Depression: why "pull yourself together" doesn't work

It rarely starts on a particular day. First, sleep stops being refreshing. Things that used to take five minutes start taking an hour or don’t get done at all. Friends hear “I’m just tired”. Then guilt arrives: life is fine, other people have real problems, so what is there to complain about? Often it is someone close who notices first: “You’ve gone quiet lately.”

Everyone has low days, and usually they pass after a good night’s sleep, a conversation or a change of scene. Depression is different: changes in mood, thinking and the body hold on for weeks or months and make ordinary life hard. It is not something a person can simply snap out of. Depression is treatable, and most people recover.

How depression shows up

There is no single sign of depression. Doctors look for a combination of symptoms.

Mood: sadness or emptiness, emotional numbness or a constant irritability, when every small thing grates. What used to bring joy stops bringing it.

Thoughts: “I’m bad”, “I’ve ruined everything”, “nothing will ever work out for me”. Guilt grows out of proportion to what actually happened, the future looks hopeless, and life can start to seem pointless, both one’s own and people’s lives in general. Thoughts of death may come too.

Thinking itself: it becomes hard to concentrate, to remember, to make even small decisions. Choosing between two similar products in a shop can become a real challenge.

Body: tiredness that sleep and rest don’t fix, slowness in movement and speech or, on the contrary, restlessness. Sleep may be broken, with waking in the early hours, or there may be too much of it. Appetite and weight may go down or up. There are often aches with no clear cause, and sex drive fades.

Activity: a person sees friends less, drops hobbies, puts off post and bills. Many keep going to work and looking after their children, and from the outside nothing seems wrong. But each ordinary task takes a lot of effort.

When it is something else

Grief is not depression, even when it is very hard. In grief the pain comes in waves and is tied to the loss, and a person’s sense of their own worth usually stays intact. In depression the darkness spreads to everything.

Burnout is linked to work: exhaustion, cynicism, a feeling that nothing is working. It often overlaps with depression, and long-lasting burnout raises the risk of it.

Low mood and fatigue can also have physical causes, such as an underactive thyroid or anaemia, or come from alcohol or certain medicines. A doctor can check for these with tests.

Why dark thoughts feel like the truth

The hardest thing about thoughts like “I’m worthless” or “nothing will change” is that they don’t feel like symptoms. They feel like finally seeing things as they really are. But depression does not open anyone’s eyes to the truth. Such thoughts are part of the condition, and they usually change as the depression lifts.

Thoughts of suicide

Thoughts of death are one of the recognised symptoms of depression. They range from a quiet “it would be easier not to wake up” to thinking about how to end one’s life.

If such thoughts appear, the most important step is to tell someone: a friend, a family member, a GP. Another option is to call Samaritans, a UK charity where someone will listen whatever a person is going through. Calls to 116 123 are free, and the line is open day and night, 365 days a year, including Christmas. A GP can be asked for an urgent appointment the same day, or NHS 111 can help. If there is an immediate danger to life, the right thing is to call 999.

For those close to someone with depression, it is worth knowing that asking directly about suicide does not put the idea in their head. Research shows that such a question does not increase these thoughts and may even reduce them: it gives the person permission to open up.

Where depression comes from

There is rarely a single cause. Heredity plays a part: when a parent, brother or sister has had depression, the risk is roughly two to three times higher. Life events often come before depression: bereavement, divorce, losing a job, money worries, loneliness, a long illness, the birth of a child. A hard childhood, especially one where a child was neglected or emotionally hurt, also makes it more likely.

Why “pull yourself together” doesn’t work

“Pull yourself together”, “get out more”, “stop moping”: people with depression hear this from others and tell it to themselves. The advice assumes that a person has the strength and the desire to act and simply chooses not to. But depression takes away exactly that: energy, motivation, the ability to concentrate and decide.

Usually people act because they want to: first the wish, then the action. Depression breaks this order. The wish doesn’t come, and waiting for it can last for months. The less a person does, the less they want to do, and their world gradually shrinks.

Will it pass on its own?

Sometimes, but slowly: in studies of people who received no treatment, mostly with milder depression, about half recovered within a year. Depression also often comes back. So waiting it out is rarely the best option.

Psychotherapy

For milder depression, psychological help is usually the first thing to try. In England, adults can turn to NHS Talking Therapies or to a private psychotherapist, psychologist or counsellor. In psychotherapy a person can understand what keeps the depression going, learn to notice the inner critic and argue with it, and gradually return to life step by step.

For moderate and severe depression, antidepressants are usually recommended, most often together with psychotherapy: the combination helps more people than either on its own.

Antidepressants

The most widely used are SSRIs, though there are other groups. A large analysis of 522 trials found that every one of the 21 antidepressants studied worked better than placebo, a dummy pill.

Antidepressants are not “happy pills”. Researchers at the University of Oxford found that a single dose helped people with depression recognise happy faces and remember positive words about themselves more readily, before their mood had changed at all. The lift in mood comes later, as everyday experience gradually builds on this shift.

What to expect:

• Timing: they usually start to have an effect after one to two weeks and can take up to eight weeks to work fully.
• Side effects: nausea, headache, dizziness, sleep problems, reduced sex drive. Many ease after a couple of weeks, and if they don’t, a doctor can change the dose or the medicine.
• The first weeks: in some people, especially those aged 24 or under, suicidal thoughts can increase at the start of treatment. This is uncommon, but any such thoughts should be reported to a doctor straight away. It is not a reason to avoid treatment.
• How long: usually for at least six months after a person feels better, and longer if depression has come back before. Stopping too early increases the chance of it returning.
• Addiction: antidepressants do not cause craving or the need for ever higher doses. But stopping suddenly can cause unpleasant symptoms: dizziness, anxiety, sensations like brief electric shocks. That is why the dose is reduced gradually, together with a doctor.

Depression narrows the world and makes it seem that things will always be like this. That feeling is a symptom too, and it changes as the depression lifts.