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Good Morning, Heartache

Depression is a daily reality against which millions struggle. Many have found a variety of strategies to help them not just survive, but thrive.

Last summer, Pata Suyemoto rode her bike from Boston to Cape Cod, 125 miles in one day. An educator who has taught everything from art to English to Reike, she's funny, she's intense, and she's passionate. Never a jock, three years ago she became a relentless road warrior, riding more than 6,000 miles the first year she took up cycling.

But she would not say that she has conquered depression. Instead, like many people who experience major depression—and there are roughly 15 million Americans who do—she has achieved a kind of delicate detente with it. She manages to live with the disorder, or in spite of it. She thinks of her depression as a recurrent illness; getting it under control demands time, creativity, and an open mind. It keeps her on her toes.

Untamed, her depression is truly ferocious. Suyemoto, 47, has been in and out of psychiatric hospitals since age 17. Ten years ago, there came a time she now refers to as the bottom of the abyss. She could hardly do her job. Mustering the energy to stand in front of a class took all her strength. After class, she'd shut the door to her office and crawl under her desk. She had a young daughter, and she was trying to write her dissertation. Then, her mother died. "I'd write a page, and cry for an hour, then write another page, and cry for another hour," she says now.

Eventually she found cracks of light in the darkness. Antidepressants didn't help much. Glimmers of hope came more from things she did. She wrote in a journal daily, even when she had to prop herself up in bed to do it. She finally found a therapist who knew how to deal with severe depression and trauma. "It was gradual, working things into my life," she says. "It was like weaving a net."

A decade later, she now cherishes a whole a list of things that help, her own personal portfolio of antidepressants. Artistic self-expression in the form of collage gives her a way to communicate the darkest feelings without getting stuck in them. Acupuncture—as often as five times a week—helps. She finally found a medication that works. She volunteers with the Massachusetts group Families for Depression Awareness, leveraging her own experience to help other people who are struggling with depression. Self-help books and tapes offer a reality check, as does a sense of spirituality that puts her troubles in context.

And then there's the bike. It's not just good exercise. It's also a way to test limits and learn when to push herself and when to play it cool.

Is she cured? No. But she has her life back.

"I still have dark times, but they don't consume me in the same way," says Suyemoto. She expects that she may have other bad times; for her as for many people, major depression comes in cycles. She is ready for it. "It's not that I'm free and clear," she says. "But in doing all these things, and weaving them into my life, I've created a much stronger net."

A lot of the news about depression these days is good: An arsenal of treatments now available allows many to lead a normal life in spite of the disorder. The best estimate is that 80 percent of people find substantial relief from their worst symptoms, which typically include persistent sadness, guilt or irritability, sleep and appetite disruption, and the absence of pleasure. "People do recover from depression," says Michael Yapko, a clinical psychologist in California who specializes in treating depression. "There are many pathways in, and there are many pathways out."

Getting there, however, is rarely easy. Few people find simple cures. Instead, they patch together many measures. "I hate it when people say, 'Just go exercise.' Or, 'Just take medication,' or 'Just' anything," says Suyemoto. "Everybody has to find their own path. Healing from depression is a not a universal thing. Everybody's going to be different."

Major depression is so common because a lot of different biological and psychological roads lead to the same place. A variety of switches get tripped—whether by genetic vulnerability, trauma in early life, chronic stress, disturbance of neurochemistry, or guilt-prone tendencies—and the end result is depression.

Given the diversity of causes, antidepressant medications alone are rarely enough. To successfully cope with depression, most people stumble onto their own idiosyncratic combination of lifestyle adaptations, therapeutic techniques, medications and mental adjustments. But the most successful approaches for the long term, says Yapko, all encourage you to take action in the face of a disorder that saps your resolve. "Eventually, if you're persistent, there's a high probability you'll find something."

First, It's Physical

For many people the process of gaining control over depression begins with physical changes. Researchers now know that depression is not just a mental disorder. It affects the immune system, the heart, and basic body functions such as sleep and appetite as well. So it only makes sense that a lot of people who successfully manage their depression are careful about what they eat and drink, how much they sleep, and how active they are.

Former Massachusetts state senator and attorney Bob Antonioni, for example, always makes time for hockey, bike riding, or swimming. "In the past if I was struggling I'd curl up on the couch—that's not good, because you become more isolated, and the isolation feeds the depression," he says. "Very often I find, if I go out and exercise, I'm better for it."

Now 50, he's been dealing with depression since his mid-30s. After his brother's suicide in 1999, it got worse. He was profoundly sad, and the depression also settled into his body. His chest constantly ached. Sometimes it seemed like his body was going into panic mode. At the same time, as a politician, he had a public image to maintain. "I'm supposed to be out and about, smiling," he says now. "I just wasn't able to. I'd go into withdrawal."

He now has a comprehensive strategy; Antonioni goes for regular therapy and takes an antidepressant. But other physical interventions are equally important. He doesn't drink anymore, except on rare occasions—not that he ever had a drinking problem, but the depressant effects of alcohol worsened his symptoms.

Sleep is his number one secret weapon. "Sleep makes all the difference in the world to me," he says. It's not always easy to explain to his aides and colleagues why he won't arrange early-morning meetings. So be it. "The adjustments come," he adds. "People are a lot more willing to be flexible than I might originally have given them credit for."

Mood and sleep share basic biological mechanisms, and, according to Yapko, the single most common symptom of depression is some form of sleep disturbance. Getting lots of sleep is crucial. The challenge is in admitting that you just may not be able to do as much as you want to—and then sticking to your guns, even when life throws drama or excitement your way.

Getting Through Despair

"I've found that I have to be careful or I crash," says Kathryn Goetzke, a 37-year-old entrepreneur who battles major depression. "You have to be pretty disciplined about it." Goetzke has her own business, Mood-Lites, which develops decorative lighting. She also founded a nonprofit, the International Foundation for Research and Education on Depression (iFred). Then her husband ran for Congress in 2006. Of course, she got involved in the campaign. "I thought I had it all under control," she says now. "I just took on way, way, way too much."

He lost, and for maybe six months afterward she struggled to do anything at all. The marriage ended, and sometimes money was very tight—two other major sources of stress. "I learned the hard way," she says. "I have to listen to my body. I can't be ashamed. The consequences are much worse, in the long run, if I ignore it."

Goetzke reached out to her mother and brothers, who "moved mountains" to help her through the worst times. When she was closest to the brink, they pulled her back. She found a good therapist and, when she couldn't afford therapy, she turned to support groups, augmented by long walks outside.

Now, she says, she feels pretty good. "I'm happy to be around," is how she puts it. But it still takes a lot of work. She quit drinking entirely, avoids eating too much sugar, gets plenty of sleep, and hikes, plays tennis, does yoga, or bikes almost every day. She relies on her dogs, and the encouragement of a weekly women's support group. She, too, takes medication.

What might have made the biggest difference, though, was inside her own head— a major psychological shift. Before she started grappling with depression, Goetzke was an escapist. Her father, also depressed, committed suicide when she was in college, and she was eventually diagnosed with posttraumatic stress disorder. She drank, and she had an eating disorder, two ways of blunting the bleakness that only made things worse.

Finally, in her 30s, she began to confront how bad she felt and actually learned to live with her feelings of despair. "I sit through my feelings of awfulness," she says. "I let myself fully experience the bad feelings, and then move it toward something positive." Mindfulness meditation, which derails the obsessive thinking that typically intensifies negative feelings, is also useful. In these ways, she has learned to accept herself—and that includes accepting the sorrow.

Being able to withstand feeling lousy has been important to her success. As a businesswoman, she has to endure constant rejection. Once, the head of product development for a major lighting company told her that she would never get her product into a store. Her Mood-Lites are now on the shelves of hundreds of Wal-Marts, as well as in spas and chiropractors' offices across the country.

Cognitive tricks and techniques may seem insubstantial against such a formidable foe as depression, but they work. Cognitive behavioral therapy and interpersonal therapy both focus on the future, teaching mental and emotional skills that challenge negative thought patterns and counteract feelings of helplessness and self-loathing.

"Psychotherapy gives you a toolbox of approaches to handle stress, which can elicit depression," says noted mood disorder researcher Dennis Charney, dean of the Mt. Sinai School of Medicine in New York. "Part of it is getting the right treatment, the right doctor, the right psychotherapist." The important question to ask a therapist, says Charney, is whether she or he is experienced in teaching techniques that work.

The Narcissism of Depression

Learning how to step away from your own thoughts and see them objectively is a technique that can short-circuit the downward spiral of despair. In her 20s, Gina Barreca was drowning in sadness and emotional turmoil. Small setbacks and difficulties regularly turned into huge cataclysms that took over her life. She cried constantly, for just about any reason. "I really think of myself in those early days as somebody blindfolded, walking underneath an emotional piñata with a bat," she says now.

Now a professor of English at the University of Connecticut, Barreca, too, eventually found a medication that helped. But she got better mostly because she learned to stop torturing herself. She fills up journals with feelings of self-loathing and misery—but that is where they stay. Over time, with the help of a smart, committed therapist, she figured out how to step around emotional chaos rather than stir it up.

Barreca rejects what she calls "the narcissism of depression," the mental habit of taking wretched feelings seriously and burrowing into them. Instead, she thinks of depression and sorrow as familiar demons who arrive as unwelcome visitors. They're nasty, and they wreck the place, but eventually they move on. Enduring them is part of life. "The hardest thing in the world to learn is a sense of humility in the face of this, that these things are going to pass," says Barreca.

Now 52, she doesn't sink into sadness, but she doesn't shy away from it, either. "I'm not bubble-wrapped," she says. "I still get furious. I still get incredibly sad." But when the tormented feelings well up, she does her best to go on with her life. She shops. She talks to friends. She goes for coffee or has a nice meal. "I do those things that actually make me feel better," she says.

Barreca has written seven humor books; her latest, It's Not That I'm Bitter, will be out in March 2009. She is a brilliant and witty writer. That's actually not as unlikely as it might seem. Finding the humor in things requires seeing them from an unexpected angle, a cognitive trick that is key to dispelling depression. "Pain plus time equals humor," says Barreca. "I've had both pain and time."

Making Light of the Darkness

There are many routes out of the isolation of depression. Both Bob Antonioni and Kathryn Goetzke turn to advocacy, going public to reach out to others and to cast off the shame. Pata Suyemoto creates artworks that express her emotional tumult. But there's something especially powerful about humor. It can connect through the terrifying darkness of the disorder, not in spite of it. Humor creates sparks of instantaneous intimacy, a rare gift for anyone—but particularly for those who feel hopelessly alone.

This unique power is the fuel for Victoria Maxwell's one-woman shows, Crazy for Life and Funny, You Don't Look Crazy. In her performances, often to mental health workers, psychiatrists, and patients, she tells the epic story of her experiences with bipolar disorder. The details are hair-raising. But in her telling, they are also hilarious.

Maxwell's bouts of depression began shortly after she graduated from college, although at first neither she nor her therapist realized quite what they were dealing with. She was binge eating and oversleeping, had trouble concentrating, and was consumed with self-hatred.

At the same time, she embarked upon a spiritual quest. On a three-day meditation retreat, a lack of sleep and food, combined with the silence and stillness, pitched her into mania. During a manic episode, some people become aggressive and others feel unstoppable; her euphoria took on a powerfully spiritual tone. She felt rapturous, like a limitless being composed only of love. But when, convinced she had transcended her earthly body, she began having visions of her grave, her parents took her to the hospital.

Maxwell left with a prescription, but soon quit taking her pills. She thought she was having a spiritual struggle, not mentally ill. During the next couple of years, she went through several more manic episodes, interspersed with horrendous depressions. Finally, one night she went running through the streets of Vancouver naked, looking for God, and got picked up by the police. A wise psychiatric nurse who recognized both Maxwell's spiritual hunger and her mental illness introduced her to a sympathetic psychiatrist who finally convinced her to seek help.

Medication quickly tamed her manic upswings, but the depressions took much longer to manage. At the age of 42, Maxwell now feels pretty stable. She is careful to sleep at least eight hours a night. Intense workouts kick-start her body when she feels slow. And she practices a version of the same technique that Barreca and Goetzke use. Following Buddhist writer Pema Chodron's counsel, she treats her depressions with "compassionate witnessing": recognition and tolerance. "I'm comfortable enough to invite those demons to come in," she says. "I don't resist them."

Performing also helps. She can connect with strangers, rather than feel ashamed of her mental illness. And the sense of love and joy that she felt during her manias still resonates. "It's really liberating to tell people you ran down the street naked, and were tied to a gurney," she says. "At the time, it was terrifying. But to be able to say that to an audience is freeing. To have people laugh with you because they relate is really powerful."

Maxwell considers her bipolar disorder "in remission," but she doesn't take her health for granted. If she's overwhelmed, she takes a day off. She still sees her psychiatrist. But it's no longer a constant struggle: "My life is more about my life than my illness, which is a godsend."

Barreca, Suyemoto, and Maxwell all say they wouldn't wish what they've been through on anyone else. But they're not altogether sorry it happened. Depression required them to learn what many people, depressed or not, never find out: the knowledge that they can get through the worst of times. And after the worst times were over, they found out, it is possible to have a sense of perspective about it all—even to laugh. "Laughter is survival," says Barreca. "It's not because life is easy. It's something you wring out of life. You make joy."