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A Plan for Stubborn Depression

Len Lantz, MD

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Synopsis: When depression hits, it’s nice when the first treatment that you try works. On the other hand, depression that gets partially better only to worsen again is frustrating and demoralizing. Having a plan for treatment-resistant depression will get you better faster. This article outlines basic steps that are part of a larger plan for getting rid of your depression.

BY LEN LANTZ, MD / 7.21.20; No. 30 / 7 min read

Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.

Why is it important to have a treatment plan?

Using a few strategies is not the same as actually having a plan. Following a plan, not just trying strategies, is important not only in depression treatment but also in many areas of life. I’ve spoken to many people who have struggled for years who have “tried meds” or “tried therapy” only to find that their depression never fully improves.

Methodically following a plan, however, can lead to dramatic results. Why is it then that we do not see more people with a dramatic improvement in their depression? In some cases, they have regularly followed every step of a good treatment plan but do not get better because they have atypically severe depression. More often, they don’t have a clear treatment plan.

To be fair, some people are not instructed on all of their options and recommendations for depression treatment. In other cases, because of their depression, they have low motivation and energy, which block them from following the recommended steps. “I don’t feel like taking a shower” or “I don’t want to exercise” are replies that I have heard more than once.

What is a treatment plan?

A treatment plan in psychiatry involves setting measurable goals and regularly checking in on the progress toward those goals. I like treatment plans, especially when they are unique, relevant to the individual and regularly reviewed. The challenge that I have seen with many treatment plans over time is that they all look the same, have the same recommendations and are ignored after they are completed.

Another difficulty I see with some treatment plans is that they do not set the bar high enough. For example, in the treatment of depression, I am not satisfied unless someone achieves full remission from their depression and can stay depression-free. Do you want to feel only partially better or do you want to be cured of your depression? If you want a cure, are you willing to do what is necessary to get there? In treating depression, I like to think about a comprehensive plan, specific to the individual, that involves strategies with a high likelihood of helping.

Ten elements of a good depression plan

I randomly picked the number 10. There may be dozens of elements to a good depression plan, but the higher the number, the more overwhelming it can feel to a person who is having a hard time simply getting out to bed. If the first thing I tried did not get my depression better, I would make sure that I at least have the following 10 components in my plan (please keep in mind that not everything listed is equally effective):

  1. An evidence-based psychotherapist: There is no substitute for quality, skills-building psychotherapy. Pills do not teach skills, but therapy can. For more information on psychotherapy, please read my articles, “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?” and “Finding Quality Psychotherapy – Moving Beyond Talk Therapy.”

  2. A good psychiatrist for diagnosis, medications and treatment guidance: First and foremost, you need a doctor who is a good diagnostician, because the wrong diagnosis frequently leads to the wrong treatment. You also want a doctor who adheres to medical standards, screens for medical conditions that cause depression, listens to you and can understand your symptoms in the context of your life. A psychiatrist can help with more complex treatment and assist in contingency planning, such as when to increase or decrease the intensity of treatment based on your symptoms or when Transcranial Magnetic Stimulation (TMS), ketamine therapy or electroconvulsive therapy (ECT) would be appropriate. For more information on psychiatry, you can read my articles, “Does a Psychiatric Diagnosis Even Matter?” and “Finding a Good Psychiatrist.”

  3. Methodical treatment and symptom tracking: “I’m better” is not good enough. The goal of treating depression is full remission – full freedom from depression. Both your doctor and your therapist can help you to methodically track your progress in your treatment and help measure and record your treatment to know what is working and what is not. Keeping track of this information can also help if you need to access more expensive treatments that require prior approval by your insurance company. Lastly, your doctor and therapist need to regularly check in with you on treatment adherence. How often have you skipped therapy, forgotten your medication, called off work or avoided exercise and other healthy activities?

  4. Exercise: Even a small amount of regular exercise helps depression tremendously. If you want to learn about how powerful exercise is for depression, you can read my article, “The Surprising Results of Exercise for Depression”.

  5. Behavioral activation strategies: Behavior activation means having many activities scheduled throughout each day that are positive and in alignment with your values. The medical research is overwhelmingly clear that behavioral activation strategies help depression immensely. My article, “Behavioral Activation for Depression,” outlines the substantial benefits of behavioral activation strategies in helping depression.

  6. Sobriety: I’m actually not a killjoy. Be honest for one second. Nearly every adult knows that alcohol is a central nervous system depressant. If you are depressed and you drink alcohol, then you need to make the responsible adult decision to stop consuming alcohol until you are free of the depression.

  7. A healthy diet: Having a healthy diet means eating more whole foods, not skipping meals only to binge eat later and not eating junk food. Avoiding processed foods and having a balanced diet means eating more fruit, vegetables and whole grains. Doing so will not only help you to develop and maintain a healthy weight but may also help your depression, as an unhealthy diet and obesity both are associated with an increased risk of depression.

  8. The right amount of sleep: Not enough sleep or the converse, too much sleep, can create substantial problems in getting depression better. If you cannot sleep, then it feels like you never get a break from depression and continue to feel even more exhausted. If you struggle with insomnia, please read Dr. Krista David’s article, “Accepting Insomnia and Other Ways to Improve Your Sleep.” Staying in bed all day when you are depressed is the exact opposite of what you need to do to get better. You cannot hide in bed for weeks and hope that the depression will go away on its own.

  9. Addressing problematic relationships (and dealing with life toxicities): Sometimes you are in the wrong job, the wrong city or the wrong relationship. You feel stuck because you know you will feel pain if you stay and pain if you make a change. To be clear, when I talk about making a change, I do not mean that you only have 2 options – stay or leave. There are other options, such as working to change the circumstances or improve your relationships. The problem is that no amount of medication will fix a stuck situation when you fear the change or seek to avoid the pain that it would bring about. People change when the pain that they are in is greater than the pain of change. Working with a therapist can help you accurately assess and cope with the pain of change.

  10. A safety plan that works: Preparing for and addressing suicidality is critical to effective treatment because when you don’t have safety, you have fewer treatment options. For example, you may need to switch from outpatient treatment to inpatient treatment. Being proactive in safety planning can improve your confidence that you will be able to be safe and master self-destructive thoughts. Being able to cope with and reduce suicidal thoughts can accelerate treatment response. If you don’t have a safety plan, please learn how to develop a unique plan for yourself by reading my article, “Your Safety Plan for Suicide Prevention.”

What is holding you back?

Is there anything on the list above that you have sworn to yourself that you would never do? Do you know why? I certainly can imagine some reasons why. Possibly you have had a bad therapist or psychiatrist in the past. With absolute certainty, I can share with you that not all therapists or psychiatrists suck. Maybe you have tried something once only to be disappointed and regret your decision to get your hopes up. There is hope for getting your sleep and diet on track. If you hate exercising or dream of spending each weekend in your pajamas binge-watching Netflix, are you sure you have come up with the right plan? Dealing with suicidal thoughts or even deciding to take the option of suicide off the table is possible and can open up even more options for getting rid of depression because when you have safety, you have the time to try more things.

When you are depressed, change is hard. It can be especially overwhelming to try to make several changes at once. So, pick one or two areas to improve, then over time work to incorporate all the aspects of your treatment plan.

Think about having an actual plan for dealing with your depression

Having a great plan for addressing depression is critical to getting better faster. You might have tried some of the elements I listed above but not in a coordinated manner and not all at the same time. The best outcomes in depression are associated with a quicker timeframe to remission. A great plan for depression isn’t just more of everything, which would result in feeling even more exhausting. However, it does involve discipline and a willingness to force yourself to take one step at a time out of the immobilizing state of depression. Each step that you take will feel easier. Imagine the satisfaction of following your plan for depression treatment and achieving freedom from depression.

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