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The rate of depression is rising. According to the World Health Organization, the international watchdog of health issues around the world, depression is currently thefourthgreatest cause of human suffering and disability around the world. That observation alone tells us how serious and pervasive the problem of depression already is. Even worse, however, is the World Health Organization prediction that by the year 2020, depression will have risen to become thesecondgreatest cause of human suffering and disability. This unprecedented rapid growth rate is strong evidence that biology is less a factor in its spread and social forces the greater factor.

Is depression really on the rise, or are people just more tuned into depression as a general topic of interest? The best evidence we have suggests strongly that depression is increasing in prevalence not only in the United States but around the world. This is not simply because more people are seeking help for depression or because wary clinicians are diagnosing it more frequently. Rather, the increase appears to be the product of more and more people manifesting the signs and symptoms of depression.

What we do to each other can too easily become the source of great hurt in our lives and can result in an enduring way of thinking, feeling, and relating to others. But, we are relearning something of vital importance that has been too often overlooked in recent years: Just as people can be a source of pain, they can also be a source of comfort and happiness and a way out of pain. In light of new research, being the strong, self-sufficient “go it alone” type no longer seems the most effective route to personal fulfillment. Instead, science is confirming what we have probably always known in our hearts:We are built to be in positive, meaningful relationships with others in order to feel good. Yet, today, our relationships are damaged and suffering in unprecedented ways.

As relationships face more challenges, whether in love, family, business, or friendship, depression is on the rise. Depression spreads in part through troubled relationships and, in this sense, is socially contagious. You can’t catch depression in the same way you catch a cold, but the latest research in neuroscience, social psychology, epidemiology, and genetics provides overwhelming support that moods spread through social conditions. Our social lives directly shape our brain chemistry and powerfully affect the way we think and feel. With modern scanning technologies, we now have evidence that our brains change with positive life experiences. In fact, brains can change as much with social circumstances as with medication. Drugs may address some of depression’s symptoms, but they cannot change the social factors that cause and perpetuate it.

What makes for healthy, strong, happy people? Why do some people face stressful and challenging events in life and seem to rise above them, while other people implode in the face of what seem like routine stressors? These questions provide the foundation for much of what I will talk about in this book. The vast majority of research into depression has focused on the pathologies within people that presumably give rise to the disorder, such as character defects, anger-turned-inward, and chemical imbalances in the brain. Only recently has there emerged a different paradigm for thinking about human experience. Known aspositive psychology,its focus is on what isrightwith people rather than on what is wrong. Instead of studying people who suffer, positive psychologists study people who have overcome adversity and thrived, who are happy, competent, and fulfilled. By striving to identify people’s strengths, psychologists hope to help those who are suffering.

One of the first tasks positive psychologists attempted was to develop a new manual that would catalogue and define many of the best aspects of human experience. Unlike the well-known psychiatric manual listing various forms of psychopathology (theDiagnostic and Statistical Manual,now in its revised fourth edition, DSM-IV-R) used by mental health professionals to diagnose patients, a new manual calledCharacter Strengthsand Virtueswas developed by psychologists Chris Peterson and Martin Seligman to identify and describe some of the best human attributes. These include the courage to speak the truth, kindness, love, fairness, leadership, teamwork, forgiveness, modesty, gratitude, and many other such positive characteristics. If you reread that list of attributes, you cannot help but notice that they are wonderful human potentials that canonlybe expressed in the context of human relationships. Simply put,how people develop their best selves is largely, though not entirely, achieved in the context of positive relationships with other people.

At a time when we are learning how vitally important it is to have positive and healthy relationships, we are seeing such relationships on the general decline. Even a cursory review of recent U.S. Census data shows us the warning signs: More people are living alone than ever before, people wait longer to marry, on average, yet the national divorce rate remains slightly over 50 percent for first marriages, and even higher (about 70 percent) for second marriages. The number of births outside of marriage has risen sharply, and single parents who must work and are thereby too often unavailable to their kids experience and transmit stresses that are widely cited as a reason why children are often struggling emotionally. Millions of children are currently on antidepressant medication, as well as other psychoactive medications for their social and behavioral problems.

As families struggle and marriages wobble, large studies of the prevalence of various disorders in the general population show rates of depression nearlyfourtimes higher than a generation ago and nearlytentimes as high as two generations ago.Social skills have declined and relationships have become less rewarding and effective. As a result, the vulnerability to depression has increased.

For over half a century, researchers have known that good relationships serve as a buffer against illnesses of all sorts. The evidence is clear, for example, that when you are happy in your primary relationships, you suffer less depression. Furthermore, people who enjoy close friendships and the support of others are happier and more productive. They also suffer fewer illnesses and, on average, live longer. We will explore the health and mood benefits of good relationships with others in the first chapter. What most of this book will be about, then, is how to develop the kinds of relationships that can help you overcome depression, and perhaps evenpreventit.

Mental health experts have generally treated depression by giving their patients drugs and shock treatments and other newer brain stimulation treatments, or by talking with them about their childhoods. Yet the social conditions that give rise to depression continue unabated, allowing the rate of depression to continue to rise at an alarming rate. New research makes it clear thatdepression is not just about the suffering of one individual, as if he or she lived in total isolation. Rather, depression occurs in a social context; it occurswithinpeople, and also arises from the hurts that take place in relationshipsbetweenpeople.

The pains of rejection, humiliation, the loss of a loved one through a breakup or death, the betrayal of trust, the trauma of violence and abuse, and the many other ways people can wound each other are all reliable pathways into depression. Simply put, depression can be and often is a direct consequence of relationships that are, well, depressing.

Depression doesn’t just affect individuals, although it’s easy to focus on the person with the symptoms. For every depressed person who gets treatment, at least four more don’t. For every depressed person who doesn’t get treatment, his or her depression affects the lives of at least three others. For every depressed parent who goes without treatment, his or her child is at least three times more likely to become depressed than the child of a nondepressed parent.Relationships can spread depression as surely as germs can spread illness. Depressioniscontagious.

More and better drugs willnotsolve the problem. People who suffer depression, and the people who love them who suffer right alongside them, must also avoid overthinking the symbolic meaning of the depressive experience. Depressed people are usually already quite good at isolating themselves and thinking too deeply about themselves. Instead of examining them even more closely under the microscope, analyzing ever smaller pieces of their psyche, as if depression is just their individual problem, the solution lies in a broader view. We need amacroscope.We need to see depression in its larger social context,see it for what it is when the world gets more dangerously crowded while people are literally dying of loneliness.

Few mental health problems have received as much attention as the problem of depression. There are many reasons: (1) Depression has a hugefinancial impacton our society because of the exorbitant economic costs associated with it; these are measured in terms of lowered productivity, more employee sick days, and diminished job performance. Current estimates indicate depression is costing the U.S. economy at least $70billionper year. (2) Depression’s cost in terms ofhealth care expensesis huge since it is so closely associated with cardiovascular disease, diabetes, smoking, drug addiction, and many other costly health related problems. (3) Depression exacts a heavy toll onindividual lives,causing high levels of suffering, anguish, unhappiness, and even the ultimate loss of life when people in despair kill themselves. (4) Depression is terribly destructive on thesocial level. Depressed people are often unable to establish and maintain healthy family environments and constructive working relationships with others, or to build loving and positive relationships with others. Some depressed people even destroy and sabotage important social bonds and harm society through antisocial acts.

The power of depression to damage and destroy lives cannot be overstated. We in the mental health professions have worked especially hard to better understand and treat depression and, over the last two decades, our understanding of depression has increased dramatically. In fact, depression has gone from being one of the least understood to one of the best understood disorders that clinicians treat.

Manythings cause depression. Some factors arebiological, some arepsychological, and some aresocial. Hence, abiopsychosocialmodel of depression dominates the field.

Thebiologyof depression is an extraordinarily complex arena of research. A young field called affective neuroscience is striving to understand the brain mechanisms underlying moods and mood-related disorders like depression. Geneticists are investigating the role of genetics in vulnerability to depression. Psychopharmacologists are striving to understand the role of neurochemistry in mood states in order to better understand how drugs might more effectively be employed in treatment. Some optimistically envision a day when “designer drugs” can be tailored to an individual’s unique biochemistry.

Thepsychologyof depression is also an extraordinarily complex area of study. Psychologists have always been interested in how people’s quality ofthoughtaffects their mood states and how one’sbehaviorincreases or decreases vulnerability to depression. The study of factors such as personal history and styles for coping with stress and adversity has generated important insights about who gets depressed and under what conditions. Many previously unrecognized factors that influence depression’s onset and course have now been identified. Great strides have been made in developing effective psychotherapies for treating depression which are based on sound scientific research.

Biology and psychology—singly and in combination—play a large role in the development of depression, but consideringonlythese domains in treatment has proven less helpful than psychotherapists had hoped. Drugs have become the most common form of treatment, even in the face of the accumulating volume of objective evidence that clearly demonstrates antidepressants—alone or even in combination with other approaches—have numerous problems associated with them. Likewise, the psychotherapy of depression has shown itself to be less effective when it treats depression only as an individual phenomenon. Talking about your depressed feelings or exploring your childhood can too easily miss the fact thatan individual’s depression occurs in a social context and is even socially defined. Your mood and outlook are powerfully influenced by your relationships with others.

It may seem obvious that our relationships with other people affect our moods, behavior, and quality of life, yet most people focus almost exclusively on the biology of depression when seeking solutions. This is primarily because the drug industry has aggressively marketed the self-serving but unfounded perspective that “depression is caused by a chemical imbalance in the brain.” We in the United States are bombarded by television, radio, and print advertising that asserts that depression is a “brain disease” requiring drug treatment. This may be true for a relatively small percentage of depressed individuals, but there is no objective test for depression in existence yet that could prove it. To the contrary, there is growing evidence available todisproveit.

As a direct consequence of these relentless, pervasive advertising campaigns, the average person has heard this message that depression is a biochemical problem so many times that he has come to believe it. By continually shining the spotlight on the biochemistry of depression, sales campaigns have left in the shadows other contributing factors. After all, you can’t package and sell relationships. Thus, the social domain of depression has largely been ignored. This has been a very costly oversight on the part of the mental health profession. Instead of making sure the value of drugs isn’t overstated and seeing that the merits of building healthy relationships are recognized, the drug sales campaigns have rolled right over us, misdirecting our attention from other more important considerations. The damaging message has been all too clear:You don’t need to change your life in any meaningful way. You don’t need to spend any time and effort learning new skills to be more effective. You need only change your biochemistry.

I am a clinical psychologist who has been immersed in the world of depression my entire professional life. I have treated depressed individuals, couples, and families for more than three decades. My focus has been on developing innovative, safe, and effective nondrug treatments. These are described extensively in professional books and journal articles I have written for mental health professionals. This work has led to my receiving invitations to teach these methods to my colleagues around the world.

Much of what I have learned about depression has led me to emphasize the role of social learning (i.e., what we learn through our interactions with others) in the onset and course of depression. During my career, I have seen depression subjected to intense scrutiny; I have seen professionals dedicate themselves to finding effective treatments; and I have seen the sharp rise in the prescribing of antidepressant medications, now the most commonly prescribed class of drugs in the United States as well as the most common form of treatment for depression.

But medications alone will not andcannotaddress the rising rates of depression. Paradoxically, medications may evencontributeto depression’s increased prevalence. How effective medications truly are is still being argued by mental health professionals, but there is increasing evidence that most of the therapeutic effect of antidepressant medications is attributable to the placebo effect, the response generated by a person’s expectations alone rather than a true therapeutic effect of the drug.Antidepressants may well have succeeded because of good marketing, not good science.

Even people who maintain an optimistic appraisal of the benefits of antidepressant medications must acknowledge thatno amount of medication can teach social skills. No amount of medication can teach someone to be a better or more empathetic listener or better source of emotional support for another person. No amount of medication can help someone develop friendships or a support group. No amount of medication can help isolated people who are wary of others become more approachable or skilled in their interactions. Simply put,drugs cannot solve the problems that lead many people into the pain and despair of loneliness and depression.

Depressed people, and those most at risk for depression, tend to view other people negatively. Do any of the following statements describe you?

• I am frequently hurt by other people.

• I am lonely or more socially isolated than I’d like to be.

• I can’t muster the energy it takes to be with others, call a friend or even just answer the phone.

• I generally avoid others whenever possible.

• I have a hard time developing and maintaining healthy relationships.

• I’m often angry at people.

• I am often disappointed by other people.

• I sometimes think people who are happy must be either naÏve or stupid.

All the negative thoughts, feelings, and perceptions about other people you may have right now don’t just work against them, they work againstyou. By using the practical tools in this book, however, you can change how you relate to others and how you relate toyourself. The positive psychology of bringing forth your best self through your relations with others is a clear path to feeling better.The research makes clear that people who recover from depression have actively learned a variety of new skills that can help them better build the lives they want.

This book has a simple theme running through it:positive and healthy relationships are vital to a sense of well-being. This simple point is extremely complex in its implications. Just telling you how important good relationships are doesn’t give you instant access to the skills you need to actually have such relationships. Thus, the emphasis in this book is on helping you understand the links between how you think, the choices you make, the behaviors you engage in and their effect on the quality of your relationships with others, and the depression you experience.

Throughout this book, you will discover two types of exercises meant to help you acquire specific skills. The “Pause and Reflect” exercises encourage you to think about and develop a positive attitude or mind-set that is associated with overcoming depression. The “Learn by Doing” exercises provide structured, active means for developing a specific skill that can help you.

It is important that you become proactive in your recovery from depression. When people get better, it’s not by accident. It’s because they spent time and energy learning and practicing new skills in thinking, feeling, and relating that make the difference in their lives. The skills described here have made a positive difference to others and I will encourage and support you as you make your way through them. I hope you will be willing to experiment and try out new ideas and behaviors. When you approach people in your social world differently, you are likely to discover how quickly your life can improve as your relationships get stronger or you develop new and better relationships. Other people really can be a source of great pleasure and comfort, if you learn to co-create these characteristics in your relationships with them. Feeling good will be a welcome payoff for your efforts.

Michael D. Yapko, Ph.D.

© 2009 Michael D. Yapko