"Don't think. Do."

This is, apparently, what is currently keeping my government out of a depression.

It is common sense, but why not have someone make some money promoting it? These are indeed great ways to beat depression. "Don't think, do" is excellent advice. Being somewhat given to rumination, I cause myself a lot of angst by revisiting and rethinking every event that happens to me. When I stop hemming and hawing and take actions, I tend to be happier.

But I do just have to bitch about this for a second:

So Ilardi wants us to look back, way back, to our Paleolithic past. To our cave-dwelling, hunter-gatherer ancestors...

I think I'm going to lose it the next time I hear someone suggest that studying the behaviors of our prehistoric ancestors will cure depression, give us insight into gender roles, explain altruism, suggest the perfect dietary plan, give rise to the next fashion trend, excuse our sins, and leave our windows streakless and shiny. Psychologists who rattle on about this stuff seem very poorly informed indeed. Evolutionary biologists are always far more conservative in their discussions of the utility of one historic period in shedding light on modern-day human behavior. This guy has some excellent ideas: I can only imagine that he finds it expedient to refer to Paleolithic people because any EP slant is a sure way to get some press and maybe some funding.

Aside from that, what he says about this is interesting:

Since World War II, as the United States had modernized and grown more urban, depression rates have risen tenfold

He's onto something, but I think it's expressed inadquately here. For one thing, the US didn't really grow more urban after WWII - it grew less rural, sure, but also less urban (welcome, urban 'renewal'!), and more suburban. The G.I. Bill assisted people in getting mortgages on new housing stock, not existing housing stock, and acreage taken out of farming provided cheap land for developers. It was in this era that the ideal single-family home far from the filth and noise of the city was celebrated. And people went for it, obviously, in droves. But the unanticipated effect of that was that families scattered. Where at one time, extended families lived within a few doors of each other on a city street, or an adjacent farms in the same towns or in neighboring towns, individuals could rely on a lot of family support for their problems: financial, childcare, job training, comfort during grief, loneliness, transitions to marital life and parenthood and old age, the whole nine yards. It was in part these family networks that helped the nation get through the Depression, let alone all the other challenges of America's first few hundred years. Families were bigger and they were closer physically, so people had support in a way that is exceedingly rare today. It's no great wonder that we're lonelier and more depressed than people who lived before the great explosion of neolocalism that we call the 1950s. The dream the country went for was "Go anywhere - people who know and care about you are just a phone call away! You can handle it! Make yourself into anything you can dream! Go away to college! There are no limits! Move across the country! We won't expect you ever to come home. We'll see you at the holidays."

Thanks for this. While I've probably heard most of it in various forms at one time or another, I need reminders of what I should be doing and how useful it can be. It's good to read that these things really work.

I did the dishes. Does that count?

Since World War II, as the United States had modernized and grown more urban, depression rates have risen tenfold

Some of my own pet theories:
- Omnipresent media and marketing assault, creating expectations, fears, and desires we can't do anything about.
- Increased office/indoor time, less exercise and daylight.
- Increased diagnosis, especially of mild/moderate depression.

First off, let's be honest: there's simply no evidence that depression rates have risen tenfold since WWII. What has risen ten-fold since then are diagnoses of depression. Also awareness of depression. And pharmaceutical treatments for depression.

Secondly, yeah - diet, exercise, increased sleep, bright light exposure, social interaction, and getting out of your own head are all age-old tried-and-true coping techniques. As Miko suggests, there's simply no reason to dress it up in some faux-nostalgic neo-primitive wrapper, other than as a marketing ploy. On the other hand, combining all these techniques into a super-spa support group facial sounds like a clever and useful treatment technique.

Miko, you nailed it. It's my opinion also that 'suburbanization' (and the related "Nuclear Family" replacing the Extended Family) has done incredible damage to the American Psyche, and I'm a non-proud example. I had what I now realize was an extraordinarily isolated childhood, with no siblings, the nearest aunts uncles and cousins 2000 miles away, an absence of schoolmates in the neighborhood and other random factors accidentally converging to increase the isolation...

On preview, DarkForest has some of the other contributing factors, the 'media age' possibly being the next most important.

And IRFH: "combining all these techniques into a super-spa support group facial sounds like a clever and useful treatment technique business plan". Fixed that for you. Whenever I hear 'treatment', I always remember that 'cure' has much less long-term income potential.

Excuse me, I'd better get off the computer and go out before I get even more depressed...

sounds like a clever and useful treatment technique business plan

It might be a good treatment technique, too, though Wendell. I'm skeptical of the way it's being marketed, sure, but combining group therapy with proven physical stimulation techniques and positive human interactions sounds like a clever idea to me.

Do drink tequila.
Do have sex in the car.
Do play hooky from work.
Do order pizza for supper.
Do watch a movie marathon.
Do crank up the stereo.
Do eat an entire cake, with ice cream.
Do cry in the shower.
Do sleep late. Very late.
Do walk on the beach.
Do take medication, if you need it.
Do remember all the people who have it worse. Much worse.
Do be kind to yourself.

Besides, I happen to think some depression is a mark of sanity. Given the world we live in, who wouldn't be a little depressed now and then?

(Consistent "happiness" takes too much denial for me.)

Pips, I love your list and philosophy on life.

Dark Forest, me too. I like to be reminded of these things. We've heard it all before. We all *know* what to do. I like that it's spelled out; Do it if you can. See what happens.

I think it's a pretty cool way to treat people too even if the caveman thing is a bit overplayed. If I lived in Kansas, I would try to get into this program. Not that it isn't doable, for the mildly depressed, wherever you are in the world. Therapists and doctors in Kansas and around the country are starting to integrate Ilardi's TLC into their practice.

Miko, I agree with you. It seems that everybody is touting the caveman way. Here is another quote from the article that we've heard a million times before: "We were never designed for our sedentary, socially isolated, sleep-deprived, poorly nourished lifestyle."

More from the AARP article:

"We've been engineering the activity out of our lives," says Ilardi. "The levels of bright light exposure--time spent outdoors--have been declining. The average adult gets just over six and a half hours of sleep a night. It used to be about nine hours a night. There's increasing isolation, fragmentation, the erosion of community."

The result? "We feel perpetually stressed. And the more we learn about depression neurologically, the more we learn that it represents the brain's runaway stress response."

Though Ilardi's results look promising, psychiatrist Peter D. Kramer, M.D., the bestselling author of "Listening to Prozac" and "Against Depression", warns that initial therapy studies often register good outcomes because of the enthusiasm of their creators. When neutral researchers study the same therapy, "the advantage disappears." And many TLC remedies, says Kramer, are already part of the therapeutic arsenal. "Many therapists working in the northern latitudes, for example, will say, 'Add bright lights in winter, fish oil in your diet, exercise...Let's see if we can get you in more supportive relationships."

Ilardi agrees that the independent verification of his results is critical, but he says therapists aren't routinely prescribing TLC's behavioral fixes.

He also disputes the commonly held notion that depression is higher among older Americans.

(he then goes on to say that more young people are depressed) and "Every successive generation is at higher and higher risk."

Ilardi says, "If throughout the course of human evolution people were as vulnerable to depressive illness as 21st century Americans, we would long since have gone extinct as a species."

I did the dishes. Does that count?

I just thought about doing the dishes. *smacks self on forehead* Pips, you're a fucking genius!

I think Miko, DarkForest, et al raise some excellent points here. Just today we were discussing the decline in cultural events here and in Vancouver, and I suggested that it was a symptom of a society that is moving from community and extended family to nuclear family to individual. One of the whines you hear about some of the local events is 'why should I pay for something I'm not even going to go to?' IANASociologist, but I would guess that both 'why should I' and 'not going to' were not nearly as common before suburbanization.

Do take medication, if you need it.

THANK YOU! It's been said before, both here and in the blue, but the problem I have with oversimplifying depression and its possible remedies is that I feel it's another way of saying that if you do the right things, you won't need to take medication. It ain't always so (and it's not always feasible if you're depressed), and it comes dangerously close to regarding depression as a character flaw rather than a medical illness.

That said, thank you LoriFLA for the excerpt. I think the ideas are interesting, and have no doubt that the approach is helpful for many people. Putting some useful tools in an easy-to-understand package makes it so much less overwhelming, which is important with such an illness.

Pips has it pretty much. In both comments.

Pips...we don't have a car.

A lot of my depression left when we bought a house that had a dishwasher in it.

Doesn't have to be your car, jonmc!

An old acting saw is "Don't Act, Do." As in, don't act like you are doing something, don't pretend to do something, really do something. All I can say is, it works for actors.

Nice post, LoriFLA.

Have I expounded my air-conditioning = downfall of civilization theory here? Because I totally agree with Miko, but I also, in my own version of that theory, add in the rise of air-conditioning. Which I decided to add after living through a hellishly-hot summer in Venice and finding that the bad weather made everyone more social in a desperate attempt to get out of stuffy apartments and down by the water to catch a breeze. And then I remembered reading that cafe culture really took off because many cheap apartments had no heat and artists and intellectuals and other apartment-dwellers had to go find a heated public space in the winter, and so would spend their entire days at cafes.

So I guess it's more of a controlled climates = downfall of civilization theory, really. We try to avoid the outdoors, and its inconvenient "seasons" at all costs, and so we have no true public gathering spaces.

And I thought I was a total kook about this until I went to a book reading for a history of air-conditioning and it turns out the author had the same theory. She said everyone blames suburbanization and television for making everyone stay inside all the time, but no one remembers the air-conditioner.

(Which is to say, I'm probably still a kook, but at least I have back-up.)

"I have no faith in human perfectability. I think that human exertion will have no appreciable effect upon humanity. Man is now only more active - not more happy - nor more wise, than he was 6000 years ago." - Edgar Allan Poe

I think I agree with Poe. And Pips.

I have believed for many years that air-conditioning has, at the very least, contributed significantly to internal isolation of communities - it becomes so hard to go outside when there is such a marked difference between the weather inside and the weather outside. It becomes easier just to stay inside and watch TV than to go to the beach to cool off, or go to the movies or the local shopping centre, or any number of public or semi-public spaces. You only have to look at what happens in a city when the power goes off - everyone goes outside to get fresh air and ends up interacting with neighbours they may have lived next to for years but never spoken to. It's a pity that never seems to continue beyond the duration of the power outage, because the lure of the air-conditioner is so strong.

I think "Don't think. Do." promotes a false dichotomy of thinking/action that most really engaged people try their damnedest to avoid. Watch a tradesman work, and you never see "Don't think. Do." You see a person thinking, doing, and having their thinking changed by the doing in which they are engaged, which changes their doing, until thinking/doing are inseparable, as activities, and the work is done.

The best tradesmen learn a lot of tricks to balance thinking/doing for best result. They learn to position their bodies, and use tools, to eliminate strain, and maximize physical effort, so as to avoid overbalancing on "Do." They learn some theory and practical history of their trade, so as to have plenty of trade craft to apply in new situations, to avoid over-thinking.

What they're about, and what I personally strive to achieve, when faced with situations where a lack of progress or an unquiet mind seem foremost, is a better balance of Think and Do. Sometimes, it's as simple as taking the dog for a walk, and getting a cup of coffee or a beer on the way home, so that Thinking has time for catching up with Do. Other times, a great deal of sweaty, straining Do is called for, which totally drowns out and stops Thinking, until Do is again in respectful, harmonious consort with Think.

I saw a great cartoon yesterday which had two cavemen sitting talking on the floor of a cave, and one says to the other 'We must be doing something wrong. We get lots of fresh air and exercise, everything we eat is organic and free-range, and yet none of us lives past thirty'.

Hmmm... excellent points all around, particularly on climate control (it has done terrible things to neighborhood life) and the think/do dichotomy.

Consistent "happiness" takes too much denial for me.

The state of non-depression isn't necessarily 'happiness,' it's contentment (calm, serenity, balance, equilibrium, or however you want to say it). With depression at one end of an extreme and manic anxiety at another, contentment sits in the middle. It doesn't require any denial. We've all known people in terrible life circumstances who are able to laugh, able to cry, and generally maintain an even keel and good self-care while still feeling their emotions. If you can do all that, you're probably not depressed.

Good one, altolinguistic. That is great.

The full article is up today.

You'll have to drag me kicking and screaming out of my dim, cool house into the bright, hot sunshine.

Interesting concept, paulsc - it's also easy to get so caught up in Doing that you forget to take time out to Think, though. If you are doing routine tasks, sure, you can cruise along almost in auto-pilot if you are familiar with the motions involved. However, it is important every now and again to down tools, stand back and Think a bit to make sure your job is heading where it is supposed to and that you haven't forgotten something or not foreseen something. As with everything, all things in moderation is what's required.

I thought it might prove helpful for me to address a few of the questions and other concerns raised about Therapeutic Lifestyle Change for depression on this forum:

1) The admonition, "don't think: do" can only be understood properly in the context of treating depression. It is not, as some of you seem to have inferred, some sort of life philosophy (presumably, one that eschews introspection); rather, it's a specific and very useful strategy for combatting depressive rumination. As you may know, depression is characterized by a relentless proclivity for dwelling on negative thoughts, over and over again, and this ruminative process serves to amplify depressed mood and - in many cases - serves to maintain an acute depressive episode. The most effective means of interrupting an acute bout of rumination is to redirect attention by means of engaging activity. Hence, the maxim (to be invoked during rumination), "don't think: do."

2) Modern-day hunter-gatherers (e.g., the Kaluli of Papua New Guinea) have been found to experience very low rates of depressive illness, despite leading very difficult lives and having none of the material benefits or medical care that characterize modern life. Americans, on the other hand, are facing a depression epidemic of epic proportions. One in four will become depressed at some point, and there has been a 10-fold increase in risk of depression since WWII. This increase is neither an artifact of increased awareness, increased self-reporting, or increased eagerness to diagnose; it is based on the same careful epidemiological methodology used to track rates of cancer and heart disease, and is corroborated by cohort analyses that document a startling increase in prevalence for each successive generation over the past century (over 25% of current 18-to-29-year-olds, for example, have ALREADY been clinically depressed). See http://psychpundit.blogspot.com for a compelling graphic depiction of the phenomenon.

3) Because the humans existed in Pleistocene, hunter-gatherer conditions for the vast majority of our history as a species, there is strong evidence that extensive selection pressures have shaped the human genome to render us well adapted to the hunter-gatherer milieu; little additional selection has occurred over the past 10,000 years after the gradual transition to an agrarian way of life. And, as it turns out, hunter-gatherers do lots of things that we know (based on extensive research evidence) confer protective benefit against the experience of depression, things like getting: extensive physical exercise, dietary omega-3 fatty acids, sunlight exposure, sleep, social connectedness, and engaging (anti-ruminative) activity.

4) Thus, the rationale for Therapeutic Lifestyle Change - i.e., it's important to recapture these protective elements from the past - is not a clever marketing ploy, as some here have alleged. No one associated with the project has made a penny off the project thus far. Because it's a research protocol, all study patients have received treatment free of charge. Before I received a very small seed grant of $6000 from the University of Kansas to support the research, I was paying for patients' omega-3 supplements and light boxes out of my own pocket!

My only goal is to develop more effective treatments for depressive illness, which is devastating in its impact - robbing people of their sleep, memory, attention, confidence, and their ability to love and work and play. Worldwide, it robs roughly 1 million people of their very lives via depression-linked suicide. I hope you'll join me in taking it seriously.

Best wishes,
Steve Ilardi, Ph.D.

Dr. Ilardi, thanks so much for responding. I find your project and treatment approach fascinating.

I've also long been a believer in the air conditioning = downfall of civilization theory. To me the one of the most obvious signs of how air conditioning has contributed to the death of social life and community is, quite simply, the loss of the front porch along with the rise of the air conditioner. We no longer needed to get out at night; to walk around the neighborhood or to sit on our front porches as the house cooled down in the evening enough to sleep in. And as we turned inward, the porch disappeared, to be replaced by a front facade dominated by a huge 2-3 car garage and one front window shining with that strange blue glow from the tube. Now we don't even know our next door neighbors and have lost the sense of community that entails.

Mind you, I don't necessarily think that life and community was all sweetness and light back when; but I do think we've lost a great deal that contributed to the simple network and skeleton of our society and communities by being able to turn our backs on the world around us, made possible in no small part by the advent of air conditioning.

You know, it sounds good to me, and I'm always in favor of new approaches to treating mental illnesses, as they give patients more choices for how to get better. The recommendations are sensible and may well work for many people. I agree with Miko, the paleo- stuff is just BS. Evolutionary psych asks the wrong questions, so the answers are frequently worse than useless, but we can safely ignore that since it doesn't do anything but provide an underpinning we need not accept in order to recommend the treatment.

Here's the thing, though:
This treatment will be no better than other therapeutic approaches. Bruce Wampold's (and others') meta-analyses show psychotherapy has an effect size of 0.80 for general efficacy (79% of people who receive therapy do better than those who want it but don't receive it), and only a 0.20 effect size for specific efficacy. In other words, only ~1% of variation in outcome is due to difference in specific treatment techniques. The rest of the change in therapy is attributable to 4 main factors: extra-therapeutic change (a new job, apartment, girlfriend); relationship with the therapist (the largest therapy dependent variable); hope for change (the placebo effect); and a plan for how to get better (a therapist's allegiance to a set of techniques, but not the techniques themselves). Psychotherapy only makes sense as a general phenomenon, not a specific one, in a contextual model, not a medical model. The results are quite robust, and make the null hypothesis the idea that all responsible therapies are as effective as all other responsible therapies. There is far more variation among therapists practicing the same techniques than there is among techniques.

Which is not to suggest that this method of treatment does not work. It does, the research predicts it will. If the structure of this makes sense, if it accords with your ideas about what might be making you depressed, then it's probably the treatment for you. But it isn't going to radically change the overall effectiveness of therapy, therapy is already very very effective. In that sense it isn't solving a problem that hasn't already been solved, or changing our understanding of what works in therapy.

(Which is ultimately what concerns me about how it's presented. Far better to talk about it as one technique among many effective techniques ("All have won, and all must have prizes!"), and put our energies to making sure that everyone who gets to see a Zoloft bouncing cloud also gets to hear the news about how effective all therapy is so that they can make an informed choice about what treatment will work for them.)

BOP's Guide To Combating Depression

1. Determine if you are, in fact, depressed. You may just be sad, or angry, or hungover, or hungry, or jonesing.

2. Masturbate.

3. Shower.

4. Go outside. (After getting dressed -- you're depressed, not crazy.)

5. Walk rapidly, repeating the mantra, "I am running away."

6. Continue walking until lost.

7. Freak out a little.

8. Think of all the good things you miss about the home you'll never ever see again, because now you're lost, you stupid fucking tool.

9. Banish that thought.

10. Walk back (because you're not an idiot, you're just depressed).

11. Arrive home.

12. Pretend you feel better.

13. Announce to anyone who will listen, "I just took the best walk!"

14. Repeat as needed.

I posted some of the material below on a related thread begun yesterday by LoriFLA (titled, "BUMP: Don't think. Do"), but I thought some of you might be interested in seeing it here. I've also added a reply at the end to yesterday's provocative comments by obiewise posted above:

1) LoriFLA - As you suspected, we introduce the six primary elements of TLC quite gradually, as it's important to enhance each patient's sense of self-efficacy/confidence by building on success. Thus, in the first group session, aside from making introductions, covering the treatment model in depth, explaining symptoms and causes of depression, etc. - the only major intervention we introduce is the omega-3 supplement. In week 2 we add material about identifying the process of rumination and various strategies for interrupting it, etc.

2) Miko - You're absolutely right . . . even though there has existed solid research support for each element of TLC for at least 5 years, they've never been empirically tested in combination before, and there has never existed an integrative protocol for helping patients put them all into practice. Several years ago I had a horrific sinus infection (my first), and my gp put me on a standard antibiotic at a standard dose. I returned 10 days later even more miserable, so he upped the dose. After 3 weeks of agony, I finally self-referred to an ENT specialist who told me, "with an infection this bad, we need to hit it with everything we have: 2 different antibiotics, a nasal steroid, a decongestant, an expectorant, and time spent with a humidifier." Within a few days I was a a new man! The same principle seems to be involved in our TLC approach to depression. Depressive illness is often a horribly difficult-to-treat disorder, and it just makes sense that we'd want to hit it with a number of different efficacious interventions.

3) Omiewise - I couldn't agree more that a key issue in fighting the depression epidemic right now is getting the word out to the public that there are effective treatments available other than meds, which often have intolerable side effects. In fact, according to an analysis by Valuck et al. published in American Journal of Psychiatry (August 2007), antidepressant use has plummeted in the past couple years since the FDA advisory regarding increased risk of suicide, but many diagnosed depressed patients are simply getting no treatment at all.

4) Omiewise - in response to your contentious, cavalier claim above, "the paleo stuff is just BS" . . . well, suffice it to say that I respectfully disagree. What's your background in evolutionary biology? If you haven't spent extensive time in this area (as seems likely from your comment), it's understandable that you may feel intuitively that it can be dismissed with an unenlightened wave of the hand, but the supportive data to the contrary are quite compelling. For example, there is no debate among biologists that the human genus was subjected to extensive selection pressure during the Pleistocene, the period spanning roughly 1.8 million years ago until just 12,000 years ago (during which all humans were hunter-gatherers). Likewise, it is clear that there has been very little time for additional adaptation to have occured in the brief interim. Thus, there is no serious doubt about the fact that in many respects the human genome is still designing brains and bodies well adapted to the Pleistocene milieu. Look at phobia acquisition. Children readily acquire a fear of spiders and snakes and 'monsters that will eat them in the dark', despite the fact that these fears are no longer adaptive, and have not been for millenia. Look at the obesity epidemic, caused in part by human appetites that are programmed for the Pleistocene, in which ever-fluctuating food supplies and lack of food storage made it adaptive to crave sweet, starchy, fatty (calorie-dense) foods, and to consume them in bulk for storage as adipose tissue during rare periods of abundance. Worked great 12,000 years ago, but not so much at present.

Regarding your other points, Omiewise, I'm afraid I'm also going to have to disagree. You suggest that the TLC interventions have been widely used by therapists for years, but that does not at all match either the self-report of patients in our clinical trials, or the report of the hundreds of depressed college students I've talked with in recent years. Most of them tell me that, at best, their therapists might have done a little hand-waving about the potential benefit of exercise or fish oil or bright light exposure, with no concrete information provided about: (a) specific dosage (e.g., of the few that had actually started taking an omega-3 supplement, fewer than 10% were taking the recommended dose of 1000mg/day of the psychoactive EPA molecule - most were simply taking one pill per day when it would have required SIX to get an adequate dose); and (b) specific guidance about HOW to make these lifestyle changes, i.e., how to go from theory to practice.

You also invoke the work of Wampold to suggest that, in effect, all therapeutic modalities are equivalent, but this reflects an incomplete understanding of the relevant treatment outcome literature. As Beutler (2002) and others have shown quite compellingly, there are numerous disorders for which specific intervention techniques/elements are paramount. The most obvious example, of course, is found in the treatment of anxiety disorders, where exposure-based habituation is the sine qua non of effective psychosocial intervention. With ocd, for example, the largest-ever, multisite, NIMH-sponsored treatment outcome study (Foa et al., 2005) found dramatic differences among treatment modalities: 86% favorable response rate for exposure-based therapy; 48% for Anafranil, 40% for SSRI med, and 10% for placebo. Likewise, for severe depression (which is not terribly placebo-responsive), Dimidjian et al. (2006) found superior results for anti-ruminative behavioral activation in comparison with either Paxil or cognitive therapy.


Finally, I'll note that our preliminary results in TLC in a sample of over 60 depressed patients (mostly severe, chronically depressed, and treatment-resistant) have been very encouraging, with a 76% rate of favorable response in TLC compared with 27% response rate among those receiving treatment-as-usual in the community (typically meds and/or traditional therapy).

I probably won't have time to make it back on this site for a while, but I want to invite anyone with further questions or comments to drop by my blog at http://psychpundit.blogspot.com.

Best wishes,
Steve Ilardi