, interventions can be delivered at multiple points, they said.

Furthermore, information from the survey can help match students who are at risk or who have already experienced suicidal thoughts and behaviors with the appropriate treatment. This will reduce the numbers of students entering the suicide continuum in the first place as well as reduce the progression from thoughts to attempts, they said.

Here is a good example of research that has a helpful policy driving message. People with a history of periodic suicidal thinking are in need of treatment. Focusing solely on those who ask for help at the time they are at greatest risk set up an identifiable population who could be treated well in advance of imminent risk. Conceivably, this could significantly decrease the number of successful suicides.

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Horwitz and Wakefield (2007) have released what may prove to be a highly influencial book titled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. The title implies that psychiatry transformed sadness into depression. It's an unfortunate catchy title that misleads the uninformed reader. Instead, the book explores in a scholarly way a fundamental principle upon which The Diagnostic and Statistical Manual (DSM) was developed.

A review of Horwitz and Wakefield (2007) by Andreea L. Seritan appeared in Am J Psychiatry 164 (11): 1764.

The central thesis of this book is a persuasive argument that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship between symptoms and the context from which they emerge. Although he remains cautious about the possibility of incorporating situational context into diagnostic criteria, Dr. Spitzer encourages psychiatrists to place this issue on the agenda for the upcoming formulation of DSM-V.

The book's title is a reminder of the central role of loss as a potentially severe life stressor leading to depression, as well as of how modern psychiatry is being blindsided into extrapolating most states of sadness into depression. In the first chapter, "The Concept of Depression," Drs. Horwitz and Wakefield address the move toward using descriptive criteria in diagnosing mental illness. In response to criticisms during the 1960s and 1970s about the lack of reliability of psychiatric diagnoses, DSM-III started using lists of symptoms to establish clear definitions for each disorder. The authors argue that this approach, while greatly increasing diagnostic reliability, has created new validity problems (p. 8). In the definition of major depressive disorder, DSM-III "fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses" (p. 14).

Chapter 2, "The Anatomy of Normal Sadness," discusses biologically based nonverbal expressions of grief, with emphasis on their universality across cultures and their presence in nonhuman primates and human infants prior to socialization into cultural emotional scripts (p. 39). Besides grief at the loss of a loved one, loss of meaningful relationships, loss of job or status, chronic stress, and disasters are listed as additional factors to be taken into account. Chapters 3 and 4, "Sadness With and Without Cause" and "Depression in the Twentieth Century" are a historical review of descriptions of depressive states from ancient times to the present. Disordered sadness is considered "without cause" (or "endogenous" in later terminology), as opposed to sadness "with cause" (or "reactive" sadness), which arises in people who suffer losses. Robert Burton's classic work The Anatomy of Melancholy, published in 1621, was the first to describe the three major components of depression--mood, cognition, and physical symptoms--that are still viewed as its distinguishing features. In his seminal paper Mourning and Melancholia (1917), Freud made the same distinction between mourning due to conscious losses and melancholia due to the experience of unconscious losses. DSM-III eliminated psychodynamic etiologies, instead focusing on symptoms. In large epidemiological studies, such as the Epidemiologic Catchment Area study in the early 1980s, diagnosis was based on structured tools administered by trained nonpsychiatric interviewers. The authors argue that prevalence data was skewed and advocate for a more specific screening process, as well as careful use of subthreshold diagnoses, such as minor depression.

Thoroughly documented, the first chapters caution readers about the limitations of psychiatric diagnosis. However, momentum is lost in the second half of the book. Chapter 7, "The Surveillance of Sadness," makes assumptions about psychiatric treatment that are not supported by the literature. For example, it is suggested that in primary care, "diagnosis of a depressive disorder tends to quickly foreclose...discussions in the direction of medication" (p. 156). The recent avalanche of data from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study suggests not only that depressed primary care patients prefer psychotherapy to medication when offered (1) but that therapy is successfully delivered in this setting, along with pharmacologic management (2). In Chapter 8, "The DSM and Biological Research About Depression," the authors again overreach, selectively analyzing individual cardinal papers and doubting their "range of applicability" without turning to the multiple evidence- based studies available in the literature (p. 176).

Although a poignant reflection on how the misapplication of psychiatric knowledge can decontextualize the lives of its patients, this book seems to miss the point that psychiatric care is a great deal more than diagnostic labeling. In practice, mental health professionals who do not rely exclusively on DSM-IV-TR use biopsychosocial formulations, viewing the individual in his or her context. Thus for many psychiatrists, treatment planning is informed by this comprehensive understanding of the person, and not solely by the description and duration of their symptoms.

Seritan has a point that many clinicians do not rely exclusively on the DSM for diagnosis. However, the classification model considered the gold standard for diagnosis DOES decontextualize diagnosis. That is a concern for training and continuing education. Given all the incentives in practice to base treatment on measurable criteria from malpractice claims, insurance payors and accreditation agencies, its very easy to slip into a comfortable criteria based practice that requires little emotional investment.

Mulder wrote an article on an even more important point about diagnosis, titled An epidemic of depression or the medicalization of distress in Perspect Biol Med. 2008 Spring;51(2):238-50.

The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model.

Mulder's point is that diagnosis is a academic exercise designed to communicate a cluster of symptoms among professional colleagues. It's a model of communication. The syndromes described have acquired meaning well beyond communication. Diagnostic labels have been elevated from theoretical constructs into real phenomena. Major depression includes a cluster of symptoms that is shared by many people who are not depressed.

Wade Schuette expresses the apparent paradox of diagnosis as a prerequisite for treatment.

If depression is largely an internal phenomenon, caused by genetics and bad wiring in the brain, that leads to one type of intervention - drugs and CBT. If depression is largely a social phenomenon, related to the well-documented collapse in social interaction documented by Putnam and the group at Duke, then personal intervention will simply deal with symptoms, and result in an ever growing prevalence of drug-dependent victims of social dysfunction - precisely the observation we find about the USA today.

The truth is all of these viewpoints have merit. Major Depression can be conceptualized and described in many ways, none of which are sufficient to explain the phenomena without considering all other viewpoints. Diagnostic categories are scientific models for communication. They are not readily amenable to measurable criteria because the concepts are complex and largely abstract constructs that fit a theory.

Sadness is an abstract concept designed to communicate a common human experience associated with grief and loss. I believe sadness is an emotion that is a critical component of a productive grief process that helps us survive and adapt to major loss. Sadness is normal and healthy. Major Depression may include sadness, maybe associated with loss, but it is a clinical syndrome that includes significant functional impairment, a loss of survival skills. Sadness is an emotional motivation that ENHANCES survival.

This looks like a good one. I'm going to watch for sure. You can even buy the DVD now.

DEPRESSION: Out of the Shadows is a 90-minute documentary about recognizing, treating, and researching depression.

DEPRESSION: Out of the Shadows . Video Preview | PBS

A lot of Americans are keeping an important, possibly deadly secret.

The National Institute of Mental Health reports that approximately 18.8 million American adults have a depressive disorder. The disease is not discriminating, seeping into all age, race, gender, and socioeconomic groups. Depression stalls careers, strains relationships, and sometimes ends lives.

So if this many people are living with the disease, why the silence? DEPRESSION: Out of the Shadows is a multi-dimensional PBS project that explores the disease's complex terrain, offering a comprehensive and timely examination of this devastating disorder.

The first component of the project is a 90-minute documentary, premiering May 21, 2008, at 9:00 pm ET (check local listings). By weaving together the science and treatment of depression with intimate portrayals of families and individuals coping with its wide-ranging effects, the film raises awareness and eliminates the stigma surrounding this prevalent disease, underscoring the fact that whether we are battling it in our families, our workplaces, or in our own minds, depression touches everyone.

Through the voices and stories of people living with depression, the film provides a portrait of the disease never before seen on American television. Along with consumers, DEPRESSION: Out of the Shadows also follows acclaimed scientists as they describe the latest neurological research and groundbreaking new treatments for depression. Following the film, broadcast journalist Jane Pauley will host a 30-minute roundtable discussion titled TAKE ONE STEP: Caring for Depression, with Jane Pauley in which nationally acclaimed experts will offer advice on recognizing and treating depression.

In addition to the broadcast and online presence, the National Alliance on Mental Illness (NAMI) and the YMCA of the USA will implement an outreach campaign, educating about depression in communities across the United States. All of the DEPRESSION: Out of the Shadows resources combine to powerfully raise awareness, eliminate stigma, and get help.

Shame has been a particular interest for me. It has appeared repeatedly as a major barrier in therapy, especially in those for whom therapy has failed in the past. It takes a lot of courage to re-enter therapy after feeling it was previously insufficient. Fortunately, a person returning to therapy after a less than satisfactory experience is significant motivated to try new ideas.

Agreeing to therapy is a humbling experience in and of itself. The American culture so values individualism, asking for help is often viewed as a sign of weakness, perhaps more likely by those who need help the most. I have previously written about the pervasiveness of shame in many long term issues I've seen in therapy. It's almost as if the person attempts to punish himself into change. But the misery extends well beyond what is helpful in motivating change into a self-imposed purgatory. Eventually, the person becomes so desperate to escape that they engage in self-destructive compulsive and addictive behaviors to temporarily escape the pain. Unfortunately, once the consequences of the escape behaviors becomes apparent, misery returns worse than before. This pattern of habitual and cyclical self-recrimination and escape could explain life long patterns of substance abuse and chronic maladjustment including depression. I've been finding some fascinating research that explores shame in therapy that has motivated some intensive research.

Hook and Andrews (2005) reviewed the literature on shame in therapy. They found that shame has recently been found associated with onset and course in depression, especially in chronic and recurrent depression. Personality traits that evoked shame were "as likely to be consequences or concomitants of depression as they were to be precursors." They speculated that "feeling ashamed of personal qualities and behaviors may lead to a chronic course of the disorder by affecting disclosure of the issues involved, thereby impeding therapeutic progress".

Hook and Andrews (2005) also studied questionnaire data of self-described persons who suffered from depression to "examine relationships between shame, disclosure in therapy, and current symptoms...." Of the study's 85 respondents, 54% withheld significant information from their therapist, 42% withheld information related to depressive symptoms and behaviors. Nearly 3/4 of respondents who withheld information said they did so because of shame. Most intriguing, those who were no longer in therapy who also had not disclosing depressive symptom/behaviors had significantly higher depressive symptoms currently than other participants. The study combined with the article's review of the literature, found that "significant relationships have been established between shame-proneness and non-disclosure of symptoms/behaviors in both therapy groups, and of this type of non-disclosure and current depression symptoms in those no longer in therapy."

This is the kind of research I can bring back to work tomorrow and use. It also appears to be a research approach and topic I may be able to emulate. One point they make in the discussion is that while many authors have spoken against assessing shame directly, "if one does not ask, one does not find out about such experiences". And the information that might be withheld otherwise would likely involve depressive symptoms and related behaviors. This finding replicates a previous study of women with eating disorders, which found a significant association between non-disclosure in therapy and shame that involved eating disorder symptoms. I have tended to teach my clients to expect that they will find that those things they most wish not to share are likely to be need disclosure and work to assure a good outcome in therapy.

Another interesting twist in the discussion was an attempt at explaining why "disclosure of symptoms may be more important for depression recovery than disclosure of other upsetting issues and experiences. One explanation is suggested by evidence from Pennebaker and Beall’s (1986) study that disclosure of feelings confers more benefit on long-term health than disclosure of purely factual information." Does that sound clinically sound or what? Ever had a client not want to share the details of a particularly shameful event? I've had some good success encouraging them to share the feelings about the event and how it affected them later, while leaving out the details.

This article is both inspiring of my interest in research as well as immediately practical in clinical applications. I'm going to be digging through this bibliography next week.

Hook, A., Andrews, B. (2005). The relationship of non-disclosure in therapy to shame and depression. British Journal of Clinical Psychology, 44(3), 425-438. DOI: 10.1348/014466505X34165

BPS RESEARCH DIGEST reviews recent research articles in professional journals. It's a good place to try to keep up with the literature. It has been a pleasant surprise indeed that many psychodynamic principles have recently demonstrated in research. Unconscious motivations, emotion based early learning have repeatedly been demonstrated. Now I was pleased to find the begins of a research demonstration of one of the most important insights into the obstacles for change that emerge in therapy: the labeling effects of diagnosis and the self-destructive nature of shame.

Psychological outcome research tends to follow the same model, matching therapy to diagnosis. The client is again little more than the holder of the diagnosis and the subject of the therapy: their individual decisions and personality are rarely considered (again, except where these are part of the diagnosis or lead to non-compliance).

Contrary to notions of the 'miracle therapy' or 'super-shrink', recent research suggests that the client contributes as much to the chances of a successful outcome in therapy as either the therapist or their technique. In fact, client factors may predict more of the outcome than therapeutic rapport and technique combined.

Anne Hook and Bernice Andrews (2005) surveyed people who had received psychological therapy for depression. Half of the current clients and a third of ex-clients reported withholding some information about their depressive symptoms (e.g. low self worth, suicidal thoughts) and behaviour (e.g. substance abuse, aggression) from their therapist.

The main reason given for withholding information was shame. People who had concealed symptoms were more depressed on completion of therapy than those who had 'revealed all'.

As their previous research had linked a tendency to feel shame to higher levels of depression, this seems a fairly obvious result: shame and related non-disclosure are simply part of the clinical picture of depression.

I like to describe shame as the self-destructive expression of guilt, the natural feeling associated with making a mistake that serves to motivate self-assessment and behavior change. Shame goes much further. A person who feels shame believes that their mistake is another demonstration of how much of a hopeless loser they are. Ultimately it becomes the core of a chronic self-loathing that leads on-going disappointment, discouragement and a sense of being a victim to one's own ineptitude, with no hope of change.

Shame provides the motivation for much long standing self-destructive and self-defeating behavior. If a person feels overwhelming shame after making a mistake, they are unable to examine their personal responsibility closely so as to facilitate behavior change. It's too painful. Instead, they engage in ruminative self-punishment that robs the individual of any remain energy to do the examination or make any changes. Such penance, because it goes well beyond a symbolic act of contrition leads to long standing self-destructive patterns of behavior. Misery extends well beyond what is helpful in motivating change into a self-imposed purgatory.

Eventually, the person becomes so desperate to escape that they engage in compulsive behaviors, what I call "temporary feel goods." These behaviors include drug and alcohol abuse, excessive gambling, or any bad habit, taken in isolation may appear harmless enough, but when it is routinely used to escape self-motivating misery, it creates problems that complicate the picture dramatically. Other behaviors are more obviously self-destructive such as sexual addictions, raging and controlling angry behavior and violence, self-injurious behavior, compulsive spending, or excessive risk taking like speeding. Even seemingly innocuous behavior like day dreaming, fantasizing, or computer game playing can take up tremendous amount of time and energy in interfere with productive functioning. That just leads to more misery, more shame and more escapist self-destructive behavior.

Breaking the pattern is more than just a matter of "cognitive restructuring". A shame-based person may already recognize their self-destructive ways. But some inner compulsion drives this incessant self-punishment. I've found that the source of much of this shame comes from early emotion-based learning, the learning that occurs in early often during school age and pre-school experiences. Another source is abuse and neglect, especially from parents or other caregivers, but can also come from abusive adolescent/adult relationships. Another common source is trauma survivors. There is strong association between the severity of PTSD and shame-based ruminations about the trauma. Feeling somehow responsible for witnessed trauma can be particularly debilitating.

Emotional learning has been conceived by Freud as internal conflict and by behaviorists as "conditioned emotional responses." Such learning is particularly persistent and difficult to change. Making those changes often looks like what has been called "reprogramming" treatment of cult and brainwashing survivors. A repeatedly revisiting of the traumatic event, or intensive prolonged exposure, has been shown to be particularly effective in changing the shame-based patterns associated with PTSD. (Journal of Consulting and Clinical Psychology 2006, Vol. 74, No. 5, 898-907, Journal of Consulting and Clinical Psychology 2007, Vol. 75, No. 3, 409-421). Gut wrenching recollection of childhood and traumatic events allows learning new emotional responses to future eliciting events.

BPS RESEARCH DIGEST

"In other words, our data suggest that effort and hard work offer the most promising route to happiness. In contrast, simply altering one's superficial circumstances (assuming they are already reasonably good) may have little lasting effect on well-being.

Temporary feel goods are just that. The only way to happiness is hard and persistent work on our difficulties.

This article lists occupations associated with depression. While I don't think that articles spin that these occupations contribute to depression. Rather I think people who are prone to depression also seek out more meaningful work.

PsycPORT.com

People who tend to the elderly, change diapers and serve up food and drinks have the highest rates of depression among U.S. workers.

Overall, 7 percent of full-time workers battled depression in the past year, according to a government report available Saturday.

Women were more likely than men to have had a major bout of depression, and younger workers had higher rates of depression than their older colleagues.

Almost 11 percent of personal care workers -- which includes child care and helping the elderly and severely disabled with their daily needs -- reported depression lasting two weeks or longer.

During such episodes there is loss of interest and pleasure, and at least four other symptoms surface, including problems with sleep, eating, energy, concentration and self-image.

Workers who prepare and serve food -- cooks, bartenders, waiters and waitresses -- had the second highest rate of depression among full-time employees at 10.3 percent.

In a tie for third were health care workers and social workers at 9.6 percent.

The lowest rate of depression, 4.3 percent, occurred in the job category that covers engineers, architects and surveyors.

Government officials tracked depression within 21 major occupational categories. They combined data from 2004 through 2006 to estimate episodes of depression within the past year. That information came from the National Survey on Drug Use and Health, which registers lifetime and past-year depression bouts.

Depression leads to $30 billion to $44 billion in lost productivity annually, said the report from the Substance Abuse and Mental Health Services Administration. The report was available Saturday on the agency's Web site at http://oas.samhsa.gov

The CDC has released a report finding a spike in successful suicides in adolescents in 2004. This increase is the largest increase since 1990. Is this the result of all the misinformation floating around anti-depressant medications causing suicide and violence in adolescents and adults? Thats about when the hullabaloo started. So that means that the increase in suicides may continue into 2007, four years of increased suicide caused by misinformation in the media. It would appear that media sources who print information on such volatile topics need to consult with professionals before doing so.

Perhaps even more importantly, researchers need to be obtaining peer review of their research before going to the media. It's become routine that new research authors send out news releases on topics that will attract media attention. I'm sure part of this is a survival method to make sure the research sponsor benefits from the research and funds them further. But the consequences of such releases need to be carefully considered.

Note that the research process on the risks of anti-depressants have unequivocally documented that the risk of anti-depressants is less than the risk of not prescribing.

And don't forget that there is also a first line of defense against depression, called psychotherapy. It's harder to face our problems with others, and sometimes more expensive. But it must be done.

Bloomberg.com.

Suicides among children and young adults in the U.S. rose 8 percent in 2004, the largest single- year increase since 1990, the Centers for Disease Control and Prevention said.

The biggest percentage jumps were recorded among girls aged 10 to 19, and boys aged 15 to 19, according to a survey released by the agency today. Suicide accounted for 4,599 deaths in 2004, making it the third-leading killer among Americans ages 10 to 24, behind car crashes and homicides, the research found.

The report, part of an annual analysis by the Atlanta-based CDC, didn't identify a reason for the increase. It found girls mainly hung or suffocated themselves, and that guns remained the primary method used by boys. The rate among Americans ages 10 through 24 had fallen 28 percent since 1990, making the current rise particularly concerning, health officials said.

[..] One possible reason for the increase may be that doctors are reluctant to prescribe antidepressant drugs to children because of warnings about side effects, said Mark Riddle, director of the division of child and adolescent psychiatry at Johns Hopkins Children's Center in Baltimore.

``It's probably reluctance on the part of clinicians to identify and treat kids with depression,'' he said in a telephone interview. ``We know that any treatment for depression in teenagers is quite effective in reducing suicidal thoughts and suicide attempts. When you take away one of the treatments, you are just leaving more kids vulnerable for trouble.''

[..]An earlier study by CDC researchers found many students in the U.S. regularly contemplate suicide. In that survey, 17 percent of high school students said they ``seriously considered'' killing themselves in the previous 12 months and 13 percent actually devised a suicide plan. Nearly 1 in 10 said they actually tried to take their own life.

The decision about how to treat depression has been entirely reframed by recent research. First of all, the debate about whether anti-depressant medications actually contribute to suicidal and other impulsive behavior has called to question routine, first choice prescriptions for Celexa, Lexapro, Prozac, Paxil, and Zoloft, the so-called SSRIs, for even milder forms of depression. Secondly, the STAR*D trials have documented that SSRIs are no magic pill.

SSRIs have been implicated in controversial criminal trials where defendants have claimed the medication made them violent, even homicidal. More recently, research has found a confusing array of results indicating a possible association with increased suicidal impulses in children and adolescents and now adults. However, retrospective studies seem to indicate a weak association of increased suicide attempts only with the younger population.

Unfortunately, the STAR*D trials were designed before the suicide risk with SSRIs hit the newsstands. The research was never designed to assess the effectiveness of medication vs. psychotherapy. However, here is one part of the study that did partly address this question.

NIMH

Switching to or adding cognitive therapy after a first unsuccessful attempt at treating depression with an antidepressant medication is generally as effective as switching to or adding another medication, but remission may take longer to achieve. These results, which are part of the NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, are published in the May 2007 issue of the American Journal of Psychiatry.

It seems clear that first choice for treatment of depression is psychotherapy. Persons who are already suicidal or highly dysfunctional with irretrievable consequences to career or key relationships should be considered for anti-depressant medication as well. But it is the clear, there is no justification to treat depression solely with anti-depressant medication.

The American Journal of Public Health published a study showing suicide rates from 1970 to 2002 by age group. Suicide rates have been dropping in all age groups. But there have been some changes, increases and decreases in rates during this time that suggest age specific pressures.

Perhaps the most significant finding is that suicide rates in the youngest group, under 18 has been consistently dropping through the time that use of anti-depressant use have doubled, and the new generation anti-depressants called SSRIs have been associated with a greater risk of suicide. That appears to be unlikely given the population statistics.

Psychiatric News

Suicide rates among teens and young adults have been on the decline since the mid-1990s. In addition, suicide rates among elderly Americans have been dropping since peaks in the late 1980s.

Researchers reporting their findings in the October Journal of Public Health said they don't have enough information to determine what may be leading to the lower rates for the youngest and oldest of four age groups studied, but they speculated on a number of possible factors including improved trauma care, an increase in healthy life expectancy, the advent of suicide-prevention and depression-screening programs, and an increase in prescriptions of selective serotonin reuptake inhibitors (SSRIs).

In an interview with Psychiatric News, lead author Robert McKeown, Ph.D., called the study results "puzzling" because "almost any explanation one might put forth for the drop in suicide rates should affect the middle two age groups."

Most significant to me is the gradual decrease in suicide among the elderly in the 70's followed by a rapid increase in the early 80's. Then the rate settles back to the lowest rate in over 30 years. What events affected the seniors unlike anyone else during the early 80's? A geographic study of suicide in the elderly from 1980 to 2000 describes it a function of the changing geography of despair can be shown to be largely the product of changing economic, social and demographic geographies. I'll be sending for this article. I'll comment or repost later.

A group of physician, patient and constituency groups concerned about confusing messages in popular culture suggesting that depression is "just the blues" or worse, a "made-up disease."

Although they don't say so, I suspect this movement intends at least in part, to counter the very well organized and highly funded lobbying effort by Tom Cruise and his Scientology friends to debunk psychiatry and depression. Instead they want us all to believe that depression is best alleviated by removing the sufferer's covering of tiny disembodied souls of aliens dispersed by the Galactic Federation leader Xenu. And to learn that technique, you must send thousands of dollars to the "Church" of Scientology. In the process you will learn all about the delusional beliefs of founder L. Ron Hubbard.

For whatever reason, they have put together a nice website and are pursuing a worthwhile educational program.

Psychiatric News

The initiative will spread science-based information to counteract "made-up" facts and misconceptions. A coalition of physician, patient, and community groups is tackling widespread misinformation about depression with a public information campaign emphasizing that the ailment, affecting nearly 19 million Americans, is serious, debilitating, and potentially fatal.

The Depression Is Real campaign, which was launched at a press conference last month in Washington, D.C., will use public service announcements, advertising, and a Web site, to increase awareness of depression and its causes and treatments.

Among the coalition members is the American Psychiatric Foundation, whose participation supports APA's "Healthy Minds, Healthy Lives" campaign. "A third of all Americans believe that mental illnesses like depression are caused by emotional or personal weaknesses, and almost that number think they are caused by old age alone," said Altha Stewart, M.D., president of the American Psychiatric Foundation. "We believe we have a responsibility to tell the public the truth about depression—based on scientific evidence and clinical research, not made-up `facts' or wishful thinking."

Coalition members said the lack of health care reimbursement parity for mental health treatments also trivializes depression and other mental illnesses.

Today, I tripped over an interesting article on assessing suicide potential.

Psychiatric Weekly

America bears witness to 30,000 deaths by suicide per year. Although clinicians have a fairly good grasp of long-term risk factors, possible short term indicators of risk have been largely overlooked. Dr. Jan Fawcett believes that, to make real headway in combating suicide, doctors need to identify patients at acute, not just chronic, risk of suicide and treat their symptoms aggressively.

[...]“We have plenty of clinical associations, and even quite a few social and epidemiological associations, for suicide risk,” Dr. Fawcett says. “However, when it comes to a clinician evaluating an individual patient, things can get difficult. Most of the associations we have predict long-term risk for suicide, but clinicians needs to know what’s going to happen tomorrow. When it comes to predicting acute risk, we’re very deficient.”

Dr. Fawcett’s work has suggested that the standard risk factors taught at medical school—prior suicide attempts, suicidal ideation, hopelessness—while strong predictors of ultimate risk, aren’t of much predictive use in the short term. “What I’ve found,” he says, “is that you often see increased anxiety and agitation and severe insomnia immediately preceding serious suicide attempts.”

Dr. Fawcett’s data suggest that increased anxiety and severe insomnia are effective predictors of short-term suicide risk in 70%–80% of hospitalized patients, although he believes the number is somewhat lower in outpatients.

“Patients at high risk are experiencing, through their anxiety and agitation, what I call ‘psychic pain’,” Dr. Fawcett says. “It’s a type of pain I don’t think anyone understands who hasn’t experienced it, but when that’s paired with hopelessness suicide can be the result.” Screening for this type of anxiety is no simple task, Dr. Fawcett explains. “Anxiety is not uncommon in depression— ≥60% of depressed patients have moderate anxiety. The real warning sign is an increase in symptoms of anxiety, but assessing the severity of anxiety goes against the current habit of classifying symptoms as either present or absent. Clinicians need to ask probing questions regarding the severity of the symptoms, and, also, find out how much of the day is spent experiencing the symptoms.” MORE

Dr. Fawcett is correct. I have found the "psychic pain" he's talking about is an existential stress where one's sense of competence and/or value as a human being has been challenged beyond what the person's self-esteem can tolerate. Thus, a imminently suicidal person believes she is no longer worth the air she breaths, the space she takes on earth, nor can her value to others be seen as no less than an annoyance, and as bad as an intolerable burden. A recent grievous loss, such as an close relationship or a job, combined with a number of other stressors, often triggers the crisis.

I've often wondered about those who are suicidal and treated by SSRI anti-depressants. A few have experienced suicidal crises apparently aggravated by the medication. This has created considerable debate about treating children and adults with SSRIs when suicidal.

As I've said before, anti-depressants AND therapy are often helpful in these crises. However, a suicide watch by family and friends may still be necessary during the crises because of the time it takes for the treatment to work.

Complicating the picture is that SSRIs cause significant side effects when first started. The symptoms are similar, but not necessarily the same as what has been called "SSRI Discontinuation Syndrome". Psychiatric Weekly has another article about this issue.

The antidepressant discontinuation syndrome is manifested by a wide array of symptoms. Onset of symptoms occurs shortly after stopping drug or reducing the dose. Common symptoms include dizziness, anxiety, irritability, panic attacks, mood lability, decreased concentration, and insomnia. Nausea, occasionally associated with vomiting, and other gastrointestinal symptoms are frequent.

[...]By rapidly decreasing the efficiency of the primary inactivating system (serotonin reuptake), SRIs initially can cause nausea, which may be blocked with agents that inhibit serotonin (5-HT)3 receptors.15,16 Adaptation to this SRI side effect occurs during initial weeks of treatment along with other changes in neuronal function. Gradual desensitization of autoreceptors during SRI treatment allows serotonin neurons to recover normal firing rates and to progressively increase 5-HT neuronal transmission, perhaps accounting for the delay in onset of their therapeutic effects.

[...]In prospective controlled trials, paroxetine has been found to have the highest incidence of post-treatment AEs compared with other SRIs. Fluoxetine, by contrast, has the lowest reported incidence of discontinuation symptoms, presumably due to the long elimination half-lives of parent drug and its active metabolite.

My experience has indicated that a few people experience very uncomfortable side effects when starting SSRIs. If they are also suicidal, then the experience of the side effects, sometimes extreme "skin crawling" agitation perhaps similar to the clinical syndrome called "akathesia" may well trigger a suicide attempt.

Suicidal clients who are starting SSRIs need close monitoring.

From the outstanding site of Anxiety Insights, there is a summary of a recent research study that produces results questioning conventional wisdom about income, poverty and depression.

None of the socio-economic indicators studied was found to be significantly associated with an episode of common mental disorder at follow-up, after baseline psychiatric illness was taken into account. The analysis of separate diagnostic categories showed that subjective financial difficulties at baseline were independently associated with depression at follow-up in both groups.

In other words, it's the subjective experience of stress rather than the experience of poverty that predicts a higher rate of depression. That is consistent with my own clinical and life experiences. I teach my clients that we control our reactions to whatever happens to us. While, we also have a lot of input on our successes, mainly by the persistence and willingness to make adjustments and keep going, but there are other factors that effect the outcome that are beyond our control in whatever we do.

The period from high school graduation until the mid-twenties, or around the completion of college, has always been the highest risk period for developing mental illness of all kinds. A University of Florida Psychologist Jamie Funderburk recently reported that an estimated 53 percent of college students, representing perhaps 26,500 students at the University of Florida, will experience some form of depression. A report prepared by the University of Berkeley Academic Affairs Office for the Committee on Student Welfare cites a

[...]recent poll revealed that 85% of colleges and universities are seeing an increase in mental health problems on their campuses. [Berkeley's The Counseling and Psychological Services reports a] 300% increase in demand for psychiatric visits in recent years [as well as] greater acuity and severity of student problems. While in the past, students presented with relationship break-ups, identity concerns and difficulties with career decision-making, today students more often present with serious clinical depression, bipolar disorder, and psychosis, requiring emergency services and hospitalization.

Rates of suicide in America are highest for college-aged individuals; according to some estimates, suicide is the second leading cause of death for Americans aged 18-24. What is even more alarming is that, in the 2002-2003 academic year, there were at least six student suicides at UC Berkeley*. This is twice the national average for Americans in this age group.

Consumer John McManamy offers some perspective.

Since 1950, the suicide rate has more than doubled for college-age women and tripled for college-age men. According to three surveys reported in US News and World Report, 30 percent of US colleges experienced a suicide last year, 9.5 percent of students say they have seriously contemplated suicide, and 1.5 percent have made the attempt.

[...]American College Health Association survey report[s] that 76 percent of students felt "overwhelmed" while 22 percent were sometimes so depressed they could not function. The situation is borne out by a survey of counseling center directors, 85 percent who report an increase in severe psychological problems over the past five years. Students have grown up in an era of the disintegrating American family, [...] but they are also more used to therapy and are more likely to seek help. In the past, many kids with severe mental problems would never have made it to college, but today, thanks to new medications, they are potential clients of college counseling services.

Student depression is of particular concern. A National Mental Health Association survey reports that 10 percent of college students have been diagnosed with depression. According to Richard Kadison MD, chief of the Mental Health Service at Harvard, in an interview with Psychiatric News:

The lifetime incidence of depression is 20 percent, and the peak age of onset is around college age. So many students have their first incidence of depression while in college, and they are completely surprised by it. They think that it is just that they have become lazy or that they have a sleep problem.

Children are our future. The stress kids feel as they enter adulthood should concern us all. This is not just an American problem, the high incidence of suicide attempts during college age is evident world wide. Japan in particular reports a rate of suicide more than double that of the US in college students, triple that of South Korea. Suicides in Japan have been associated with pressure to succeed and failing grades.

A study in the British Journal of Psychiatry (2000, 177, 360-365) found that the most predictive risk factor for suicides was loss, be it loss of a person, material possession or health. The authors speculate what is lost is an "cherished idea" offering what might be a fruitful approach to intervening with someone who is suicidal.

The recently released "World Map of Happiness" offers circumstantial support to the concept of subjective interpretation of experiences is more closely related how one feels than the affluence of the individual. Unlikely countries like Brunei, Bhutan, Antigua and Barbuda, Malaysia and the Seychelles rank with higher subjective happiness than the US (23rd) with many more modern economies ranking relatively unhappy (35. Germany; 41. UK; 62. France; 90. Japan).

Truly to a large extent, seeing the glass as half full, rather than half empty, has a lot to do with how happy or depressed one feels.

Tom Cruise's latest tirade against psychiatry inspired physician-columnist for the Telegraph Max Pemberton to go undercover in London's Scientology Headquarters.

I told her I was feeling low and she told me I was suffering from depression and that it was likely to be caused by someone near to me, possibly a friend or member of my family. Alarm bells were now ringing full volume. Fear not, I was assured by the wide-eyed, smiling Sharon, Scientology could help.

She wanted to tell me more, she said as she gently guided me further into the building, which was milling with people. The majority of illnesses, she explained, including diabetes, cancer, schizophrenia and depression, were the result of our being "suppressed" by other people, but this suppression could be cleared away by Scientology. Or I think that was what she told me. Her words were cloaked in impenetrable language, which I was informed could be further explained, at a price, on one of the courses run by the centre.

Sharon wouldn't elaborate further - she wanted me to sign up for a course - but I've since learnt that Scientologists believe depression is best alleviated by removing the sufferer's covering of tiny disembodied souls of aliens dispersed by the Galactic Federation leader Xenu. Ah, yes, I think I missed that lecture at medical school.

This is no joke, though. Scientologists are aiming their "teachings" at people with mental health problems, some of the most vulnerable in society. MORE