Understanding and Coping with Depression (1) - Not a Walk in the Park...

Depression or major depressive disorder is a remarkably common problem, with lifetime prevalence rates between 10-20%. Meaning, that 1 or 2 people out of 10 will experience a clinical episode of depression in their lifetime. Hopefully, if you struggle with depression, this removes some stigma for you. You deal with fairly common, but often debilitating problem that extends it's dark tendrils into virtually every part of your life, but you're not alone or terminally flawed. The good news is that research is revealing more and more about what causes depression and how we can treat it.

Psychiatric medications (antidepressants and other classes of medications) are the primary form of treatment that most people receive. And this makes sense to an extent - they are cost effective compared to therapy, are more convenient than weekly therapy appointments, and they can improve or alleviate depressive symptoms. Operative word, 'can.' For many, antidepressant or other medications are not sufficient or satisfying for those taking them. A significant portion of the population continues to experience residual depressive symptoms after completing a full course of antidepressant medication - perhaps a fourth or more of those taking such medications do.

The risk of relapsing and returning to a depressive episode returns once such an individual ceases medication - the more previous episodes a person has had, the greater their chance of a future episode, suggesting a progressive and perhaps chronic nature for depression. What is interesting is that individuals who have received high quality psychotherapy - often cognitive, cognitive behavioral, or behavioral activation therapies - show a decrease chance of relapse, even when ceasing medications. This suggests that quality therapy can potentially retrain the brain and mind, helping us to think differently and respond differently to low mood and depressive symptoms in such a way that it acts as a partial vaccination against future episodes.

So what causes depression? A full discussion would require volumes of work and is beyond the scope of this brief article. For today, we will focus only on one major factor - cognitive rumination. Rumination is a style of thinking defined as "recurrent and repetitive thinking on symptoms (e.g. fatigue, low mood), feelings, problems, upsetting events, and negative aspects of the self, typically with a focus on their causes, meanings, and implications" (Watkins, 2016, p. 6). Rumination tends to be cyclical, passive, self-referential, and abstract. It focuses on "why" and "what does this mean about me or the future," which no matter how much you ask, you cannot sufficiently answer, rather than concrete thinking that focuses on "What can I do specifically now to feel better or manage a problem.

Rumination is implicated in several ways in depression. It remains

as a residual symptom of depression. Levels of rumination predict initial episodes of depression, severity of depression, and relapses into depression. What this means is that if we can find ways to address or decrease rumination we can potentially relieve depressive symptoms. Several different interventions may decrease rumination: acceptance strategies, meditation, concrete problem solving, and perhaps even physical exercise.

Today we'll talk about the application of a combination of mindfulness and nature walks. Mindfulness is a type of awareness define as paying attention to the present moment, with an open, accepting attitude. It has been studied in recent decades for its clinical utility and is not included as an essential component of several scientifically supported therapy models (ACT, DBT, MBCT). You can practice mindfulness of anything with the follow basic instructions: Pay attention to xyz. Let thoughts come and go. Allow your emotions and feelings to be as they are. When you notice your attention has wandered, guide it back to xyz. Mindfulness can be applied to formal meditation periods, mindful breathing, mindful eating, etc.

One way to apply mindfulness is on nature walks. Such walks in of

themselves have been shown to improve mood and decrease levels of depressive symptoms over that of walking in an urban environment (Bratman, Daily, Levy, & Gross, 2015; Bratman, Hamilton, Hahn, Daily, & Gross, 2015). To add nature walks into your regular self-care and depression coping tool box, pick a length you can reasonably expect to accomplish. Studies showed benefits from 50 to 90 minutes, but start where you can and work up to longer distances. While walking you can practice one of two types of mindfulness: 1) open attention to the full experience of walking, 2) focused on different aspects of the experience.

In the first, pick your nature destination to walk and as you do, direct your open, accepting attention to the full experience. Purposefully notice all that you can see, hear, smell, and touch, remaining open and receptive to it all. When you notice yourself getting stuck in thoughts and rumination, gently (as if guiding a small child or puppy) redirect your attention back to the experience of the nature walk.

In the second, try the following routine. Set a timer to beep every five minutes as you walk. For the first five minutes practice mindfulness of sight, specifically directing your attention to all that you can see. For the second five minutes practice mindfulness of sound and notice all that you can hear. For the third five minutes practice mindfulness of movement and really try to tune in to the sensations of walking in your body, the movement of limbs, the contact with the ground. For the fourth five minutes, practice mindfulness of breath, and focus your attention on your breath. With it all, adapt a curious, open attitude to your experiences and when you notice your attention has wandered, gently guide it back to your experience. This can be repeated several times or you can switch to an open mindfulness after completing the four five minutes periods. Aim for 1-3 mindful nature walks per week.

When practicing mindfulness it is important to be gentle, compassionate, and patient with ourselves. This is especially true when experiencing depressive symptoms. The urge will be "to get it right," but a harsh performance mindset will only work against us. Also, rumination is sort of like scratching mental mosquito bites - the more you've done it, the more irresistible it is. Truly, it becomes a mental habit. Breaking down this habitual pattern takes time and beating ourselves up over it will only exacerbate our already depressed mood.

Taking these regular mindful nature walks can be a useful adjunct to both medication and psychotherapy treatment approaches. Plus, you'll get the added benefits of improving physical fitness and improved self-esteem associated with exercise.

Gregory N. Bratman, Gretchen C. Daily, Benjamin J. Levy, James J. Gross,(2015). The benefits of nature experience: Improved affect and cognition,Landscape and Urban Planning, Volume 138,2015,Pages 41-50.

Gregory N. Bratman, J. Paul Hamilton, Kevin S. Hahn, Gretchen C. Daily, James J. Gross, (2015). Nature reduces rumination and sgPFC activation. Proceedings of the National Academy of Sciences, 112 (28) 8567-8572.

Edward R. Watkins, (2016). Rumination-Focused Cognitive Therapy for Depression. The Guilford Press: New York, New York.