Sunday, September 7, 2014

My Experiences With SAD Interventions

[Content note: Depression, self harm, social anxiety, eating disorders.]

Several people (at least five) have asked me recently about my experiences coping with depression. In response, I've put together a list of interventions I've tried, and what happened. There are probably lots of things missing from all parts of this list. I have a bit of a memory problem here, because I'm sort of two different people, and since the depressed version of me is sleeping, her past experiences aren't very available to me. But here are the things that are salient right now. I think I've probably gotten all the really big ones.

About my history: I've gotten depressed during the winter since puberty, and probably earlier. It's gotten worse all my life up through age 21 or so. I began purposful recovery three years ago (maybe four?) when it didn't get better during the spring.

Things that have helped me with Seasonal Affective Disorder

in order (mostly) of apparent effect size:

  • UPDATE 2/17/2016: We have a winner! Although I've tried light boxes in the past and seen no improvement, it turns out there just aren't any sufficiently powerful light boxes on the market. Eliezer built me a mighty patronus so effective that I didn't get depressed this winter at all. I'm still on bupropion, so I don't yet know if the lights are enough without that, but I plan to go off of the meds this summer and see what happens next winter. Instructions for building a LUMINATOR, as he calls it, are available here.
  • It not being winter. Duh. Didn't realize this was useful to know until it finally occurred to me that I might try moving to the southern hemisphere for the US winter. Giving that a go this time around. The plan is to come back in mid February so I can try out a few more interventions without having to put up with an entire winter's worth of depression should they fail. [UPDATE 2/17/2016: I didn't have a great time going to Chile by myself for four months, but it was definitely the right decision.
  • Bupropion (300mg/day sustained release)
    • I started this during the deepest depths of depression I've so far experienced, and it pulled me out.
    • This took care of most of the problem.
    • There was still enough of the problem left to be minorly crippling. I can be a student or hold a job during the winter if my life depends on it. I'm still almost constantly suffering in the winter, though. My concentration, creativity, and ambition are nearly totally shot from late fall through late spring, and I sink deeply enough into "my dark side" that compassion is just about impossible, and my most common form of positive emotion is cold amusement. I'm not going to go into any further details about having depression here. (I do talk a bit about it in these two posts.) Just trying to let you know approximately where I stand with it at the moment.
    Curing my social anxiety.
    • I had to get my depression mostly under control before this was even thinkable.
    • but they're really a nasty combination. Depression is much easier to deal with without social anxiety.
    • I'd probably be even better off if I weren't also introverted, but changing that is not the next thing on my to-do list. [UPDATE 2/17/2016: It is now, and I'm making progress that I'm bound to write about eventually.]
    • If you want to hear about effective interventions for social anxiety, skip down to "And so it began." in the "Lob's Theorem Cured My Social Anxiety" (which, in addition to being the title of one of my most popular posts, has been noted as taking the cake for the most Lesswrongian phrase ever). For the crazy mysterious thing that kicked it once and for all, read to the end. But I don't actually expect that last thing to work for other people.
  • Eating enough and regularly
    • It took me a ridiculously long time to figure out that this was a thing.
    • My mood gets way, way worse when I'm hungry. Unfortunately, all sorts of things come together to prevent me from eating.
      • For one, my stomach is apparently the last part of me to notice that I'm hungry, and for a long time I didn't believe people who told me I should eat, unless my stomach agreed with them. I suspect this has something to do with the bupropion, since it reduces appetite reliably enough to be prescribed as a weight-loss drug.
      • I was poor for a long time, so most of the food available was sufficiently uninteresting that it took pretty extreme hunger before cooking and eating was better than continuing to be hungry.
      • Cooking takes time and energy. Turns out there's some fairly tasty frozen food these days. I was not aware of this until recently.
      • Depression is not good for body image, and I didn't want to become what felt like "even more fat".
      • My body is apparently excellent at homeostasis; instead of losing weight, it mostly just shuts down all non-vital processes when I starve myself. And I guess it doesn't consider much of my brain necessary. I only actually lose weight from exercise. When I hadn't realized this was possible, I thought the fact that I wasn't losing weight was strong evidence that I was eating plenty.
      • In retrospect, I think the sensation of extreme hunger probably distracted me from the psychological pain in the same way cutting myself did, so I wasn't so quick to stop it. (Useful self-harm thing I learned recently: Sticking your hand in a bucket of ice water is really painful, but harmless for 15-minute periods. If you use a mixing bowl instead of a large bucket, the ice will heat up to a non-harmful temperature before it could possibly be a problem.)
      • UPDATE 2/17/2016: For the past month or so, I've been eating Meal Squares with whole milk for about 2/3 of my food, and it's wonderful. I no longer have food problems. I eat regular food when I feel like it, and Meal Squares when I don't. My energy levels are more stable than I remember them ever being, and I've lost somewhere between 5 to 10 pounds of fat (which I'm happy to lose) so far while still gaining muscle (I could do zero pullups a month ago, and can do 3 now). I think I could pretty easily stop losing weight by simply eating more, but because I have far fewer food cravings, and because my energy stays so even and it now takes at least an hour before I start to lose concentration when I'm hungry, it's very easy to eat *just* enough.
  • Daily or near-daily exercise.
    • It's been very important to use exercise I actuallyenjoy. For me, that's mostly meant running, and especially running outside. When I'm down, it's much easier to convince myself to go explore a trail through a forest than to slog along on a treadmill for half an hour.
    • When I injured myself and couldn't run for a long time, it was a huge problem. When I was on campus, I could largely make up for it by dancing. But in El Cerrito last winter, dancing was too far away. I turned out not to enjoy swimming enough, plus it was relatively inconvenient.
    • I ended up mostly doing weightlifting last winter, which was not nearly as good as cardiovascular exercise, but was better than no exercise.
    • When I finally got a bike, it turned out to be better than weightlifting, but not as good as running. Probably just because I don't like it enough to do enough of it to wear me out more than once or twice a week. If you like cycling, I expect this will work fine.
  • Learning to think of my pain as objectless when it was objectless.
    • It's easier to get stuck in a harmful obsessive cycle when you believe you're sad or angry about something. Early on, I'd let myself direct my feelings at a person or situation. Since I knew from experience that talking to the person or changing the situation wouldn't have much of an effect on how I felt, so I'd just agonize over the thing endlessly.
    • Installing robust anti-rationalization habits kept my beliefs in line with the truth, and the truth was harder to obsess over. It was too diffuse and abstract to really latch onto emotionally. (For more cognitive skills I picked up as a result of dealing with depression, check out Corrupted Hardware: Things I Learned From My Broken Brain.)
    • This had two main effects. One was that I directed what energy I had toward finding actions that had actually helped me feel better in the past (like exercising, going outside, talking to someone, or even eating chocolate).
    • But very often when you're depressed, there's just nothing you can do. You're going to feel like shit no matter what happens. I have what might be a weird way of dealing with this.
      • Most distance runners are familiar with the sensation of coming up against a wall of exhaustion. There are a few ways people push through it.
        • Some people distract themselves. They try to get really into the music they're listening to, or they think really hard about what they're going to make for dinner.
        • A second type of runner focuses on the goal. They have thoughts like, "Just another half mile and I can stop. That's just a few minutes. I can put up with this for a few minutes. Just stick it out 'til then." This sort of person usually knows how far they've gone, how long they've been running, and how long they have left.
        • I'm a third type. What I do when I encounter a wall of exhaustion is imagine that it will never ever end ever. I take note of the specific sensations I'm feeling--the burning in my muscles and lungs, the desperate desire to give up, the overall tremendous discomfort--and I pretend that this is just how my life is now, and how it will be forever. And there's nothing I can do about it. So I'd better just find some way to exist in this state. Maybe I can even adjust my appraisals of the sensations so I end up wanting to feel like this. (I should note that I am both a masochist and a submissive, so I may have unusual psychology that lets me submit to pain when others couldn't.)
      • So it might be that noticing you feel like shit and you can't do anything about it ought to be your cue to distract yourself. I used to do that, actually, but it wasn't really sustainable for me. It turned me into a workaholic, and I eventually burned out.
      • Or maybe it means you should focus on getting through this particular rough patch. "Just three more hours, then I can go home." I have a hard time imagining what it would be like to be the kind of person who could benefit from that, but I'd not be at all surprised to hear that it does actually work for some people, given what I know of runners, and given how many times I've heard the phrase "one day at a time".
  • Having fun reasons to spend time outside.
    • It's really hard for me to just go outside for no reason when I'm depressed. And being told to go outside feels like a punishment. This may be a leftover psychological response to when my dad and his wife would tell my brother and I to go play outside (presumably mostly because they wanted to be left alone). I'm actually not quite sure what's up with this, because I like sunshine. *shrugs*
    • Excusesto go outside, however, work great. They don't even have to be good excuses. Walking to the store even though I could just as easily drive, for example. Going to the park to read with my toes in the fountain. (I live in California where we don't have real winter. You might substitute "building a snowman".) Going on adventures is always good for me. I'm especially happy to leave the house and be outside for a while if there's food at the other end of the adventure, so traveling to restaurants and coffee shops is great.
  • Waking up early.
    • This sounds like a no-brainer, since waking up early means maximizing your exposure to sunlight. It's likely this deserves a place at the top of the list for you.
    • For me, it's all the way down here because I've found it extremely difficult to maintain. One of my symptoms is insomnia, so waking up early often means getting little enough sleep that it's a huge energy drain.
    • Melatonin helped a lot, though, as did building an elaborate bedtime ritual. The bedtime ritual made it easier to go to bed on time, and the melatonin increased my quality of sleep so I felt more refreshed after fewer hours of sleep.
  • Translating feelings of despair into feelings of exhaustion.
    • This actually helped almost as much as exercise, but it took a really long time to learn. Well, that's not quite true. Once I thought of it, I could do it almost immediately. But I think it required a whole bunch of other skills that I had to learn first, like thinking of my pain as objectless, having conversations with personified parts of myself, and adopting new mental postures on purpose (like Val's "againstness" training.)
    • This is a super useful trick if you can manage it, though. I find it much easier to cope with being tired all the time than with being painfully sad or completely emotionally empty.
  • Borrowing my friends' brains.
    • It can be hard to be friends with a depressed person. Not so much because they're always being sad at you, as because there seems to be nothing you can do to help. Consequently, people seem to actually like it when when I ask them for specific small things that will actually help me.
    • In particular, what I have in mind is outsourcing straightforward cognitive tasks that you just can't manage right now even though you have to.
    • I don't recall a specific instance of countering depression with this just now, but here's one from anxiety. Once, when I pulled the car over because I was having a panic attack, I found that my brain wasn't working well enough to generate possible solutions. So I called a friend whom I trusted to make generally good decisions, and asked to borrow his brain. I told him what was happening, and asked him what he thought I should do. He told me to try to relax for a few minutes, then, if I couldn't drive, text him my location and he'd come by with another person who'd pick me up, and he'd take my car home for me. It's an obvious plan when your brain is working properly, but non-obvious when you're panicking or thinking through dense brain fog.
  • Modafinil
    • This actually makes me feel almost completely better. I end up a bit unstable, subject to mood swings, but I get what at first feels like a huge flood of ambition, creativity, and concentration that is probably mostly just my summertime self reemerging.
    • Unfortunately, I seem to become habituated after about three days.
    • It also makes me feel like like I'm on the edge of a panic attack for hours at a time, which is definitely not pleasant.
    • Bonus effect: It seems to make orgasms way more awesome. I have no idea what that's about. Many they're only awesome compared to wintertime orgasms, and normal for summertime orgasms. I haven't kept careful track of my experience of sex and sexuality across the seasons, except to notice that I'm almost completely asexual when depressed, and only mostly asexual when I'm not. [UPDATE 2/17/2016: Things are actually considerably more complicated than that.]
  • Commitment mechanisms
    • These are quite effective when I pick the right ones. Many a time have my past selves pulled my future selves kicking and screaming through necessary responsibilities.
    • They're also dangerous. Turns out if I force myself to deal with too many things, I do in fact completely crash. This is how I ended up taking an incomplete in every single class at the end of one semester.
    • I now use commitment mechanisms very sparingly and as a last resort. It's often better to simply not do the thing.
  • Happify.com. Happify is gamified cognitive behavioral therapy/positive psychology. I kept this up for about two months before I got distracted by the existence of HPMOR, CFAR, Lesswrong, Leverage, Eliezer, and the Bay Area. I think it was probably helping in small but consistent ways.

Things I've tried that haven't had perceptible effects on me

  • Fluoxetine (aka Prosac, an SSRI)
    • I tried this during the deepest depths of depression I've so far experienced, and it didn't pull me out. I've not tried it since then.
  • Spending half an hour in front of a SAD light box in the morning every day for three weeks.
    • Yes, I know. I notice that I'm confused as well.
      • It might not have been a powerful enough light.
      • I probably need more than 30 minutes.
      • I might need to surround myself in lights rather than having one sitting directly in front of me.
      • I might need to actually look straight at the light instead of reading in front of it.
      • I might need repeated exposure throughout the day instead of just one stretch in the morning.
      • I might need a different color of light--this one had a cold blue clinical color that made me sad.
    • Everything I've ever read about SAD says something in this direction should work. This is almost certainly worth trying if you haven't, even though I didn't respond to it.
    • Light therapy is something I'll be giving another shot. I would have tried modifications, like more powerful lights, the first time around, but the problem with ineffective depression interventions is that when they don't work, trying again is really hard. Similarly for trying other things after the first thing only worked a little bit.
    • UPDATE 2/17/2016: THIS WORKED! I'M FREE! I just needed more and brighter lights for a longer time. It's February and I've been 100% not-clinically-depressed all winter. I get sad sometimes, but only in healthy normal ways. I am now completely cured of SAD, as long as I keep my lights with me during winter. Here are instructions for building a LUMINATOR like mine.
  • Vitamin D supplements.
    • This is something I did give a second shot two years later. This time, I made sure I had the right form of D (D3), and the other vitamin needed to process it, namely K2.
    • Still didn't seem to help.
  • Reading letters to my dark side from my summer self. This actually has very perceptible effects, I'm just not sure if they're net good or net bad. I think the correct evaluation is probably "dangerous". I probably have a lot of things to say about what it's like to be made aware that you're two people with distinct value sets, but this is probably not the post for it.
  • It's important to note that the patient is often the last person to notice improvement. It's possible to be almost completely recovered and not know because you still feel like shit, despite the rest of your life having put itself back together. So these things may have actually helped, and I just didn't notice. On the other hand, neither did Eliezer when he observed the results last winter.

Interventions with net negative effects

  • Caffeine
    • This drastically improves my concentration, creativity, and motivation, though it doesn't have as strong of an effect on my mood as modafinil.
    • I've sworn it off, though, because I become not just habituated but horribly dependent very quickly. And I become quite a bit more depressed during withdraw than I'd be if I'd never touched the stuff.
    • It also starts fucking with sleep big time as soon as I'm dependent enough that I can't function in the evening without using it right up until bedtime.
    • Caffeine is largely responsible for the big crash that plunged me into the depressive state that finally started me toward purposeful recovery.
  • Alcohol
    • This was actually supposed to be an intervention for social anxiety, not depression. It was very effective for social anxiety.
    • But it increases my depression for a day or two after I use it.
    • I've stopped drinking alcohol entirely since noticing this at the beginning of last winter. UPDATE 2/17/2016: I now drink small amounts of alcohol occasionally, maybe two drinks a month. I'm still noticeably less happy and energetic the next day, but it doesn't seem psychologically dangerous like it is when I'm depressed.
  • Marijuana
    • This provided a much-needed respite when I used it occasionally during my workaholic period.
    • But I'm pretty sure it caused the same downswing that alcohol did. It's hard to tell since I'd often smoke and drink simultaneously, and I'd often stay up too late while stoned, then compensate with extra caffeine the next day.
    • This would probably be worth some more experimentation were it not for the fact that ever since I started taking bupripion, weed has given me all of the paranoia and none of the buzz.
  • Feeling guilty
    • I never would have thought of this as a possible intervention if I hadn't read Hyperbole and a Half by Allie Brosh, who apparently gets just about everything done no matter her mood by noticing how horrible she'd feel about herself if she didn't do it. (Also, her depiction of being depressed [1, 2] is DEAD FUCKING ON and beautiful.)
    • Feeling like a bad person has approximately zero power to deter me from something, and in certain moods it has the opposite effect.
    • Attempts by myself or others to make me feel guilty simply shut me down. My response is either, "Pfft, fuck this shit," or "Never mind, I'm no longer interested. I'll just sit here in a ball sobbing until I starve to death".
    • But hey, maybe it'll work for you. Mindspace is deep and wide.

Things I plan to try in the future

  • More, brighter, differently colored lights for longer periods and at different times of day. UPDATE 2/17/2016 This worked! See above under "light boxes" for more details.
  • Modifying my medication, either by increasing the dosage or by adding supplemental meds.
  • A variety of dietary supplements I need to research some more but have heard tell might help. UPDATE 2/17/2016: I've been taking Equilibrium. Unfortunately, since I started in the fall, I can't distinguish its effect from the effect of the lights. If you try this independently of other interventions, I'd love to hear about it!

Hope that helps. I'm completely open about this topic (and pretty much all topics, really), so feel free to ask questions.

4 comments:

Doug S. said...

There's been exactly one thing that I've found that reliably pulls me from the "I just want to lay in bed and cry" state to the "Life sucks but I might as well go deal with it" state: putting on one of my favorite music CDs and not thinking about anything else. "Music from FFV and FFVI Video Games" tends to work best for me, but you probably don't have the emotional hooks that I do for those particular tracks.

Aceso Under Glass said...

I don't have regular SAD, but I suddenly developed it after a course of exotic antibiotics. Vitamin D and the sun lamp helped a little, but what really cured it was inositol. Inositol is either produced or consumed by gut flora, and there's some evidence some of the benefits fecal transplants involve inositol.

Fiona Paul said...

SAD light boxe is very good skincare product.

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