I'm Still Human: Understanding Depression With Kindness (Expanded Edition)

I’M STILL HUMAN

Dr. Phang Cheng Kar (M.D.)

Reminder

This is a book on mental health, not a religious book. Any reference to Buddhism, it is general in nature and only reflects the universal value of kindness.

This book should not be used as a substitute for consultation with medical or mental health professionals if you’re suffering from depression or any other psychological illness.

Online versions of this book are available in 3 languages at the following link: https://www.mindfulgymalaysia.com/post/i m still human

Comments by reviewers

This book has come together for all of us to learn about life accepting, loving and living meaningfully. All three parts of the book describe the core components of a human being: Part 1, “Mind, knowledge, understanding,” Part 2, “Heart, tears, pain, acceptance,” and Part 3, “Coming together, kindness and love will prevail.” I have experienced tears, love and healing as I was reading this whole book. Thank you Cheng Kar, Jasmine and everyone. This book will reach deep into the hearts of many people, as it speaks the truth about love and life.

Ms. Low Mi Yen

Clinical Psychologist,

Director of Turning Point Integrated Wellness; Vice President, KL Buddhist Mental Health Association.

This is an excellent book, with very useful and practical tips for people suffering from depression, as well as for their caregivers. Dr. Phang is correct in identifying kindness as the key to understanding depression. Patients with depression need to be kind to themselves in order to overcome this illness. Family and friends need to exhibit kindness in dealing with patients suffering from depression. Jasmine’s journey through depression is very touching and brings out a positive message - there is light at the end of the tunnel, and people with depression should seek help and can recover. This book also provides essential information on activities that are conducted for “understanding depression with kindness.” All these efforts are very practical and useful in giving hope and support to caregivers and patients with depression who are looking for help, kindness and understanding.

Professor Dr. Sherina Mohd Sidik

Family Physician, Universiti Putra Malaysia.

Jasmine had shown great courage in sharing her seemingly endless suffering from depression during the past two years. She knows she is not the only one facing the agony of depression. With her readiness to reveal her struggle and ways of coping, it will encourage those who suffer in silence to

come forward and seek help. In this book, Dr. Phang has given a comprehensive yet easy to understand guide for those who need help and are offering help to the depressed.

Ms. Yeoh Kim Yeok

Panel Counselor, National Population & Family Development Board; T-Lotus Support Group Coordinator.

The book is well written by a "clinically passionate heart" psychiatrist to educate patients to understand depression and have better coping skills in life. I also recommend this book for clinicians or therapists to improve their communication skills in dealing with patients and their families.

Dr. Firdaus Mukhtar

Senior Lecturer, Clinical Psychologist & CBT Therapist, Universiti Putra Malaysia.

Great book! Extremely well written! The book is simple, precise and practical. It provides clear guide for clients with depression, their family members, helpers and general public. A very much needed book in this challenging era. Congratulations and well done!

Dr. Lee Chee Siang

As the saying of the Maori people goes, “What’s the most important thing in the world? It’s people! It’s people! It’s people!” Thank you to Dr. Phang for this very informative and ‘people oriented’ book I’m Still Human. Certainly, he is a psychiatrist who sees beyond his patients’ illness and reaches out to them with his compassionate heart. Most importantly, he guides them to be kind to themselves while coping with depression. Jasmine’s transformation through kindness is a wonderful lesson for us. I’m delighted to say that this is a must-read book for all.

Dr. Tee Bee Chin

Psychiatrist & Head of Department, Department of Psychiatry, Kulim Hospital, Kedah.

The author uses simple yet illustrative descriptions to guide the readers in understanding the ‘what and how’ about depression. I like how he incorporates information and insights about depression both from professionals’ and patients’ points of view. This enables readers to better understand depression from different perspectives. It also has useful suggestions on dealing with depression and the depressed. I must congratulate Dr. Phang on another of his great piece of work. I would highly recommend this inspirational book to you.

Ms. Liu Moy Yub

Clinical Psychologist/Clinical Supervisor, Centre for Psychological & Counseling Services, HELP University.

Depression is a complicated disease and not merely an emotional problem. It takes special skill and talent to dissect this complicated disease into something simple and practical; Dr Phang has done it very well. He can read the minds of people in our community and address their concerns about depression. He is kind, honest and humble in sharing information reading the book is like having a good friend sitting beside and guiding us. There’re many stories and case reports in which most of us could identify with. I am sure that this book will benefit anyone who is kind enough to spare some time reading it. I will definitely get a few copies of the book and keep one for myself.

Dr. Hazli Zakaria

Senior Medical Lecturer & Psychiatrist, Universiti Kebangsaan Malaysia Medical Centre.

PART 1:

Understanding depression

• What is depression? 1

• What depression is not 3

• What are the symptoms of depression? 4

• How painful is depression? - 10

• Depression and suicide 11

• How common is depression? - 12

• What should I do if I or somebody has depression? 13

• Who should I consult for professional help? - 16

• How can I get help from mental health professionals? - 20

• 12 ways to encourage a person to seek help - 26

• What is expected in the psychiatrist’s consultation room? - 30

• What to expect from a counselor or clinical psychologist? 32

• What is the cause of depression? - 35

• How is depression treated? 40

PART 4:

Jasmine’s journey of recovery

Foreword I

It is an honor and privilege to write this foreword. I have come to know Dr. Phang Cheng Kar as a kind and compassionate Buddhist psychiatrist who has done Dhamma work for more than ten years, in particular the formation of the Kuala Lumpur Buddhist Mental Health Association (BMHA). This book adds to the list of books, CD’s and products Dr. Phang has generously produced for the public. He helps us to understand mental illness and to find relevant information to address our suffering.

This book provides a deep perspective of the multidimensional aspects of depression. It also covers the various treatments involved. A particularly useful part of the book is a list of ways to encourage someone with depression to seek help. It also demystifies what happens in the consultation room of a psychiatrist. For those who suffer from depression, the story written by a patient of her journey from hopelessness, suicidal thoughts and self-harm to gratitude for her treatments, new discoveries and final full acceptance of her illness, is most touching.

An exceptional aspect of this book, not available in most self-help books on depression, is Part Three. This section helps the depressed to cultivate kindness towards themselves. The depressed need not label themselves as weak or feel alone. They can learn to

forgive themselves and others by practicing compassion. This is a Buddhism-influenced way of transforming depression into wisdom and it is practical and most beneficial during the recovery phase. This should also assist in the prevention of relapse.

Also, 20 Frequently Asked Questions (FAQ’s) used during depression treatment will help many patients and their relatives. The DVD attached to the book consisting of a forum on depression presented by BMHA with Venerable Kumara, clinical psychologist Ms. Low Mi Yen and three patients is worth viewing. Finally, a further reading list is thoughtfully added to complete this comprehensive book.

This book will help not only those who suffer depression, but also their relatives and professionals in the field.

Dr. Tan Eng Kong (MBBS, MPM, FRANZCP)

Consultant Psychiatrist & Analytic Psychotherapist; Director of Metta Clinic, Sydney, Australia;

Founder President of YBAM (Young Buddhist Association of Malaysia) & AABCAP (Australian Association of Buddhist Counselors & Psychotherapists); First Director of Training, Buddhism & Psychotherapy Professional Training Course of AABCAP;

Former Chairman of Training, Psychoanalytic Psychotherapy Association of Australia (PPAA).

20th August, 2012.

Foreword II

When Cheng Kar asked me to write a foreword for his latest book, I immediately accepted the invitation as I knew this would be a task that I would do with great pleasure. I have known Dr. Phang for more than five years now. I first met him while I was a visiting professor at the National University of Malaysia (UKM), and he was in his final year of training as a psychiatrist. We shared many common interests, especially mindfulness based psychotherapy and evidence based practices in psychotherapy. Our journey in mindfulness and psychotherapy, in particular Cognitive Behavior Therapy (CBT) has expanded our application of the Buddhist concept of mindfulness into “meta mindfulness” in psychotherapy. The expanded concept of meta mindfulness in psychotherapy provides a good ground for this book - I’m Still Human: Understanding Depression with Kindness.

Dr. Phang Cheng Kar (M.D.) is a psychiatrist and also a practicing Buddhist. This kind of combination is very unique indeed among mental health workers. This uniqueness is clearly reflected in the way he helps people suffering from mental health problems. It also allows him to produce many practical books, useful DVD’s and self help materials for people with mental health problems and for the general public to prevent mental suffering. This book - I’m Still Human - is another excellent addition to his achievements.

The book suggests that depression is treatable and people with depression can, and in fact, should get help early. Another important part is that it demystifies not only depression itself, but also the way to find and communicate with mental health professionals in Malaysia. A case study written by a former patient has enhanced the usefulness of this book. Perhaps the greatest strength of this book is Dr. Phang’s use of kindness and compassion as tools for combating depression. This combination of Eastern (Buddhist) and Western (psychiatry) knowledge in combating depression is natural given Dr. Phang’s background training and current practices. I am optimistic that this book will be well received in Malaysia and that many people will benefit from it. Both sufferers of depression and their caregivers will find this book easy to read and very useful in helping them deal with depression.

We started our journey five years ago and I am sure our journey will continue into the future. I have benefited from our journey and I am sure many people will benefit from this book.

With Metta, Tian Po Oei (Ph.D., FAPS.)

Emeritus Professor of Clinical Psychology, The University of Queensland; Director, CBT Unit, Toowong Private Hospital, Brisbane; President elect, Asian Cognitive Behavior Therapy Association (ACBTA). 26th August, 2012.

Dedication

This book is joyfully dedicated to all my patients, especially Jasmine, who suffer from and cope with depression. Thank you for sharing with me all the experiential knowledge about depression. Without that, this book will not feel so ‘real.’ Many people are unaware that they suffer from depression. This book unmasks the many myths about depression. The book is published for free to benefit those struggling with depression. I’m sure that it will help many people: the depressed, their caregivers, relatives, and friends, as well as readers in general.

Prevention of depression is better than cure. In this fast changing, a highly competitive society where interpersonal relationships get colder, people are increasingly stressed out. Furthermore, many people have an unhealthy lifestyle that predisposes them to depression. Therefore, this book also introduces ways to reduce stress, such as relaxation exercises and healthy food habits. I wish to print this book for free distribution and dedicate it to every reader who comes across this book. By the power of this good deed, may all beings be free from depression and live happily.

Yours Kindfully, Dr. Phang Cheng Kar (B.Sc., M.D., Dr.Psych.)

Preface

I wrote this book with Jasmine to commemorate my 10th year of service, caring for people with mental health disorders. Wherever I go, there're many people with emotional suffering. People who seek help in my clinic for depression are also increasing. Therefore, it’s time that we have a simple and practical book to guide those struggling with depression.

Many books have been written on depression. This book is unique in three ways: 1. It focuses on the practical aspects of depression in a local Malaysian setting, e.g. how to encourage a depressed person to seek help, 2. It emphasizes the humanistic aspects of depression, e.g. how to cultivate kindness for coping with depression, and 3. It has an experiential part by Jasmine, our ‘depression journalist,’ who brings you through her depression and recovery journey.

This book isn’t a comprehensive textbook on depression. But it will be a kind and useful companion to those who suffer from or care for people with depression. You’ll notice that I've written this book in a conversational style. It’s intended to be that way so that it’s more personal and inspiring. If you’re ready, kindly turn over to the next page, and the book will soon be ‘reading you’…

Understanding depression…

Albert Camus

What is depression?

Depression is a serious psychological illness which affects the way we THINK, FEEL and BEHAVE. It’s more than just occasional low moods, which is part and parcel of life. In depression, the feeling is more intense, persistent and it interferes with our functioning at work and home.

It’s important to understand that depression is an illness just like diabetes, hypertension or cancer. This right understanding facilitates early treatment and recovery. Depression is an illness because:

• There’re recognizable signs and symptoms (page 4).

• There’re known causes, e.g. genetic, hormonal, excessive stress.

• There’re associations with biological changes in the body, e.g. lack of serotonin for nerve transmission in the brain.

• There’re mental health professionals, e.g. psychiatrists and psychologists who specialize in the treatment of depression.

• There’re psychological tests for depression, e.g. Beck Depression Inventory.

• Depression can be treated with medicines, e.g. antidepressants.

The names used by doctors, scientists and psychologists for referring to depression as an illness are: “Major Depressive Disorder,” “Major Depression,” or “Clinical Depression.”

Depression damages the functions of cells in the brain (neurons)

What depression is NOT!

•

• It’s NOT pretending or faking.

• It’s NOT laziness or a bad habit.

• It’s NOT a sign of weakness.

• It’s NOT due to spiritual disturbance or charm.

•

It’s NOT something that you can easily snap out of.

It’s NOT that you’re crazy or psycho.

•

It’s NOT occasional sadness or stress like Monday morning blues.

The main features of depression are a persistent feeling of sadness, loss of interest in activities, and tiredness. Below is a depression checklist to find out if you or someone you know may have depression (other symptoms of depression are in the checklist). For more than 2 WEEKS have you? Tick √ in if ‘Yes’ 1. Felt sad, down or miserable most of the time? 2. Little interest or pleasure in doing things?

6. Moving or speaking so slowly that other people could have noticed OR being so fidgety or restless that you have been moving around a lot more than usual?

How does a depressed mind think?

People who are depressed often have these negative thoughts:

I hate myself

Interestingly, almost everyone who is depressed has similar thought patterns. That’s what I repeatedly hear in my clinic the ‘lyrics’ of depression. It may be in a different language - but the content is the same. This reinforces the fact that depression is an illness with predictable patterns of thinking, feeling and behaving.

physical symptoms of ‘stress’ which often (but not necessary) come with depression. The word ‘stress’ is a general term to refer to any mental and/or physical tension. When stress is excessive, due to whatever reasons (stressors), it can lead to depression, a well defined and specific psychological illness. That’s the relationship between stress and depression depression is more than just stress.

Due to the physical symptoms, people who are depressed often go ‘doctor shopping’ consulting various medical specialists for investigation. This is usually followed by the typical explanation, “There’s nothing wrong with you physically,” or “Mmmhhh…this could be due to psychological factors,” before referring you for depression treatment. Depression is a ‘systemic disease’ – it affects the brain and various organs in the body. It’s associated with neurotransmitter (brain chemical), neuro-hormonal (blood chemical) and neuroimmunological (immune system chemical) changes. That’s how it affects physical health and leads to ‘doctor shopping.’

Though the basic symptoms of depression are the same, it has unique features in different populations (Table 1):

Table 1: Unique features of depression in different populations

Population

Special features of depression

• Tend to perceive it as a sign of weakness.

Men

• Less likely than women to acknowledge and express the feelings of sadness or hopelessness.

• They tend to complain about fatigue, irritability, sleep problems, and loss of interest in work and hobbies.

Women

• More likely to appear in the form of violence, reckless behavior (e.g. reckless driving), and substance abuse (e.g. alcohol, amphetamine).

• Higher risk of completed suicide than women.

• Associated with hormonal factors, e.g. premenstrual syndrome, postpartum depression, and perimenopausal depression.

• More likely than men to have excessive guilt, sleep too much, overeat, and gain weight.

• There is a risk of ending life together with the children.

• Irritability is the predominant symptom. Unexplained body aches and pain are also common.

Children & Adolescents

Elderly

• ‘Bad’ may actually be sad depression manifests in the form of disciplinary problems, e.g. truancy, smoking, drug abuse.

• Often associated with bereavement, loneliness, health problems, and loss of independence.

• Tend to complain more about the physical rather than the emotional symptoms of depression. Irritability is also common.

For further assessment or if you ’ re concerned about any of the mentioned symptoms, please consult a medical doctor or mental health professional (i.e. psychiatrist, clinical psychologist, counselor). Remember, depression is treatable and effective treatments are available. The earlier you seek help, the better the outcome.

How painful is depression?

It’s not uncommon to hear patients with depression express that the pain of depression (e.g. no mood, hopelessness, tiredness, restlessness) is worse than the pain of any physical illness. Some even physically hurt themselves, e.g. cut their hands with a blade to induce physical pain; the physical pain distracts them from the emotional pain. According to World Health Organization (WHO), depression will be the 2nd most disabling illness by 2020. Because of the tremendous suffering associated with depression, it’s not surprising that some people choose to commit suicide to end depression. Please don’t do that you don’t need to continue suffering. Depression is a treatable illness get treatment early. Soon, you’ll be well and moving on with life.

Depression and suicide

If I had no sense of humor, I would long ago have committed suicide Mahatma Gandhi

According to the National Suicide Registry, there’re on average two cases of suicide in Malaysia every day. From overseas studies, more than 90% of people who die of suicide have clinical depression or another mental illness (e.g. schizophrenia, substance abuse). Having major depression is a risk factor for suicide. Up to 50% of people with depression have suicidal thoughts. About 15% of people hospitalized for depression kill themselves. Other risk factors of suicide include previous suicidal attempts, family history of mental illness or suicide, being male, substance abuse, chronic physical illness, and keeping firearms at home. Warning signs that someone may be thinking about or planning to commit suicide include:

• Making statements like, "It will be better if I’m no longer around," or “Soon, I’ll be gone…”

• Making preparations to die, e.g. making a will, indicating preference for one’s funeral, giving away valuable possessions.

• Tendency towards unnecessary risky behavior that could lead to death, e.g. driving at high speed and without seat belts.

• Sudden and unexpected switch from being very sad to very calm or happy (relieved as decision has been made to die).

Suicide is preventable. Early recognition and treatment of depression prevents suicide you can make a difference.

How common is depression?

Depression affects about 10% of the Malaysian adults (1 in 10 persons). Depression affects people at all ages; it’s 2-3 times more commonly reported in women than men. Despite being so common, there is relatively little awareness of depression; as many as two thirds of people with depression don’t realize that they have depression. As for those who realize, there’s often delay in appropriate treatment due to a social stigma on mental illness. So, you ’ re not alone be kind to yourself and seek help immediately.

What should I do if I or somebody has depression?

It can be difficult to take the first step in seeking help. If you think you or someone you know has depression, talking to a general practitioner or family doctor is a good place to start. A general practitioner can discuss treatment options and can do a medical assessment to rule out whether other conditions, e.g. thyroid disorder may be responsible for a person’s symptoms.

If you ’ re concerned about someone with depression, it can be hard to know what to say or do. Here are some tips:

• 1. Talk to the person about how they’re thinking, feeling and their experiences. But try to talk about something casual first (e.g. weather, news, family, TV) before going into their problems. Talking about their problems may be intimidating especially when trust and rapport aren’t established yet.

• 2. Lend them a pair of listening ears. Sometimes, a person may not be seeking advice, but just needs to express his concerns. Be empathetic, and just let them ventilate their thoughts and

feelings or cry (you can offer tissue paper). At times, giving advice, especially prematurely, may invalidate their feelings, make them feel more useless, not understood and cause them to further withdraw emotionally.

• 3. Use open ended statements such as, “So, tell me about…how…and what happened after that?” Show in your facial expression, body posture and tone of voice that you really care. These ways of asking require more than a “yes” or “no” answer and can be a good way to facilitate conversation.

• 4. You may not need to talk much. You can easily facilitate the conversation by ‘M.I.Y.A.O.W?’ “Mmmmm… I see… Ah ha… Ya, it’s horrible… Oh, like this… Wow, you’re so strong… What happened after that? What do you plan to do?” Feel free to change the sequence of M.I.YA.O.W?, while nodding intermittently to indicate that you’re caring and paying attention.

• 5. It’s unnecessary to pressure yourself to give a solution; after all, not all problems have a solution. Often just spending time with the person is good enough to convey the message that we’re trying to understand and care – that’s already therapeutic.

• 6. If the person refuses to talk, respect the decision and get back to him or her at another time. You may say something like this,

“I know that you’re going through a tough time and don’t feel like talking now. But I wish to let you know that I care for you no matter what happens. When you feel like talking or think there’s something that I can do for you, feel free to contact me…”

• 7. Due to the nature of depression, some may talk in a way which unintentionally annoys you negative, repetitive, blaming, stubborn. Remember, that’s part of the illness (they’re suffering yet can’t get it out) take deep breaths, relax and be patient. When you ’ re calmer, you can respond better; if not, you’ll probably react negatively and get sucked into their depressive rumination.

• 8. Take good care of yourself. Supporting someone with depression can be very demanding and tiring. So, make sure that you take time off to look after yourself. Otherwise you too may end up with depression. When you ’ re mentally refreshed, you can care more effectively be kind to yourself while caring for the depressed.

Who should I consult for

professional help?

As it’s much easier to access the service of a general medical practitioner or family doctor, this is a very good start for those with depression. All general practitioners know about depression.

They can do an initial assessment and advise you on the treatment plan. If the depression is mild, they may choose to treat you themselves in the clinic. If the depression is more severe, they’ll probably recommend you to a mental health professional (psychiatrist, clinical psychologist or counselor) for further assessment and treatment.

Who are you referred to? When depression is serious or requires more thorough assessment, it’s more helpful to consult a psychiatrist (a medical doctor specializing in psychological medicine). This applies in the following situations:

• Elderly (> 60 years old).

• Having multiple medical problems, e.g. stroke, diabetes.

• Having suicidal thoughts, plans or attempting to commit suicide.

• Have psychosis, e.g. hearing invisible voices, religiously preoccupied, suspicious of others.

• Very poor appetite, lose a lot of weight, not drinking.

• Significant impairment in social and occupational functioning, e.g. unable to work or hiding in the room most of the time.

• Disorganized behavior, e.g. talking nonsense, gesture inappropriately.

• Verbally abusive or physically violent, e.g. throwing things and hitting people.

• Medicines or medical certificate (MC) for leave are required (as counselor or psychologist won’t be able to provide this).

When depression is less severe, clinical psychologists or counselors can offer various types of effective talk therapies, e.g. personcentered therapy, problem solving therapy, marital therapy, interpersonal therapy, relaxation training, and cognitive behavior therapy. One main difference is that they don’t prescribe medicines like psychiatrists.

If you ’ re not sure of who to consult, get advice from a general practitioner for a start. Don’t worry too much about consulting the right person. Clinical psychologists and counselors are able to

recognize severe depression and recommend you a psychiatrist for more intensive treatment. On the other hand, psychiatrists often work with clinical psychologists and counselors for the benefit of patients, especially in terms of talk therapies.

Who to consult also depends on the available of services. Over all, as of 2022, there’re very few psychiatrists (about 500) and clinical psychologists (about 400) in Malaysia. There’re more registered counselors (about 9500).

Due to limitation of resources, we can’t always have the best; but we can always make the most of whatever is available.

Here’s a simple description of the overlapping roles of various mental health professionals in Malaysia:

• Psychiatrist: a medical doctor who specializes in the diagnosis and treatment of mental illness, e.g. depression, schizophrenia, bipolar disorder.

• Clinical psychologist: a psychologist (with at least a master degree in clinical psychology) who specializes in the assessment and treatment of mental illness (including depression).

• Registered counselor: a person (with at least a bachelor degree in counseling and is registered with the Malaysian Counselor Board), who is specially trained to attend to your psychological needs, e.g. work stress, relationship issues, which may or may not be associated with depression.

For a list of mental health and psychiatric services in Malaysia (psychiatrist, clinical psychologist & registered counselor), you may go to the links below: Directory of psychiatric services*:

https://mmha.org.my/media resources#sppb tab2 1

Directory of counseling services*: https://mmha.org.my/media resources#sppb tab1 2 Directory of clinical psychology services: https://www.mscp.my/clinical-psychologist-registry *Source: Malaysian Mental Health Association (MMHA).

How can I get help from a psychiatrist?

Here’s what you can do if you wish to get help from a psychiatrist. If you prefer an early appointment (within a day or week), a preferred day and time for consultation, and a regular doctor present each session, I suggest that you go for private psychiatric services. Referral letters aren’t necessary.

If you prefer treatment at a more affordable professional fee, I suggest that you go for psychiatric services in government hospitals. All major government hospitals have psychiatric services. You’ll need to bring a referral letter* from a general practitioner or family doctor to get an appointment date – you may not be seen immediately unless the situation is serious and urgent attention is needed. The waiting period depends on the patient load of the hospital; it can be up to 1 2 months.

* A referral letter is a letter which is usually written by a medical doctor, recommending you to seek further help from more specialized medical service. If the referral letter is from a government hospital or clinic, the fee for the first consultation in government psychiatric service may be lower.

In government hospitals, you may be attended to by a medical officer in psychiatry instead of a psychiatrist. A medical officer in psychiatry is a qualified medical doctor who assists psychiatrists in the hospital. Don’t worry if you ’ re not attended by specialists; they always work as a team to attend to your needs.

If your friend or family member is having severe depression, needs urgent attention and may need ward admission (e.g. suicidal, endangering others, not eating or drinking), it’s advisable to bring them to the accident and emergency (A & E) department of the nearest government hospital. A referral letter isn’t necessary. It may not be helpful to bring them to a private hospital as most in Malaysia don’t have in patient psychiatric service (psychiatric ward) at the moment. It’s OK to consult a private psychiatrist first (for convenience sake), followed by a transfer to government psychiatric services. This is often the case when one needs to save cost for consultation and medicines. No problem, but don’t forget to request your private psychiatrist to write you a referral letter with your diagnosis (name of your illness) and the medicines that you ’ re on. Not all the medicines that you ’ re taking are available in government hospitals. But replacement with similar medicines is usually available. Table 2: Private versus government psychiatric services.

psychiatric services GOVERNMENT ** psychiatric services

1. Earlier appointment date.

2. Referral letter isn’t necessary.

3. You get to choose your doctor (e.g. one who speaks the same language). You’ll be attended to by the same doctor each visit.

4. You’ll be attended to by a psychiatrist.

1. Later appointment date unless for serious or emergency cases.

2. Referral letter is necessary.

3. You may not get to choose your doctor and may be attended to by a different doctor every visit.

4. You may be attended to by a medical officer who assists a psychiatrist.

5. Consultation and treatment fee is more expensive. 5. Consultation and treatment fee is much cheaper. 6. Psychiatric ward isn’t available if hospitalization is required. 6. Psychiatric ward is available in main hospitals if hospitalization is required. 7. Service is usually only available during day time.

7. Service is available 24 hours. After office hours, psychiatric services are still available but at the accident & emergency (A & E) department.

* Private psychiatric services in Malaysia: https://psychiatry-malaysia.com/public/list-ofpsychiatric services/private practice/

**Government hospitals with psychiatric services in Malaysia: https://psychiatry malaysia.com/public/list of psychiatric-services/government-hospital/ Source: Malaysian Psychiatric Association (MPA).

• Qualification of the therapist (counselor, clinical psychologist, specialization, e.g. family therapist, play therapist, etc)

• Length of the session (i.e. first session, follow-up sessions), charges and payment method (i.e. payment by session or package, cancellation policy, etc.)

• Others: availability of trainee counselor or clinical psychologist, discount for services, location of the place, facilities of the centre (e.g. car park). 2. Choose the service after thorough consideration. It’s important to ask yourself the 4 ‘W‘s & 1 ‘H’ questions:

• Which setting are you comfortable to receive service in? NGO’s, government hospital or private centre?

• What kind of service are you looking for? Marital therapy, family therapy, cognitive behavior therapy, etc?

• Where is the place for therapy? It’s important to find a place which is easy to access in order to increase the probability of you attending therapy.

• Who would you like to see? Any preference for gender, age group, ethnic, language, expertise, years of experience, etc

• How much is the consultation fee? How much can you afford to pay? Any alternative which is free or more affordable?

3. Register yourself for the service. Taking action to step out and get help is the biggest step in healing. After the registration, give yourself a big hand for your courage to invite positive changes to your life. If you ’ re seeking counseling or psychotherapy at a government hospital or clinic, you may need to get a referral letter from a medical doctor for registration of service.

4. Schedule the first appointment. Normally, your therapist will contact you to make an appointment for the first session via phone or emails. If you don’t receive a call within one month after your registration, you may call to check on the progress of your registration. While waiting for the first appointment, it’s normal to have anticipatory anxiety. Take repeated slow deep breaths and assure yourself, “Don’t worry too much, you ’ re on your way to recovery it will be a fruitful learning experience.”

5. Attend the first appointment. Be clear on the location of the centre and go out earlier to avoid unpleasant situations, e.g. late due to traffic jam. Bring the necessary documents (i.e. identification card) for the administrative purpose. Prior to seeing the therapist, you’ll be guided to fill out some forms (i.e. basic information about yourself, consent for service, psychological questionnaires). You can check with the administrative staff if you have any concerns. When your name is called, therapy will soon begin…Yeah.

12 ways to enc ourage someone with depression to seek help

• 1. Repeatedly assure them, “Having depression doesn’t mean that you ’ re weak. It probably means that you have been strong for too long we care for you, we want you to be happy, let us help you.” Reassure them that willingness to seek help is a sign of bravery courage isn’t the absence of fear; it’s acting in spite of fear.

• 2. Having someone in the family or community whom the person respects and trusts, e.g. pastor, monk/nun, ‘ustaz/ustazah (Islamic religious teacher), family doctor, good friend to encourage them will likely make the session more successful. Repeatedly and consistently convey the message, “Depression isn’t weakness; it’s an illness.”

• 3. Share with them that there’re many people who have depression, including many celebrities and successful people. If you have gone through depression yourself, you may also share your experience if you ’ re comfortable with it. Here are two You Tube clips on famous people with depression: - Celebrity depression http://www.youtube.com/watch?v=ci 2GDoGWHU Idols who suffered depression & anxiety https://youtu.be/8VsPMZmnXHk • 4. Seek help from a general medical practitioner or family doctor first. Due to social stigma, this is more acceptable than consulting a mental health professional. Seeking help from a counselor may also be more acceptable than a psychiatrist or clinical psychologist. • 5. Seeking help from a private mental health professional may be more acceptable because you get an earlier appointment (within a day or week), a preferred day and time for consultation, and the availability of a regular doctor in each appointment. • 6. Expose them to pamphlets, books, magazines, talks, CD’s, websites, etc. that are related to depression and mental health. Hopefully they will have a better understanding of depression and are willing to seek help soon.

• 7. It’s OK not to use the word ‘depression.’ Let them know that we ’ re seeking help for sleep difficulty, poor appetite, body aches, tiredness, poor concentration, etc which are part and parcel of depression. Also consider the use of other more acceptable terms, e.g. ‘emotional flu’ or ‘severe stress,’ or ‘mood disorder.’

• 8. Educate them that they will not be sent to a psychiatric institution, e.g. Hospital Bahagia (previously known as Hospital Tanjung Rambutan). The majority of patients in Hospital Bahagia suffer from schizophrenia not depression. Schizophrenia is a much more serious mental illness characterized by hallucinations (e.g. hearing invisible voices), delusions (e.g. false belief that people want to harm them), disorganized speech (e.g. talking non-sense), and disorganized behavior (e.g. walking around naked).

• 9. Remind them that whatever they tell the doctor is kept strictly confidential. No clinical information will be released without a patient’s consent, unless in emergency situations (e.g. suicide). Be aware of social stigma - don’t unnecessarily reveal information to friends, family, neighbors or colleagues.

• 10. At the moment in Malaysia, no insurance policy covers psychiatric treatment. If financial constraint is a concern, seek help from mental health services in government hospitals. The total

consultation and medication fee in Ministry of Health's hospitals (e.g. Kuala Lumpur Hospital, Kajang Hospital) is RM5 for follow-ups and FREE for first visit; but referral letter from a government doctor is needed. It's more in University's hospitals (e.g. UKM and UM Medical Centre) - about RM 50. If financial constraint is still a concern, one may seek help from the hospital's medical social welfare service through the doctors in the psychiatric department. Try to convince a person with depression that having depression and not being able to work is more ‘expensive’ in the long run.

• 11. Help to arrange appointments; remind them when the appointment date comes. Provide transport and accompany them for the consultation. Help them to relate their experience to the doctor, collect medicines, get the next appointment date, and remind them on treatment compliance. These may seem simple but require enormous effort when one is depressed. Depression is painful try to make it easier for them.

• 12. Be kind and understanding to them. Try to gently explore the reasons for not seeking help. The reasons could be individual, e.g. believing that it’s due to punishment from God. It could also be a perfectly understandable one, e.g. unpleasant experience with previous psychiatrist. When we understand, we ’ re able to care more effectively.

• 5. Help you to identify the factors that contribute to your depression.

• 6. Do physical examinations and blood investigations* if necessary, e.g. a thyroid hormone disorder may contribute to depression.

• 7. Educate you and your friend or family on depression.

• 8. Ask about your previous treatments for depression.

• 9. Propose a treatment plan medicines or/and talk therapy.

• 10. May monitor your progress with certain psychological questionnaires*, e.g. Patient Health Questionnaire (PHQ-9) & Generalized Anxiety Disorder (GAD 7).

*Not all psychiatrists do that or it may not be necessary at times.

This entire session may take up to between 30 minutes to an hour, depending on how busy the clinic is. Subsequent clinic follow-ups will usually take a shorter time. Sometimes, more than one session is required to complete the above-mentioned. It’s OK for you to cry or break down. Your psychiatrist will know what to do to support you. Have a good cry and you’re on your way to recovery. It’s also OK if you’re not clear about your experience it’s your psychiatrist’s role to guide you – don’t worry, it’s going to be fine.

What to expect from a counselor or clinical psychologist ?

These are some of the things that you may expect from your counselor or clinical psychologist depending on your needs and types of therapy:

• Help you to explore and understand your problems. • Help you to understand your depression better. • Perform some psychological tests, (e.g. personality test) to help you know yourself better. • Recommend some dietary or lifestyle changes, e.g. exercise. • Teach you certain relaxation exercises, e.g. deep breathing. • Teach you certain skills, e.g. communication, time management skills, parenting. • Guide you in solving your problems, e.g. academic stress. • More specialized therapy, e.g. grief counseling, cognitive behavioral therapy, interpersonal psychotherapy, art therapy. As counselors and clinical psychologist aren’t medical doctors, they will not: • Give you medicines • Give you medical certificates (MC) • Perform medical tests, e.g. urine, blood, X Ray • Do a physical examination, e.g. check your heart

Kindly be reminded:

1. Be open and honest with your therapist. Therapy isn’t about listening to your therapist, like attending an educational talk. It’s an active process whereby both of you need to work together to address your issues. Therefore, it’s important to address your concerns about the therapy process if you experience any discomfort.

2. Follow up on the therapy session. Consistent attendance in therapy is important to enable an effective and collaborative working relationship with your therapist. Update and discuss your progress from time to time. Therapy is a process that requires commitment from both you and your therapist.

3. Terminate the therapy session. A final session can be suggested, either by you or your therapist, after achieving the purpose of the therapy. At times, earlier termination session can be suggested in order to accommodate you or your therapist’s needs. In the termination session, your therapist will facilitate you to review the therapy process and provide resources or recommendation for your self help. If you need ‘booster’ (refresher) sessions later, you may get a new appointment date you won’t be rejected.

Do psychiatrists practice counseling and psychotherapy?

Most psychiatrists in Malaysia do some basic counseling and psycho education on your illness (i.e. depression) and medication (e.g. antidepressant). For more thorough counseling and psychotherapy work, they will usually recommend you a counselor or clinical psychologist. A few psychiatrists do practice more thorough and specialized psychotherapy, e.g. cognitive behavior therapy, psychodynamic psychotherapy.

What is the cause of depression?

“Depression” is just a label for anyone who experience the signs and symptoms mentioned earlier. But the factors contributing to a person’s depression are often unique and multiple. Identifying the factors is important as some of them can be modified as part of treatment (e.g. abstaining from alcohol).

Among the common factors contributing to depression are:

• Genetic inheritance.

• Chemical imbalance in the brain, e.g. serotonin and noradrenalin.

• Hormonal imbalance, e.g. hypothyroidism.

• Negative automatic thoughts.

• Long term use of certain medications, e.g. steroid, beta-blocker (a type of high blood pressure medicine).

• Family, marital and relationship problems.

• Past physical, sexual and emotional abuse.

• Job and financial difficulties.

• Studies and exam-related stress.

• Chronic medical problems, e.g. stroke, diabetes.

• Personality, e.g. low self-esteem, easily anxious.

• Death or loss of a loved one.

• Political instability and natural disaster.

• Substance abuse, e.g. alcohol & cannabis.

• Vitamin deficiency, e.g. folic acid & B12.

• Inability to cope with positive change, e.g. graduation, promotion, getting married, moving to a new house.

• Other mental illness, e.g. obsessive compulsive disorder.

Sometimes, it’s useful to classify the ‘cause’ under ‘R.T.M.’

• Risk factors – what causes someone to be more vulnerable or have higher chance of getting depression, e.g. strong family history of depression (genetic influence), past sexual and emotional trauma.

• Triggering factors a recent stressor that precipitates or starts off an episode of depression, e.g. recent divorce and child custody issues, financial difficulty, examination stress.

• Maintaining factors what causes someone to have poor recovery from depression, e.g. poor compliance with medications and counseling, ongoing alcohol abuse, anxious personality.

Understanding the various R.T.M. factors explains why some people become depressed but some don’t (despite having similar stressor/triggering factor, e.g. divorce). It’s because some have risk factors (e.g. family history of depression) and some don’t. On the other hand, some with a certain risk factor (e.g. family history of depression) may not get depression as they’re either free from or able to cope with the triggering factor (e.g. divorce). The R.T.M. concept also explains why some recover well from depression but some don’t (due to the presence of maintaining factors). It’s much more important to know

Sir William Osler

People with serious and long term physical illnesses are at higher risk of developing depression. Depression often worsens the

outcome of physical illness, e.g. feelings of hopelessness affects compliance with cancer treatment. Conversely, people who are depressed are more likely to develop physical illness. So, mental and physical illnesses are inter connected and affect one another. For some people, the cause of depression can be mainly biological, e.g. due to genetic inheritance, neurotransmitter or hormonal imbalance. They may experience sudden mood swings without or with just mild psycho social stressors in life. Because of that, they’re often unkindly judged as ‘mentally weak.’ This is unfair – it’s like to scolding a person with back pain and spinal problems for not being able to carry heavy things. Please be empathetic and kind to them.

Right understanding of the ‘causes and conditions’ of depression is important; it affects whether a person will seek help early and the choice of treatment plan. Instead of a sign of personal failure, it’s more helpful to understand depression as a natural consequence of various factors (e.g. brought up in a dysfunctional family, having stroke with impairment, terminated from job recently) one will be more likely to accept and seek help.

When we ’ re in a situation with similar factors, we’ll very likely be depressed too. It’s natural, just like weeds growing when the conditions are suitable. So, depression is impersonal and you ’ re not alone. Be kind to yourself and seek help immediately.

Besides ‘cause,’ there’re several protective factors; factors in a person’s life that promote mental health and well-being. Research in positive psychology is exploring more on these factors, which can be promoted to prevent and cope with depression:

• Good family and social support.

• Positive mental attitude, e.g. positive thinking, hope, forgiveness.

• Physical exercise, smile and a sense of humor.

• Having a sense of meaning and purpose in life.

• Practicing religion and spirituality, e.g. prayer, meditation.

• Positive emotions, e.g. gratitude, savoring life’s joys.

• Random act of kindness or selfless service.

• Engaging in activities that involve one’s signature strength (unique abilities, e.g. organizing, cooking, sewing).

• Effective communication and good social skills.

• Effective coping skills, e.g. stress and anger management.

How is depression treated?

The most commonly prescribed class of antidepressant is selective serotonin reuptake inhibitor (SSRI), which includes Fluvoxamine (Luvox), Sertraline (Zoloft), Ecitalopram (Lexapro). Antidepressant is prescribed by a psychiatrist or any other medical doctor. It’s very important to have proper understanding of antidepressants:

• Antidepressants have very low potential for addiction.

• Antidepressants aren’t sleeping pills or tranquilizers although they can help with sleep and have a calming effect (also used in the treatment of anxiety disorders).

• Antidepressants don’t make us violent, uninhibited (e.g. talkative, sexually preoccupied) or become zombie like. They improve mood and allow us to make positive changes in the way we think and act.

• Antidepressants don’t cause brain damage or memory problems – it improves concentration and memory.

• Antidepressants don’t cause kidney or liver failure when taken according to a doctor’s recommendation and with proper monitoring.

• Antidepressants take a minimum of 2-3 weeks to work.

• Antidepressants need to be continued for at least 6 months after you’re well.

Although it’s generally safe, antidepressant shouldn’t be taken conveniently like panadol (i.e. easily bought over the counter, taken

only when it’s necessary, and without monitoring). IT MUST BE TAKEN

ACCORDING TO A DOCTOR’S RECOMMENDATION & MONITORING.

Counseling and psychotherapy: This includes psycho education on depression and its treatment. It also includes various types of effective talk therapies, e.g. person centered therapy, problem solving therapy, cognitive behavior therapy, interpersonal psychotherapy, grief counseling, art therapy, marital therapy, etc. Regarding what to expect from a counselor and clinical psychologist, kindly refer to page 32). Electro-convulsive therapy (ECT): ECT involves passing a small amount of electrical stimulus through the brain over a brief period (less than a minute). It’s given under anesthesia in a specialized setting and usually reserved for severe depression, e.g. actively suicidal, refusal to eat or having severe psychosis. Despite having bad press, ECT is life saving in severe depression. However, for effective treatment of depression in the long term, ECT should be used together with medicines, counseling/psychotherapy, and other non-medication strategies. Other non-medication strategies: family support, regular exercise, exposure to sun or bright light, healthy and balanced diet,

sleep hygiene (page 128), contemplative practices (e.g. yoga, qigong, meditation), relaxation training (page 130), depression support group, prayer, etc. The non-medication strategies and issues about medications will be covered in more detail in part 3 of the book (under 20 FAQ’s during depression treatment).

It’s important to discuss with your mental health professional on your choice of treatment, as we have different needs and views.

Their role is to guide you on treatment options; instead of forcing their opinions on you. You got to take charge of your life and make decisions; of course, with guidance.

The next part of this book (Part 2) is the diary of one of my many patients (Jasmine) who is coping with severe depression. She’ll bring you to visit the realm of depression. It’s going to be an experiential and inspirational journey; way beyond the mere listing of symptoms (which has been covered in Part 1). It represents hope that, after the journey, one will understand depression better, seek help immediately (if it’s not done yet), and be more courageous in combating the storm of depression.

Have a wonderful journey…

I’m an introvert with a pessimistic personality. I didn’t realize I was depressed until I visited a general practitioner about two years ago because of my horrible mood swings and I cried most of the time without any reason. Most terribly, I had very frequent suicidal thoughts. I was then referred to a psychiatrist for further treatment. In the psychiatric clinic, I was given a set of depression questionnaires to answer and interviewed by the psychiatrist as part of thorough psychological assessment. The psychiatrist confirmed the depression and I was disappointed with the diagnosis.

Up to this point in time, I still wonder whether I really suffer from depression, despite having two doctors confirming the fact. I’ve doubts, plenty of it - I keep thinking that it’s just me instead of depression. I feel very confused, lost and of course, depressed.

There’re times that I break down and cry. I feel like I’m at a crossroads, not knowing what to do and how to get out of this depressive ‘shell.’ I’m grateful to my psychiatrist who encourages me to write down my experience along the journey through depression. It’s a therapeutic assignment for me and also to benefit others with a similar experience. Dr. Phang, thank you for your continuous trust, hope and inspiration.

This is certainly a very challenging assignment as it’s painful to pen down the stormy journey of depression. My tears flow like a river; my heart oozes with ‘blood’ of sadness. After every chapter of the journey, I got to make extra effort to sooth myself. Nevertheless, I’ve no regret in taking up this challenge. I now know that I’m not alone; there’re many others with similar experiences. I hope that my sharing can help others to have a better understanding of depression. May you be at peace with your depression, able to cope with it and move on meaningfully with life. Last but not least, thank you for your interest and time spent reading my journey.

~ Hopeless ~

My life is like a withered flower! No dream, no hope, no future. There is only one color in my life GREY!

When I have a relapse of depression, I feel completely hopeless and useless. Feeling frustrated, I wonder why my life has to be this way.

What is the point of living if I’m going to feel terrible like this repeatedly?! No matter how diligently I take the medicines, how best the psychotherapy, how great my psychiatrist is there is no point in moving on. Once again, I’m unable to see the rainbows of life. I’ve been crying almost every night. I beg God to answer my big “WHY?!” But there is no answer.

My hope for a complete recovery is gloomy. I don’t dare to hope and ask how well or soon I can walk out of depression. There’re too

many obstacles in my life. I’m tired of fighting; I’m getting weaker and weaker.

Many times, I feel that my life is like a burning candle amidst the winds of hopelessness. The flickering flame will vanish any time and the candle is expiring. When will I be gone too?

I like the song, “End of the World,” by Skeeter Davis…

This is my healing diary that I use to compile all the valuable advice and encouragement given by my psychiatrist for me to cope with depression. It’s some sort of a reference book in my life for battling with depression.

I love the diary - it’s life-saving. But it’s also sometimes stressful to read this diary, especially when I have a severe depression relapse. “Why?” you’ll probably ask. It’s because I find myself useless for not being able to practice correctly according to the suggestions given by my psychiatrist.

I truly understand that my psychiatrist has done a great job by trying endlessly to treat my resistant depression. Yet I can’t make

the best effort to walk out from depression. I’m so useless, I’m not even a good patient, and I’ve disappointed so many people in my life (besides my psychiatrist).

I notice that I’ve been so useless since young. I’ve always failed to reach my goals in life!!! I always behave like an ostrich when facing problems; avoiding, hiding and running away. “Jasmine, you’re completely useless! 100% useless! - no doubt about that,” I often tell myself. I hate myself so much…

Very often, I’m not a good mother. I feel guilty whenever I can’t perform my role as a mother well. I often lose patience with my kids when I need to guide them in their studies. The same goes when they’re playing loudly. I know that they’re just kids (it’s not their fault), but I just can’t tolerate them. I’ll yell at them when my mood is horrible. I even cane them badly for their misbehavior. I’m also losing interest in being with and playing with them. See, I’m such a terrible mother, I’m sure you’ll agree with me. Two weeks ago, my mood was swinging terribly and I needed a quiet moment for myself. As usual, I hid myself in the room. At that moment, my little daughter came in and talked to me. Like a mad woman, I lost control completely and chased her out of my room. My daughter was stunned and frightened by my inexplicable behavior.

She cried and said, “Mummy, what has happened to you? You don’t love me anymore? I’ll be very sad if Mummy doesn’t love me anymore. I feel you don’t love me nowadays,” in a pitiful voice. I was saddened by her words and immediately hugged her tightly. My poor little darling, how could I treat you so cruelly? What has happened to me? I’m becoming a monster. I felt extremely guilty at the moment and immediately responded, “Mummy is very sorry and I didn’t mean to hurt you. I love you forever.” I feel like shouting and confessing all my sins to the world. Please forgive me (if you think that I’m still worthy of requesting for forgiveness). My heart feels extremely painful and regretful for hurting my daughter. She is just six years old. I’m an evil mother. I can’t forgive myself for hurting my kids. But, HOW?! I feel very irritable when my mood is down. I feel like the demon is eating up my love for my children whenever I hurt them…

I always feel like a huge burden to my family and best friends, despite trying to think and say that I’m not. I always feel bad because I’m holding everyone back, and making their lives more difficult and miserable. Everyone is busy with their lives including my husband. How much time can they actually spend with me? How much patience and tolerance can they have for me? Deep down inside my heart, I know the answer very well. No one is interested to listen to problems over and over again. Nobody is patient enough to understand and accept my mood swings. In fact, I don’t think anyone can really understand my feeling. Sometimes, I can’t even understand and tolerate myself.

Strangely, I even feel like a burden to my psychiatrist for giving him a hard time when my emotion gets out of hand. I feel frustrated and fed-up with myself when I’m not be able to cope with my negative emotions. I run madly around the horrible maze; finding a solution to stop troubling people. I feel guilty towards my psychiatrist for always troubling him with my problems, although it’s his responsibility to treat my illness and he’s OK with that (that’s what he always assures me).

Several times, I was thinking of ending my life so that I don’t have to burden those people whom I care about. Perhaps, I’ll have peace of mind (R.I.P.) when I leave. My loved ones will feel sad but at the same time relieved…I’ll feel relieved too…isn’t that wonderful?

One of the main reasons why I have depression is due to my pessimistic personality; low self esteem, lack of self confidence, inferiority complex, negative thinking. That’s me - Jasmine.

I have been like this since young; only became worse when I was diagnosed with depression. I hate this personality; I hate my life, myself, the entire me. It’s like a big rock that I have to carry wherever I go. Because of this, I’m at risk of depression relapse over and over again it’s so painful. I would honestly and confidently (at least about something in life) say that NO PAIN IS

WORSE THAN MENTAL PAIN!!! I would rather suffer physical pain than mental pain. Even childbirth pain was more bearable as it was just over a short period of time.

My life’s journey is like sailing on the sea without direction. My mind is always full of question marks about life; never ending questions with no satisfactory answers. With my inherent weaknesses, I’m completely lost, stuck and have no way out.

Combating depression is like sailing on a rough sea with strong wind and waves – it’s so scary. Complicated by my pessimistic personality, I strongly believe that it’s never easy to get well and remain so, despite the continuous support from my psychiatrist.

The road to recovery from depression is long, tortuous and thorny. It’s is full of potholes. Worse still, it often feels like I’m going off track or even backward instead of forward. And I got to restart the journey from square one – it’s so frustrating and tiring. I really hate this journey! When can the journey be ‘game over’?

~ Gloomy Evenings ~

Generally, people like the moments when evening comes. It’s time to stop work, return home to relax and spend time with family. However, it’s a different story for me. When the sun is down, my fear starts to creep in.

I feel very scared when the sky gets darker. The same thing happens when the weather is gloomy. End of the day feels like the end of the world to me. The shadows of hopelessness, helplessness, loneliness, listlessness – all take turns to haunt me as the sky becomes darker.

Every evening, it’s a time for battling with depressive storms. As the storm comes, it brings with it all the unpleasant memories of the past.

No matter how hard I try to stay calm in the storm, I’m usually the loser. When that happens, I’ll normally retreat to my dark room, lock myself in and cry profusely. Yes, crying does help to release the painful emotions…

~ Suicidal Thoughts ~

Life is indeed full of suffering and very painful!!! How long more can I bear with it? Continue or just give up? This is the scary question that visits my mind on and off.

Thoughts of suicide keep flashing in my mind. It tells me that the game is over and I’m the loser. It’s time for me to give up, stop striving and rest in peace.

Are you afraid of dying?

I’m not. But, I’m concerned about my kids. I neither want to leave them behind nor let them live without a mother. It would be very painful for them. Finally, I thought of bringing them along with me

wherever I go – including the graveyard. I know it’s very cruel and unfair to the kids. I don’t want to do that. But I really have no other choice?! There’s no way out. I’ve been contemplating various ways of committing suicide. I’m making preparations to leave a final good bye. I’ve told my best friend to liaise with my hubby on my choice of decoration during the funeral ceremony. Finally and luckily, I’ve decided on an alternative, one that is less drastic (next page).

Whenever I think of ending my life, I feel sharp pains in my heart, like being stabbed with a knife repeatedly. My mum will feel very sad when I’m no longer around. Will she? I think so; I’ll feel very sad if my daughter ends her life. But, do I have a better choice? Maybe it will be better for everyone in the long run…

~ Self-harm ~

I know I’m not supposed to kill myself to end my pain. But at the same time, the pain is really unbearable. Finally, I discovered a way to get relief from my emotional pain - SELF HARM.

In order to reduce my mental pain, I harm myself physically (i.e. I violently pinch myself or to shower in high temperature water) to induce physical pain. The physical pain helps to divert my attention from the mental pain which is much worse. Whenever I can’t cope with my mental pain, this self harm tendency will crop up; it’s becoming a habit.

I understand that this isn’t the healthy way. But I don’t know of a better way. I would rather have physical pain than mental pain.

Nothing is more painful than the mental torture of depression - I can’t stand it, I’m so helpless.

I’m sad and mad with myself for having such a crazy habit. I’m regretful every time I physically hurt myself. “But, that’s better than ending my life,” I console myself….

~ My Struggle with Medicines ~

No matter how many times my psychiatrist explains to me the effectiveness of medicines, I still feel very reluctant to take them. Compliance with medicines is a big issue for me. Despite repeated assurance from my psychiatrist that the medicines are important and safe for me, I still doubt. I’m worried about side effects. I’m not sure whether the medicines will work for me. I still sometimes doubt that I have depression. So, even if the medicines work for depression, it may not work for me as I don’t have depression. Maybe it’s a big mistake on the part of my well-intending psychiatrist; wrong diagnosis.

I used to cry when I had to take medicines. As the medicines entered my body, I thought to myself, “Why do I have to suffer from depression?! Why me?! Why do I need to take medicines?! Why can’t I stop my medicines?! Why?! Why?! Why?!” As you have probably guessed, I have never gotten satisfactory answers.

Several times, I managed to convince my psychiatrist to reduce my medicines. Unfortunately, I had very bad relapses and almost ended up killing myself. Now, I realize that medicines aren’t everything; but they’re essential together with other treatments for depression, e.g. psychotherapy, family support, exercise, nutrition, spirituality, etc.

Nowadays, instead of condemning my medicines when I take them, I have learned to consume them with a positive mental attitude. When I put the medicines into my mouth, I radiate positive thoughts to my medicines, body and mind. And I try to bless them with love and compassion. It’s not easy, but I’m trying. I’m sure many of you who are depressed, reading this, share similar experiences. I truly know how you feel. But please don’t give up –we shall go through this together we ’ re not alone. I wonder when I can reduce my medicines again. I’d better not think this aloud, or else my psychiatrist will be very upset with me…

~ Electro-convulsive Therapy (ECT) ~

“Twinkle, twinkle little star, how I wonder what you are. Up above the world so high, like a diamond in the sky,” I was crying like a baby while singing this song.

It was so lonely and scary in the psychiatric ward. All the patients had some form of mental illness and they looked so pitiful. Some of them were hostile due to their illness and needed to be restrained on the bed so that they couldn’t harm themselves or others. “This is temporary and for their own good, while waiting for the medicines to work on them and cure them,” assured my psychiatrist.

Due to my severe depression and attempted suicide, I was advised by my psychiatrist to go for a series of emergency and life saving treatment known as Electro-convulsive Therapy (ECT).

ECT is a safe and effective treatment for certain mental illnesses especially severe depression. During the ECT, while one is asleep under anesthesia, a small amount of electrical current is passed through the brain within a minute. This current causes a therapeutic seizure that ‘charges up’ the entire brain in a positive way, including the parts that control mood, energy, appetite and sleep.

I was warded for two weeks for the ECT. After some time, I managed to make friends with some patients in the ward. They were not as scary as when I had perceived them earlier. Gradually, I got to know some of their life stories; many of which were more pathetic than mine. Many of them had nobody to care for them at all; no friends, no family members, and not even a proper place to stay or food to eat. I’m so lucky compared to them; I have a wonderful family, a good psychiatrist, access to expensive medicines, able to join a depression support group, etc. It’s an eye opening and priceless experience to be in the psychiatric ward…

~ Not My True Self ~

“Trust me, Jasmine. You’re in a severe relapse state! We need to add a new medication…please allow me to do that,” said my psychiatrist as I struggled in the quicksand of depression.

During my depression relapse, I felt completed defeated and devastated; everything was back to square one. My mind was full of negative thoughts, all that you can think of, including the various reasons that I should kill myself. Out of concern, my psychiatrist insisted that I should increase the number of medicines that I was taking (I hate that).

I had no choice but to listen to his professional and genuinely caring advice. The new medication caused me to be “abnormal” for a few days; I slept most of the time as my body needed time to adjust to the new medication.

However, I also noticed other strange and ‘uneasy’ feelings besides the sleepiness. The new medication made me feel calmer. The mood was better with less negative thoughts. But I felt weird with my new self as I was so used to the Jasmine with negative thoughts and horrible feelings. That really prompted me to contemplate deeply Who am I? Which is my true self? Who is Jasmine?

Well, I got to admit that my doctor is right and I’m glad that he’s right medicines aren’t everything but they’re very important!

~ The Story of a Pothole ~

This is a meaningful story shared by my psychiatrist. It serves as a reminder whenever I fall into the depressive POTHOLE again.

Once upon a time, a lady, always fell into the same pothole in a familiar stretch of road while walking along it. She sought help on how to avoid falling into the pothole again. She practiced all the methods diligently and never gave up. It took her a very long time but she finally conquered the pothole and ‘RECOVERED.’ This is her eight-stage journey of recovery:

1. Walked on a road... fell into a pothole...totally unexpected...pitch dark and scary...didn't know what to do?!?!

2. Walked again on the same road and fell into the pothole...surprised that she fell again...but at least now she realized the reasons that made her fall again into the pothole...

3. Walk around the pothole a few times...yeah, able to avoid falling for awhile...but finally still fell into the pothole...felt frustrated, but able to learn new ways to avoid the pothole...

4. Walk around the pothole anxiously many times without falling...yeah yeah...but still stuck around the pothole without moving on along the road...

5. Able to walk around the pothole with no fear...and then moved on along the road...but didn't know where to go...”what should I do if I’ve no fear or depression?”

6. Able to walk around the pothole confidently...and then moved on along the road happily towards a meaningful destination...but at times still felt that something was missing in life…

7. Able to walk past the pothole confidently many times...one day, saw someone with similar problem...but was sad as she couldn't help the person and others to 'cross over'...

8. Able to walk along the path meaningfully...and helped many to walk meaningfully as well...she was also grateful to

the pothole that had taught her many meaningful lessons in life. “Don't give up. We’ll walk and grow together,” said my psychiatrist numerous times, giving me hope and inspiration. And I wish to say the same to you as well – let’s journey along together. Many discoveries await us…

• Feelings of worthlessness or inappropriate guilt

• Loss of concentration or indecisiveness

• Recurring thoughts of death or suicide

I’m blessed to have a professional and experienced psychiatrist with me along the journey of depression. I hope you too can find a good doctor and treatment for yourself. I feel less lonely these days as I’ve a group of supportive friends with me along this journey; some of them also have depression like me. We hold one another’s hands tightly as we overcome challenges and discover happiness in life. My psychiatrist always reminds me that with each battle with depression, I’m becoming stronger and stronger. He often says, “Everything happens with some good purpose.” Well, I certainly never asked to be depressed. But since I already have it, I might as well make good use of my experience for growth, thus sharing and building a better world.

2 October, 2011 A gloomy day and the depressive storm was coming. “I must not surrender. I must do something to protect myself,” I reminded myself. I managed to do something this time gardening.

Throughout the activity of pulling weeds in my garden, I finally understood that the mind is also like a patch of garden. I discovered that my mind garden is full of weeds too. I never bothered to pull out the weeds. Worse still, I “fertilized” them. That’s how I ended up as the hopeless, useless, weak and depressive Jasmine.

I remember clearly that my psychiatrist told me that besides pulling weeds, I need to plant good seeds in my mind garden so that the

flowers and fruits of happiness can grow. I did as advised but was impatient; I dug out all the seeds before they had a chance to sprout and grow.

I do a lot of good deeds (e.g. community service) and things that are conducive to healing of my depression (e.g. exercise, learning about parenting, etc). People compliment and thank me for what I do for them. But I always feel that I’m not good enough - I blame, criticize and find fault with myself.

To avoid a depressive relapse, I got to constantly remind myself, “You’re good enough,” echoing the advice from my wise psychiatrist.

“Whatever you ’ re doing isn’t perfect but good enough – keep it up and you’re on your way to recovery. But you ’ re too impatient for the seeds to grow. You dig out the seeds and scold the seeds, ‘Why aren’t you growing?!’ You doubt whether the person who recommended you the seeds was right after all. You doubt whether the seeds will ever grow trust me, they will surely grow, just be patient,” said my psychiatrist. He’s right and I’ll never forget that. It’s an important realization.

While reading a self-help book on cognitive behavior therapy (CBT), I had another important realization I can’t depend on my

psychiatrist too much. I’m responsible for my healing. He can only guide but not support me all the time.

Through my reading in CBT, I also gradually discovered that my depression is actively fed by my negative and unhelpful thinking patterns, which I’m learning to transform. If you ’ re interested to know more about CBT, you can look for this book, “Fight Your Dark Shadow –Managing Depression with Cognitive Behavior Therapy,” by Dr. Tian P.S. Oei.

Rosenvald, Therrie, and Oei Tian P S. Fight Your Dark Shadow: Managing Depression with Cognitive Behaviour Therapy. Australian Academic Press, 2009.

~ Let’s Be Friends ~

Dear Depression, Do you know how much I hate you? I’m very angry and upset with you for intruding into my life. You have spoiled everything, especially my happiness in life. Worse, you bring along your ‘friends’ hopelessness, helplessness, uselessness, loneliness and guilt. They take turns to visit and torture me – it’s terrible! Do you know how painful I feel whenever your friends visit me?! I hate you so much for making my life horrible!

I’m frustrated and don’t know how to deal with you. I’m so helpless; I can only hide in the room and let you torture me. Don’t you think you’re very cruel? You can’t do this to me – it’s unacceptable! But do I have a choice?

In order not to let you to hurt me further, I have thought of a way TO BE A FRIEND to you. If I can’t beat you, at least allow me to make peace with you. Are you OK with that?

I’m sorry that I didn’t take care of you since the first day we knew each other. Sorry for being rude to you as I always chased you out from the door of my heart. From today onwards, I promise that I will try to welcome you and your ‘friends.’ Kindly introduce them to me; I wish to know them better. I want to befriend them.

Thank you for coming into my life. You mean a lot to me; you make me stronger and wiser. Because of you, I learn to love myself more and be stronger. I can also share ‘our story’ and ‘relationship’ with others. It’s so nice that we can work together to benefit others.

I’ll not be down and sad when you visit me again, I promise. I believe that everything happens with some good purpose. I might not understand it now, but I have faith that it’s just a matter of time that the understanding will unfold itself.

I’m sure you’ll guide me towards a more meaningful life. Who knows because of you, I will have a chance to help people with depression and other mental illnesses one day. With your presence, I learn to treasure life more. I’m grateful to have you with me in this life’s journey. You’ve given me an opportunity to see things clearer and better the pathway to happiness.

I love you, my dear depression.

With gratitude, Jasmine.

~ A Grateful Journey ~

It hasn’t been easy in my journey of recovery from depression. I have made so much effort in getting out from the depressive pothole every time I fall into it. It’s sometimes very tiring. But it’s is a fruitful experience I notice that I’m getting stronger and wiser, yeah. I’m grateful that I’m still alive in this world and able to write this to share with you. I’m grateful to my psychiatrist, Dr. Phang for rescuing me from death several times deeply appreciated. As recommended by my psychiatrist as part of therapy, I’m counting my blessings every day that’s equivalent to nourishing the good seeds in my mind garden.

I got to be honest and admit that many of my challenges in life aren’t resolved yet. The shadows of depression still visit me occasionally. But I’m grateful that I’m more resilient now. I’m grateful that I’m part of the KL Buddhist Mental Health Association’s Stress, Anxiety & Depression (S.A.D.) Support Group (a.k.a. T Lotus). I’m grateful to associate with the T Lotus members as they always lend me a pair of listening ears, and motivate me to move on whenever I’m afflicted by emotional flu.

Perhaps some of you may be surprised or even think that I’m crazy when I tell you that I’m grateful that I have severe depression. No doubt, there’s a lot of pain deeper than the deepest ocean. But there’s no regret. I’ve learnt a lot about the illness. I’ve come a long way in battling with depression. I have experiential understanding of depression. I’m able empathize easily with those are suffering from depression. I’m also able to use my little experience to share with others and contribute to a better world.

Amidst the sufferings, there’s enough hope in life I’m glad that there’re rainbows after rain. I know that it may rain again. But it’s OK. I’ll learn to sing in the rain while waiting for the rainbows to appear that’s good enough!

~ Thank You ~

My journey through depression has been the biggest challenge of my life. I would like to take this opportunity to extend my sincerest gratitude to my psychiatrist, Dr. Phang for being with me throughout this painful and unforgettable journey.

I would also like to extend my appreciation to my loving husband, wonderful kids, dear family members, T-Lotus support group buddies and good friends for their continuous support and shoulders to cry on. Thank you for always being there for me.

Last but not least, I thank you for spending your precious time to read about my journey. May you be well and happy.

Jasmine, Email: jasminechiam1@gmail.com

(Feel free to contact me to share your experience in coping with depression)

Kindness amidst depression

Hello, welcome back from the realm of depression. I’m sure you had a wonderful journey with Jasmine, our depression journalist and tour guide. By now, you would have acquired the basic information on depression (Part 1). With Jasmine’s (Part 2) and your personal experience, you would have also acquired experiential knowledge on depression. It’s time that we move on with more strategies to cope with depression.

It was mentioned earlier that there’re several protective factors that can help us to prevent and cope with depression. One of them is kindness and its related positive qualities. Part 3 of this book will emphasize the application of kindness and other effective self help strategies to speed up recovery from depression. Let’s march forward, transforming depression into wisdom and compassion…

10 ways to cultivate kindness for coping with depression

Supported by research in positive and humanistic psychology, kindness and related positive qualities, e.g. compassion, peace, gratitude, gentleness, patience – are all helpful in healing of depression. They buffer the pain of depression, facilitate recovery, promote wisdom, and prevent depression relapse. On the other hand, negative states of mind, e.g. anger, guilt, grudge, frustrations, discontentment will maintain or worsen depression. Below are some suggestions on how we can cultivate kindness for coping with depression.

1. YOU AREN’T ALONE:

Remember that depression affects one in ten persons. It’s a natural consequence of various risk factors and stressors that you ’ re going through. If I’m in your shoes, I’ll probably have depression as well. This positive mental attitude is important as thoughts of, “Why me?! Why only me?!” often create a sense of frustration and isolation that worsens depression. Not surprisingly, people who participate in a depression support group often feel

relieved, when they discover that there’re others with similar experiences.

Depression is painful but I’M NOT ALONE – Yeah!

2. YOU AREN’T WEAK:

Be kind to yourself; don’t criticize yourself you’ve suffered enough. When we have depression, it doesn’t mean that we ’ re weak; it probably means that we have been too strong for too long. It’s quite common to hear patients say, “Doc, I don’t know why I’m like this now… (sighing). I wasn’t like this previously. I was a positive and happy go lucky person. I’m the eldest in the family and I used to support all my siblings. My friends and colleagues often come to me for advice when they have problems. Now…..(crying), it’s different, I’m so useless…”

Ms. E has just started work in a new company. She’s having a stressful time adapting to her new work environment. Her father left the family and her siblings are overseas. When she returns home, she has to take care of her mother with severe anxiety and depressive disorder.

Mr. C has diabetes mellitus, cholesterol problem, and suffered a stroke. He’s also unemployed and financially tight. Recently, his teenage son showed bizarre behavior and may have schizophrenia.

Ms. J needs to work to support her family. At the same time, she has to take care of two family members at home; a mother with Alzheimer’s disease and a sister with mental retardation both are unwell and quarrel every day.

Madam O is a dedicated school teacher; her students like her very much. She’s having a difficult time at school due to a heavy workload and interpersonal problems with some colleagues. Recently, her beloved husband passed away due to kidney failure. While grieving over the loss of her husband, she has to support her children who are still schooling.

Are they strong or weak?

Yes, they’re indeed very strong. It humbles me when I listen to their unique experience behind the diagnostic label of ‘depression.’ While listening emphatically to them, I often think to myself: “Would I be able to cope like them if I’m in similar situations? I’ll probably be depressed too, more than enough reasons to be depressed.”

People who don’t understand depression may say that you’re weak. Ignore and forgive them for their ignorance – they don’t know what they’re talking about. They’ll probably understand when depression visits them one day. Meanwhile, be kind to yourself and be patient with them.

Be more kind & gentle to yourself

3. FORGIVE YOURSELF:

People who are depressed often feel guilty over trivial matters. They actually haven’t done anything really wrong and totally unforgivable. That’s often the nature of a depressed mind. This can even develop into a more serious symptom known as ‘delusion of guilt’ a fixed and false belief than one has done something wrong or sinful (despite everyone thinking otherwise).

Tormented by guilt, a depressed person may think:

“I don’t deserve to get well”

“It’s punishment from God I shouldn’t get well!”

“I must go through the suffering it’s my bad kamma/sin”

“I’m useless. Not only that - I’m evil too”

“It’s not depression. I’m a bad person! – no point taking medicines” I’m sure you can see how guilt easily interferes with depression treatment. You may use the ‘F.A.R. 2’ formula as a guide to make peace with guilt:

F Forgiveness.

• Ask for forgiveness from those whom you have hurt.

• Ask for forgiveness from God or divine beings.

• Remember that God is loving and forgiving when you sincerely repent.

A Aspiration

• Make an aspiration that you’ll not repeat the mistakes.

• Ask someone respectable, e.g. priest to be a witness to your aspiration.

R – Remedial action

• Try to compensate - ‘right’ the ‘wrong.’

• E.g. donation or voluntary service to orphanages if you feel guilty over past abortions.

• Ruminating over how bad or evil you are isn’t helpful –do something useful instead.

R Rejoice over the goodness in you

• To err is human, but we have done good things in life too.

• Make a list of all the good things and review them periodically.

• Depression causes memory bias –you’ll tend to remember the bad things more than the good ones.

• Getting an opinion from a trusted friend helps to put things in perspective.

It’s OK to feel guilty (part and parcel of depression). Don’t feel guilty for feeling guilty double guilt you’ll get sucked deeper into the black hole of guilt. Instead, learn to cultivate ‘F.A.R. 2’ and move on with life.

It’s important to remember that forgiveness doesn’t mean we approve of our mistakes – they’re still mistakes. Forgiveness is about making peace with the past so that we can move on meaningfully with life for ourselves and loved ones it’s an act of kindness.

Story: One evening an old man told his grandson about a battle that goes on inside every person. He said, "My grandson, the battle is between two wolves inside us all."

"It’s a terrible fight and it’s between two wolves. One is evil – guilt, anger, envy, sorrow, regret, greed, arrogance, self pity, resentment, low self-esteem, lies, false pride, ego he has all of them." He continued, "The other is good he has kindness, joy, peace, love, hope, serenity, humility, benevolence, empathy, generosity, truth, compassion, and faith.“

“The same fight is going on inside you - and inside every other person, too," said the old man wisely. The grandson thought about it for a

minute and then asked his grandfather, "Which wolf will win?" The old man simply replied, "The one you feed". So, starve guilt and feed kindness depression will R.I.P. (rest in peace).

4. FORGIVE OTHERS:

Forgiving others doesn’t mean that we approve of their mistakes. We forgive others because it’s an act of kindness to ourselves; it helps to free us of our emotional pain and move on with life more easily. It’s useful to forgive others. Or else, we’ll be hurting ourselves as harboring grudges and revengeful thoughts is unpleasant and detrimental to happiness in the long term. Depression is already painful enough – don’t add more suffering to life, “Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you ’ re the one who gets burned,” (adapted from a Buddhist saying). “Getting angry at someone is actually punishing ourselves for another’s mistakes,” said Master Cheng Yen, echoing the same message.

Forgiveness is always easier said than done. Here are some ways to make it more manageable:

1. Empathize with the person. He or she may be having problems in life or even in depression. That’s why he’s so mean to others –only unhappy people ‘like’ to hurt others.

2. Touch the ‘good seeds’ in the person nobody is totally terrible, e.g. a nasty female boss may be a caring mother.

3. Remember that we have made and learned from mistakes too to err is human and I’m still human. Be generous and offer them the altruistic gift of forgiveness. After all, it’s not our duty to punish others; we have more meaningful things to do in life.

4. Look for hidden lessons in the hurt, e.g. because someone has betrayed us, we ’ re more cautious in trusting others. We also learn to cherish genuine friendships more.

5. Find your own happiness, e.g. by always counting the blessings in life. When we’re happy, it’s much easier to forgive. Don’t wait anymore, be kind to yourself and get yourself a gift for depression today by forgiving others.

5. COUNT YOUR BLESSINGS:

Yeahoo, life is wonder-full; Let’s ‘google’ the wonders… - Zhen-Phang –

Depression causes memory bias. Due to ‘state dependent memory,’ we tend to recall the horrible things in life instead of the happy ones. Unpleasant events tend to stick in the mind like velcro; while pleasant ones slip off easily like teflon. That’s why, it’s a good practice to keep a diary to note down all the pleasant things in life and recall them repeatedly. As you do this regularly, you’ll discover that life may not be that cruel to you; good things do happen in life and to you.

You may use this as a guide to help you recall the pleasant things in life (my own examples are in italics):

• Be grateful that somebody has complimented you. My students say that I’m a good teacher.

• Be grateful that someone has expressed appreciation to you. One of my patients gave me a “my best doctor award.”

• Be grateful for a mistake that you have made and now know how to avoid.

I have learned not to work too hard. When I rest more, I do things more effectively and with more joy.

• Be grateful for something new that you have learned today.

I have learned how to design the cover of a book with Adobe Photoshop and Illustrator computer software.

• Be grateful that there is someone who cares for you. My mother and sister care for me. My patients also care for me; they sometimes prepare me a home-cooked lunch when they know that I may not have enough time to eat.

• Be grateful that you ’ re able to do something that you have planned.

I have the experience and time to write this meaningful book that will bring happiness to many people.

• Be grateful that you have the basic needs of life, e.g. food, shelter, clothes.

I have a comfortable library at home for me to enjoy my reading and writing.

• Be grateful for something that you have worked hard for and achieved success in.

I manage to get plenty of donations to reprint this book for free distribution in the community.

•

Be grateful that you managed to help somebody. I’ve helped several young doctors who were depressed.

• Be grateful that you have a certain skill or talent. I’m a good and kind listener.

According to research by Professor Dr. Robert A. Emmons (editor in chief of the Journal of Positive Psychology), grateful thinking can increase happiness level by as much as 25% have a grateful day.

6. SELF-COMPASSION ACTIVITIES:

Depression may be a signal that you have neglected someone very important in life – YOU. Yes, you need to care for yourself more. As part of depression treatment, I often ask my patients to plan and do things that can make them happy.

Depression is associated with lack of interest in activities; it’s part of the illness. You may not feel like doing anything at all this is absolutely understandable. But try to recall what you used to like doing before falling into depression, and trust Nike’s advice Just do it! When you start doing them little by little, the mood will slowly return. It may not feel as good as previously, but it’s often good enough to motivate more activities and offer a feel of ‘getting back to normal.’ Tiredness and moodiness in depression isn’t overcome by more rest; it becomes worse you’ll feel more tired, abnormal and useless.

Trust me, gradually engaging in more activities, especially those that you once liked, is the right strategy soon you’ll rediscover the sparks of life.

DO VOLUNTARY SERVICE:

Life laughs at you when you are unhappy Life smiles at you when you are happy Life salutes you when you make others happy

Anonymous

Reaching out to help others through voluntary service has ‘pro-happinessant’ (promote happiness) effects:

• You’ll discover that you ’ re not alone; many people have similar problems like you. You may even realize that your condition isn’t that bad after all.

• You’ll feel that you ’ re useful; you ’ re capable of doing something meaningful to help others and make a difference to the world.

• You’ll become less preoccupied with your own problems. To stop negative thoughts is difficult. I know many people have advised you to ‘think positive,’ but it’s never easy. It’s easier to do it by distracting yourself with useful activities.

8. RADIATE KIND THOUGHTS TO OTHERS:

• Take a few slow deep breaths to relax your mind and body.

• Think of the people in your life especially your loved ones.

• Mentally, send good wishes to them, like sending a mental SMS, e.g. “May you be happy,” “May you get a promotion,” “May you be healthy.”

• Smile to them and visualize them being happy. Imagine that they smile back and thank you for the good wishes.

• Repeat this for a different person or group of people.

• You may also expand your kindness to animals and nature.

This is helpful for depression in several ways:

• 1. It trains the mind to focus on a positive emotion, i.e. kindness, instead of a negative emotion like fear.

• 2. It stimulates the production of a neuro-hormone, (i.e. oxytocin) which gives a sense of warmth and security (the same chemical is produced during breast feeding).

• 3. The kind thought and feelings can facilitate positive behavior, (e.g. smiling and being friendly to others) that improves interpersonal relationships.

9.

TRANSFORM DEPRESSION INTO WISDOM : He who has a WHY to live can bear almost any HOW Friedrich Nietzsche Though depression is painful, it’s not uncommon that patients report that they have learned something useful from their illness. Everything in life happens with some good purpose. Here are some of the possible lessons from depression:

•

“Depression is like a compass; It reminds me about self care and focusing on what’s important in life”

• “I have learned to be less serious and laugh at myself”

• “I’m more kind to others”

We don’t ask for depression to come. But since it’s already here, let’s learn to befriend depression and grow from the relationship. Hi ‘Cikgu (Teacher) Depression,’ thank you for coming into my life…

10. BE KIND TO YOUR MEDICINES:

It’s extremely important to have a positive mental attitude towards your medicines. Suppose each time you take medicines and think, “Oh shit, I got to take these medicines again…it’s destroying my kidneys and liver. When can I stop taking medicines? I hate seeing the sickening doctor,” it may interfere with your recovery from depression as the mind is very powerful in affecting healing.

Case report: Once, there was a patient with depression who attempted suicide by

overdosing on her antidepressant medicines that she believed would kill her. She was admitted to the intensive care unit (ICU). Unfortunately, she remained unwell despite all ICU monitoring showed that she was normal. She only ‘recovered’ when her psychiatrist told her that she was actually on placebo antidepressant drugs (a sugar pill with no active medicines).

Kindly remember If you believe that a medicine or treatment is effective, the outcome will be better, and vice versa. No doubt, antidepressants work. But they work even better when:

• The patient believes that it works.

• The patient’s doctor believes that it works.

• There’s a good relationship between the patient and doctor.

12 ways to be kind to people with depression

Various kindness based strategies have been suggested in the previous chapter for patients to cope with depression (internal). It will be even better if we can extend kindness to those who are suffering from depression (external). With a full dose of kindness (internal and external), recovery from depression will be much easier. How can we be kind to those who are depressed?

• 1. Don’t stigmatize them they’re not crazy, mad, psycho, violent or bad. They’re human beings like you and me (but with a psychological illness), who are capable of being good, happy and successful in life.

• 2. Try to understand depression as much as possible. Recall the occasional periods of sadness and lack of motivation in your life. Amplify that 10 times that’s probably how it feels to have depression as an illness. When we understand, we’ll be able to care more effectively.

• 3. Gently remind them to take medications and do whatever necessary to get well, e.g. engage in more activities, read about depression, eat healthy food, and go for clinic follow-ups.

• 4. Spend time with and accompany them for their activities, e.g. exercise, a walk in the park, buying things from the market. Don’t just tell them to do it; invite them to do it with you and give plenty of encouragement with every slight progress.

• 5. Offer practical support, e.g. cooking, cleaning the house, giving a lift to the clinic, settling the bills, taking care of children, collecting medicines, etc.

• 6. Don’t compulsively give advice, “Try this/that…don’t do this/that…must do this/that…” Though with good intentions, you’ll probably make him/her feel more confused and helpless. Be a good listener - explore their concerns and empathise, before offering suggestions.

•

7. Don’t be over protective. They need to be trusted that they’re capable of doing things on their own with support. Sometimes we also need to be firm with them for their own good, e.g. insisting that they should stop abusing drugs (e.g. cannabis), compliance with medications, clinic follow-ups and daily exercise.

• 8. Give them equal opportunity for employment when they’re well. Allow them to take leave just like any other illness when they need to take time off for clinic follow-ups.

•

9. Forgive them if they’re sometimes impatient, unreasonable or even hostile. They’re sick and in pain; may sometimes behave like an injured scorpion that stings those who help them. The fact that they reveal their unpleasant side to you may mean that they actually trust you enough. Be grateful that you ’ re the ‘chosen one’ willing to endure with compassion.

10. When they’re not ready to be helped, empathetically leave them alone for the time being. I know that it’s helplessly painful ‘doing nothing.’ Bear in mind, most likely, they’re aware that you care, but they’re not ready to seek help yet. They need more time to accept the reality of depression; acceptance is a process, not an onoff switch. Be kind to them by being patient and not rejecting them.

•

• 11. Repeatedly assure them in words that you love, care and respect them unconditionally. It’s not they don’t trust you; they actually don’t trust and probably hate themselves depression has damaged their self-confidence and self-worth.

Be mindful of false kindness

Sometimes kindness can be misunderstood, applied wrongly and thus not helpful in dealing with depression. Kindness in coping with depression doesn’t mean:

1. Allowing ourselves to abuse alcohol or illicit drugs (e.g. cannabis, heroin, amphetamine) to drown the depressive pain. Even though it’s understandable, this isn’t self kindness it’s self destruction. A better way would be getting professional help for depression.

2. Self pity – repeatedly ruminating over how terrible life is (‘poor me syndrome’). It’s done mainly to seek attention without any willingness to do anything to make life better. A better way is to take charge of our lives and make practical changes for improvement.

3. Blaming everyone and demanding the world to change. This isn’t self-love it’s self-centeredness. This kind of expectation will only cause more disappointment and interpersonal conflicts. A better way would be to gradually adjust our attitude and behavior to build a better world.

4. False acceptance of illness. Some people totally ‘surrender’ to depression; they don’t get help or do anything to get well. They may also think, “Since depression is an illness, I’ll let my doctor make all decisions and do the treatment. I don’t have to do anything.” This isn’t true acceptance – it’s wrong understanding, denial and avoidance. Kindly refer to page 26 on how to encourage someone with depression to seek help.

5. Making all decisions for someone who is depressed. This may be appropriate during the initial period when he or she is very sick; it’s not helpful in the long term. It’s better to slowly guide the person in problem solving and decision making using ‘I.D.E.A.L.’ (page 133).

6. Doing everything for someone who is depressed. This is also not helpful in the long-term; the person can’t resume independence. It’s better to support them by dividing their task (e.g. cleaning room) into smaller and more manageable parts, and let them do it.

This helps to build confidence and promote independence. 7. Keep nagging and pestering the depressed to change. This is often done in the name of kindness, “It’s for your own good!” We need to be mindful that at times, this could be a reflection of our impatience and non acceptance. The expected improvement is also sometimes more for our needs rather than theirs (e.g. we feel shameful that we have a family member with depression). A better way is to stay calm, be honest and kind with our feelings, listen to their needs, and be generous with encouragement.

The next part will be on the frequently asked questions (FAQ’s) that I received from my patients during their depression treatment. Feel free to ask your mental health professional on anything related to your depression. Be kind to yourself, you deserve good service your satisfaction is our inspiration. Of course, it’s impossible for me to answer all questions related to your depression treatment. Therefore, If there’s anything that isn’t answered through the 20 FAQ’s, kindly refer to your mental health professional or more information available in “Further reading on depression (page 198).”

20 FAQ’s during depression treatment

1. Why am I like this/that? (referring to the various signs and symptoms of depression). You’re like this/that because you have a psychological illness known as depression which affects the way you ‘think feel behave’ and your body functions. For a review of the signs and symptoms of depression, you may refer to page 4. If there’s anything which isn’t mentioned, please refer to your mental health professional.

Some patients say, “I have this and that symptoms… but I don’t have ALL the symptoms. So, I don’t think I have depression.” This may NOT be true. You don’t need to have ALL the symptoms for a diagnosis of depression. Kindly refer to page 4 for the minimal number of symptoms and criteria required.

those modifiable factors, (e.g. alcohol abuse) as removing the factor will be part of your depression treatment plan. Some patients say, “I don’t have depression, I only have financial problems.” Bear in mind that from a medical/psychological perspective, a diagnosis of ‘depression’ is generally made irrespective of the stressors (as long as the signs/symptoms and criteria on page 4 are fulfilled and significantly interfering with a person’s life).

methods (page 122). To some, it may be easier to take medicines than focusing on other methods that require more effort it’s their choice and we should respect the choice. I usually use both methods; antidepressants for short term and the rest (counseling/psychotherapy and non-medication methods) for long term and relapse prevention. Often in a Malaysian setting, by the time people are willing to seek help from a psychiatrist; the depression is usually rather severe Antidepressants and other medicines are needed for stabilization while working on other methods. So, if you wish to recover fast from depression without the use of medicines - seek help early. 4. I don’t want to be addicted to medicine. I want to do be able to do something besides taking medicine.

Antidepressants are NOT sleeping pills or tranquilizers (which excessive usage can easily cause addiction). Antidepressants are extremely unlikely to be addictive. Besides taking antidepressants, there’re many other things that you need to do for recovery (page 122). So, you’re not relying only on antidepressants. In fact,

antidepressants take a minimum of 2-3 weeks to work. So, even if you ’ re on antidepressants, there’re many things that you need to do now, while waiting for the antidepressant to work.

5. Will I get side effects?

If you take antidepressants according to your doctor’s recommendations with proper monitoring, you’ll be SAFE. You’ll NOT get brain damage, kidney failure, liver failure, heart attack. If you still worry (understandable), we can do regular medical check ups and blood tests to ensure your physical fitness. With this arrangement, you’re very likely to be healthier than those in the general population (who may not be so health conscious).

Some may get mild side-effects like nausea, gastric problems, headaches, sweating and giddiness, etc. It’s usually transient, not dangerous and easily resolved - there’s no need to be overly worried. If you have concerns over any particular side effect (which is perfectly understandable, e.g. weight gain, dry mouth, sedation), feel free to discuss with your psychiatrist for options: dose reduction, change the type of antidepressant, reduce the number of medicines, or even a trial of non-medication treatment plan.

If your psychiatrist isn’t helpful or you somehow don’t click well with your psychiatrist, I suggest that you consult another psychiatrist (page 23). It’s OK – be kind to yourself, you deserve better service.

It’s not helpful to read on the internet of possible side effects and, scare yourself unnecessarily, and stop the medicines without any discussion with your psychiatrist. Sometimes, the reported ‘sideeffects’ (e.g. tiredness, poor concentration/memory, low libido) could actually be part of the depression, instead of true side-effects of antidepressants. A better way is again to discuss with your psychiatrist.

It’s important to understand the side effects of antidepressants in proper perspective; together with their benefits. Sometimes the benefits of antidepressants (e.g. able to work and prevent a severe relapse with suicidal tendencies) outweigh the side-effects (e.g. weight gain). In this situation, it’s better to continue with the antidepressant and overcome the weight gain by dietary and lifestyle changes.

In summary, taken and adjusted correctly, antidepressants can give a lot of BENEFITS not side effects.

6. How long do I need to take the medicine?

Antidepressants should be taken for at least 6 months. To be more specific, it should be continued for at least 6 months from the time that you ’ re well (NOT from the time you first started taking it). When stopping, it should be done gradually especially if you ’ re on a high dose of antidepressants. If you ’ re thinking of taking antidepressants for only a few days or weeks, you might as well forget about it it won’t work. Antidepressants shouldn’t be taken like panadol (only when it’s necessary). In fact, it takes about 2 3 weeks before they work.

Besides antidepressants, your psychiatrist may sometimes prescribe you another medicine of the benzodiazepine group, e.g. alprazolam (xanax), midazolam (dormicum), diazepam (valium), clonazepam (rivotril). They work immediately for sleep and relaxation; hence also known as sleeping pills or tranquilizers. Their advantage is immediate effect (while waiting for antidepressants to work); the disadvantage is risk of dependence or addiction when taken for long periods. So, it shoudn’t be continued for more than 2 3 weeks. If you ’ re taking it for a longer period, ensure that your psychiatrist is aware of it and monitoring its use.

Before you stop your antidepressant, it’s important that you strengthen your non medication methods (e.g. changing pessimistic attitude and passive lifestyle) to cope with depression. Or else, you may easily get a relapse upon stopping the antidepressant. It’s also not helpful trying to stop medicine during stressful periods, e.g. working in a new company it’s more likely to be unsuccessful.

Some may need to take antidepressants for a longer time, e.g. 3, 5 years or even life long, depending on situations, e.g. a person with repeated suicidal attempts, several hospitalization, unresolved stressors, and poor family support. The good news is antidepressants are generally safe even if taken for a long period of time, if taken correctly with monitoring.

Multivitamin supplementation (especially folic acids and vitamin B’s) may also be helpful, particularly for those who aren’t eating well and has various medical problems.

9. How am I going to tell my family members?

It can be tiring and frustrating trying to answer all the confusion related to depression. To make it easier, you may request your psychiatrist to break the news for you (it’s a kind thing to do for yourself). Your psychiatrist may also give them a booklet or pamphlet on depression to read. These can clarify any doubts that they have on depression, e.g. on how to support you the do’s and don’ts. Of course, you can also pass this book to them. It will be helpful if friends and family can be around during consultation. They can help to clarify doubts and remember the doctor’s advice depression often affects memory and concentration be nice to yourself.

10. Can I recover?

I have enough patients who recover enough to motivate me to remain in this meaningful profession as a psychiatrist. More than 80% of my patients with depression are well enough to move on with their lives. Only some don’t really get well and need to be on long-term

medication. This is usually due to various unfavorable factors: long duration of untreated illness, poor compliance with medicines and therapy, abusing substance (e.g. cannabis, alcohol), poor social support, unconsciously wanting to remain sick for attention, having more than one psychiatric illness. So, if you wish to recover quickly, seek help early and follow the treatment plan you’re already halfway to recovery.

11. When will I recover?

This depends on various factors, e.g. the severity of your depression. There’re also individual differences in how fast a person responds to treatment. Generally speaking, it will take several weeks to see significant improvement in mood and behavior definitely not in a few days be patient. I suggest that you should be mentally prepared to spend at least 3-6 months for a complete treatment plan. Take this positively, like signing up for a certificate course on depression enjoy your learning. You’ll be a better person after this.

12. How do I prevent a relapse?

If you ’ re on antidepressants, please don’t stop too early (it should be continued for at least 6 months after you ’ re well). Try to maintain whatever you practiced that brought you out of depression and kept you well (e.g. all the non-medication recommendations in this book). Just like physical health, mental health doesn’t come free we need to put in effort to maintain wellness.

Relapse often occurs with a unique set of symptoms specific to an individual. Some people call this, ‘signature symptoms’ (e.g. poor

sleep, constipation, bad-tempered). Knowing them enables early effort (e.g. relaxing more, go for counseling, resume medications) to prevent a full-blown relapse.

13. Can I work? Can I have a family, etc?

When you ’ re well, you can do whatever you want in life (as long as you don’t harm yourself or others). Many very successful people in life (e.g. politicians, scientists, musicians, doctors, lecturers, etc) have gone through depression (page 27). Some people also reported that their lives became even better after going through depression.

14. Will my medical records be confidential?

Yes, it’s private and confidential, except during emergencies, e.g. when you ’ re actively suicidal (we may need to get help from your trusted family or friend to support you). We will not reveal your clinical information to your employer, friends, relatives, etc. without your consent. Don’t worry, we ’ re here to help you not give you more problems.

15. How can I sleep better without sleeping pills?

The following ‘sleep hygiene’ practices can help you to have better sleep:

• 1. Avoid caffeine (coffee, tea, Chinese tea, dark chocolate, Coca-Cola) in the evening. Keep away from cigarettes and alcohol.

• 2. Consume hot milk or milk-based products before sleep, e.g. cheese. Avoid heavy dinner or supper.

• 3. Conducive environment for sleep, e.g. quiet, dark, appropriate temperature.

• 4. Do physical exercise during day time (avoid within four hours before sleep), and relaxation exercises (page 130) before sleep.

• 5. Try to sleep and wake up around the same time every day. Avoid nap during daytime; if you’re really tired, close the eyes and rest for awhile on a chair don’t fall into deep sleep.

• 6. If you can’t sleep, don’t lie in bed or stare at the clock. Get up and do something boring outside the bedroom. When you feel tired, try to sleep again.

• 7. Bed should only be used for 2 things; sleep and sex no other activities, e.g. playing computer games. • 8. Have sleep rituals to wind down, e.g. brush your teeth, say ‘good night,’ change into pajamas, read inspirational quotes. Try to avoid exciting activities, e.g. e chat on Facebook. • 9. If you have a lot of worries, write down your ‘to-do-list’ or ‘worry-list’ before you sleep – to be continued tomorrow when you ’ re refreshed. • 10. Review all the pleasant things that have happened throughout the day – smile and have sweet dreams.

16. I’m very restless. What can I do?

Sometimes the cure for restlessness is just rest Colleen Wainwright Restlessness and feeling nervous or anxious often come together with depression. You’ll feel better as your treatment progresses. The following are some ways for you to practice relaxation and cope with restlessness: • 1. Learn to elicit ‘Relaxation Response (RR).’ This is a term coined by Professor Dr. Herbert Benson (Harvard physician), referring to a relaxed state of mind and body. All of us are capable of eliciting RR – here’s the 4-step method: n Find a quiet environment.

n Sit or lie in a comfortable position.

n Place your attention on any ‘mental device.’ This can be sound (e.g. wind chime), word (e.g. “Relax”), phrase (e.g. “All is well…”), prayer (e.g. chanting), fixed gaze (e.g. candle flame), mental image (e.g. fresh flower), breathing or even movement (e.g. walking). This helps to restrain the mind from wandering restlessly.

n Adopt a passive attitude, i.e. don’t worry about the outcome and repeatedly return your attention to the ‘mental device.’

You may practice this for 10-15 minutes at least twice a day. It’s very helpful for relaxation antidote for restlessness.

• 2. Practice ‘Four Pleasant States Imagery’ and other audio guided relaxation exercises from the MINDFULGym CD. http://tinyurl.com/4Pleasant

• 3. Practice ‘Mindful Body Stretching.’ https://youtu.be/o93rxliG-bY This is very good for relaxing the muscles and relieving body aches. A body massage is also a good option.

• 4. Physical exercise, (e.g. brisk walking, badminton), can help to lessen nervous energy. It also helps the brain to produce endorphins which helps to calm the mind and body.

• 5. Express your worries and concerns that can generate restless feeling (either to someone or in your diary). Emotional ventilation will make you feel calmer. You can also pray or

communicate with God or other divine beings for hope and strength to move on with life.

“God, please grant me the Serenity to accept the things that I cannot change, Courage to change the things that I can change, and the Wisdom to know the difference”

- Serenity Prayer by Reinhold Niebuhr -

• 6. If it’s severe, a low dose of benzodiazepine, e.g. xanax (alprazolam) for short-term can be very helpful. Discuss with your psychiatrist. This should always be combined with the above methods as excessive use of benzodiazepine can lead to addiction.

17. I’m very confused and indecisive – should I…?

Don’t make hasty decisions (especially serious decisions, e.g. divorce) when you ’ re not well. Depression can distort your perception of reality and lead to regretful decisions. It’s wiser and kinder to postpone your decision (e.g. whether to quit studying in a university) until the mind is clearer. Your psychiatrist can help you to write a letter to your university (or other authorities), indicating your illness and your need to defer decisions. When your mind is stronger and clearer, you may use the ‘I.D.E.A.L.’ guide to help you in decision-making or problem-solving:

E – Evaluate the pros and cons for each option.

• E.g. Start work immediately

- Pros: Good, my savings are running out.

- Cons: I need more time to figure out my career direction. You can get help from others for this evaluation process be kind to yourself ask for help.

A – Action plan for the selected option based on pros/ and cons.

• E.g. Rest for another two weeks and start work. I need to call up the company to see whether they’re ok if I start work after 2 weeks.

L Learn from whatever decision you have made the good and the bad, e.g. I’m glad that I didn’t accept the job offer hastily. I sought advice from my friends and discovered that there’re other better job offers. A problem is something with a solution. If there is no solution, then there is no problem - Harold Macmilan -

18. How can I change my negative thoughts?

Cartoon by Robin Hall

Congratulations for asking this important question. When you’re aware of and wish to change your negative thoughts, it’s already a milestone in your recovery process. Changing negative thoughts is important as thoughts have the power to generate feelings and influence behavior; feelings and behavior will in turn affect thoughts. So, how can we skillfully change our thoughts?

First of all, be aware that negative thoughts have certain recognizable patterns (cognitive errors/distortions). According to cognitive psychologists, these are the 10 patterns:

1

Fortune Telling or Catastrophic Thinking

Expecting a bad or the worst outcome of something.

e.g. I will definitely fail my exam; he will definitely reject me; there is no more future; I won’t be able to do it; what if this/that terrible thing happens?!; “sure die one,” “ but it won’t work…”

Making generalized conclusion about reality.

2

Labeling or Over-Generalization

e.g. Men never listen; women always talk a lot; local products are bad; government doctors are useless; I’m useless/a failure; he’s a drug addict; I’m schizophrenic; she’s a coward…

Thinking which is either all or none.

3

Black & White Thinking

e.g. If I’m not successful, I must be a failure; If he doesn’t call me again, he’s a bad friend; If I don’t win, I’m a loser…

Focusing and amplifying the terrible things in life.

4

Mental Filter or Tunnel Vision

e.g. I had an accident again; horrible things always happen to me; the internet isn’t working; the maid has run away; my boss is terrible; the phone bill isn’t settled yet…

5 Discounting Positive

Ignoring the good things in life. e.g. I’m not a good mother, those are just my basic responsibilities; I passed my driving test because the examiner was lenient …

6

Blaming or

Personalization

Excessively finding fault with ourselves or others. e.g. It’s all my fault, if not because of me, he wouldn’t have died; I told you, I’ll ruin it; he’s the one who made me suffer; it’s all her fault…he/she should…!!!

Comparing with others in a way that is unfair and undermines ourselves. e.g. My consultant is really good…I’m stupid, why can’t I get it right?; I used to be very good at it before I was sick…

Making decisions and actions based on

e.g. I felt scared during the presentation, I must have done badly; If I’m angry, someone is to be blamed; I’m tired, I should rest more; I‘m scared, I should avoid it…

Telepathy or Mind Reading

Making assumptions about others’ thoughts and feelings. e.g. She doesn’t like me; he thinks that I’m fat; he’s cheating on me; they’re laughing at me; he’s not saying it but I know… 10 Perfectionism or

Rigid in thinking & expecting everything to be ideal. e.g. Everyone must like me; I must always make people happy; everything should be under control; you should listen to me; I must know the cause…why like this/that…why, why, why?!

Adapted from the work of Aaron Beck, Albert Ellis & David Clarke.

Once you’re pretty good at ‘catching’ the negative thought patterns (like having good computer anti-viral software), you can now learn to change them. Before that, it’s important to relate to the thoughts with a right attitude - kindness. Try to imagine dealing with them, as though you’re pacifying a crying baby be gentle. Or else, you’ll end up hating yourself more, “Oh Shit! I have these stupid thoughts again…I’m really horrible,” This perpetuates depression as thoughts often become more ‘sticky’ (emotionally charged and increased in number), when we relate to them with frustration.

Be kind and gentle with negative thoughts. Remember, even people who aren’t depressed have these negative thoughts; only less in amount, frequency and credibility. Let’s look at the ways to transform negative thoughts. I’m introducing the word ‘transform,’ replacing ‘change’ to highlight a kinder and gentler attitude in relating to thoughts.

Five ways to transform thoughts:

1. What is the evidence for and against what I’m thinking? Is there any alternative or more likely explanation?

2. What thinking errors/distortion may I be having? How can I think in a more helpful way? How would I advice a friend or child

3. When you find yourself worrying too much, assure yourself, “What can the worst be? Is it that terrible? What can I do about it now?

4. When the reality is painful and cannot be changed, try to reflect, “Am I alone? Could it be worse? What have I learned from it?”

5. Thoughts may not be facts. Allow them to come and go, like clouds or birds passing through the sky. Practice relaxation (page 130) to calm the mind first; re-examine the thoughts later before believing or acting on them.

These 5 ways of self-questioning and self-reflection (which is based on cognitive behavior therapy CBT) will help us to effectively transform our thoughts, feelings and behavior become more positive and helpful.

Last but not least, again, be kind to yourself you can always get help from your friends in this kind of mind transforming exercise.

Watch your thoughts, for they become words…

Watch your words, for they become actions…

Watch your actions, for they become habits…

Watch your habits, for they become character…

Watch your character, for it becomes your destiny

Frank Outlaw

19. Are there different types of depression?

Yes, there’re different types of depression.

Understanding them is useful as the treatment plan (especially medication) is different. Here are some of the common types of depression:

• Major Depression: This is the most common type of depression seen in clinical practice, which has been described in Part 1 of this book. ‘Major’ here doesn’t mean a severe type of ‘major depression.’ It means depression as an illness (more than the occasional sadness). Major depression is further divided into mild, moderate and severe, depending on the number of symptoms and degree of impairment of function.

• Major Depression with psychosis: This is a severe form of major depression. Besides the usual depressive symptoms, it also has psychotic features hallucinations (e.g. hearing voices, “You should kill yourself”), delusions (e.g. false belief that the organs in the body have rotted). Besides antidepressants, treatment will include antipsychotic, e.g. risperidone.

• Depression of Bipolar Disorder: In this type of depression, mood swings extremely between depression and mania (excessive happiness or irritability, very talkative, over friendly, reduced need

for sleep, increased libido, spending spree, a lot of plans and activities). Treatment will include antipsychotic (e.g. risperidone) and mood stabilizer (e.g. lithium or epilim).

• Post-partum Depression: This is a form of major depression that occurs in 10 20% of mothers a few days or months after childbirth. This should be taken seriously as there’s risk of harming the baby. It’s different from postpartum blues, i.e. a passing state of sadness which occurs in about half of mothers after childbirth.

• Dysthymia: This term is used to refer to low mood which is long-standing (more than 2 years), but low grade (depressive symptoms aren’t as many and severe as in major depression). Stressful events (e.g. unemployment) may trigger a major depression in those with underlying dysthymia – this is also known as ‘double depression.’ Treatment for dysthymia is more of counseling and psychotherapy; antidepressants have only a minor role.

• Adjustment Disorder with Depressed Mood: In this kind of depression, you feel hopeless and sadder than would be expected after a stressful event. Many types of events can cause stress, such

as changing schools or jobs, divorce, the birth of a child, death of a loved one, a severe illness). You usually feel depressed starting within three months after the event and get better in six months or less. The depression is less severe compared to Major Depression and shorter in duration compared to Dysthymia. • Substance/Medication-Induced Depressive Disorder: This is a kind of depression that is caused by using alcohol, drugs (e.g. opioid, amphetamine, cannabis, cocaine) or medications (e.g. steroid, chemotherapy drugs).

20. How do I find meaning and purpose in life?

I don’t mind to suffer as long as it’s for a good purpose Dr. Victor E. Frankl Having meaning and purpose in life energizes us, and it’s important for preventing depression relapse. Life is like riding a bicycle; we got to keep on cycling, to move forward. Or else, the bicycle will stop and fall to the side. Similarly, we got to move on meaningfully in life. Otherwise, we can easily fall - back into depression.

Here are some ways to help us to find meaning and purpose in life:

1. Think of or read about someone who inspires you, e.g. Mother Teresa. Maybe you should try doing something like that.

2. Recall your childhood dreams, e.g. becoming an artist. Maybe it’s time to revisit your dream.

3. Try to do something new and meet new people in life, e.g. new hobbies, new hairstyle, join a book sharing club, go for a holiday in Tibet. You may discover new experiences and purpose in life.

4. Try to do something routine in different ways be creative, e.g. different food for breakfast, taking a different road to work, teaching using new methods. “The real voyage of discovery consists not in seeking new lands but seeing with new eyes.” Marcel Proust.

5. Read about religion, spirituality and philosophy. It broadens the way we think about life.

6. Consider following your heart; not what society says you should or shouldn’t do, e.g. a man becoming a home maker, a medical graduate becoming a chef.

7. Know your signature strengths, (e.g. good listening skill, like to help others, reflective), and use them more to spice up your life, e.g. be a counselor, professionally and in voluntary service. Of course, when the bicycle stops, we can always stretch our legs to the ground to prevent the bicycle from falling. This is like pausing for awhile in life to find new meanings and purpose. It’s OK, but don’t pause too long we got to move on. Often, it’s in the process of moving on that we discover new directions. Enjoy your new journey in life

What should I s ay to support a person with depression?

Effective treatment of depression includes good social support. Despite with good intention, we sometimes say things that are unhelpful or may worsen a person's depression. Below are 10 things not helpful to say to them and what you can try to say instead:

Say: It must be very frustrating feeling tired and moody all the time. You won’t be able to do things for yourself and others. That must be a terrible feeling.

(2) Nothing is impossible; think positive and be strong.

WHY NOT? Having depression isn’t a sign of weakness. Depression is an illness, not a weakness. Many great people in the world had depression, e.g. Winston Churchill (British Prime Minister), J.K. Rowling (author of Harry Potter), and Jim Carrey (actor and comedian). Say: I'm sure it's tough going through all the difficulties. Maybe you’re too strong for too long, and it's time for more self-compassion.

(3) Be grateful; many people have a worse experience.

WHY NOT? This response may be invalidating or disrespecting the emotional pain of a depressed person. They may also think, "Yes, I'm so ungrateful and useless. People can cope and move on, but I can't. I’m a burden to others."

Say: It’s unfortunate that so many bad things had happened to you. Thank you for sharing your experience. We’ll see what we can do to help you cope with the challenges.

(4) It’s a result of your bad karma or sin; do more good and let go-lah!

WHY NOT? We may induce or worsen guilt and shame feeling which are common in depression. It may also trigger thoughts of worthlessness, "I'm not good enough.”

Say: Bad things sometimes do happen in life and nobody knows why. It happened to me/ my relatives/ my friends too (share your experience). It's painful. Let’s try to move on together.

(5) How long more do you want to be depressed?

WHY NOT? Being depressed isn’t a deliberate choice. People with depression are often victims of abuse (e.g. bullied in school) and discrimination (deprived of a job opportunity).

Say: Wow, you’ve been struggling for so long. It must be challenging to go through this alone. Well done for not giving up. Let me know if there’s anything that I can support. We care for you.

(6) You think you’re the only one with problems?

WHY NOT? Yes, all of us have problems. But we have different strength and weakness in coping with problems. It’s not helpful to judge people’s ability to cope.

Say: I also have issues (share your experience). We have different strength and weakness. We can help each other to solve issues. Let me know if you wish to share yours. Maybe we can discover a solution together.

(7) Stop pretending to be depressed!

WHY NOT? Nobody chooses or pretends to have cancer. The same applies to depression, a medical condition with neurobiological changes in the brain and body. A small number of people with depression might have personality issues (e.g. using the illness to avoid responsibilities or seek attention). Bear in mind that they're the minorities. Most of them want to recover from depression but are helpless in battling the disease.

Say: Perhaps you don’t have to try so hard pretending to be happy. Sometimes, it’s OK not to be fine. I know you've tried your best. It’s a horrible illness.

(8) You must be too free and thinking too much. Why don’t you do something useful, e.g. exercise?

WHY NOT? Depression isn’t necessarily caused by having too much of time, doing nothing, or thinking negatively. A person with depressive mood has biochemical abnormalities in the brain and body that cause them to have no strength to work on things. Just as a person with knee injury can’t walk, a person with ‘mood injury’ (depression) can’t work.

Say: Feeling restless and like you’re wasting time is an awful experience. Let’s start with doing the easy tasks.

(9) Never have suicidal thought. Your family will be hurt if you die of suicide.

WHY NOT? Nobody wants to end their lives prematurely. People with depression want to end their pain; not their lives. Having suicidal thought isn’t a choice. It’s the consequence of the pain of depression. Don’t add more pain by making them feel sorry for having suicidal thoughts.

Say: Depression is painful, and it’s understandable that you wish to end the pain. Depression is treatable! Let’s seek advice from mental health professionals for

proper treatment of the pain. I know this good doctor personally/ I heard of this excellent doctor. Would you like me to help you to get an appointment? (10) Your depressive mood will become a form of negative energy to others. WHY NOT? A depressed person knows very well that moodiness and negative thoughts are unhealthy (just like a person with chickenpox infection knows that it’s contagious). When we say the above, they may feel guilty for emotionally disturbing the people around them. Say: It’s natural for a person suffering from depression to feel moody. I know you don’t wish to be like that. No worries and don’t feel bad as people wouldn’t blame you if they have a proper understanding of depression. Let’s move on. You have my support. Speak only if it improves upon the Silence Mahatma Gandhi

Forum for u nderstanding depression with Kindness

In order to highlight the value of kindness in coping with depression, we organized a forum entitled, “Understanding Depression with Kindness,” under Kuala Lumpur Buddhist Mental Health Association. It was held at Utama Bodhi Vihara (Bandar Utama) and well-attended by more than a hundred participants. Moderated by Ms. Low Mi Yen (clinical psychologist), Venerable Kumara (Buddhist monk and meditation teacher) spoke on depression and kindness from a Buddhist perspective. The forum was very inspiring and we had 3 special guests (Jasmine, Yin Hun and Chwee Fang) who courageously shared their experiences in coping with depression. Below is a brief report on the forum by Sis. Chew Poh.

Forum for understanding depression with kindness

6th July, 2012 - I attended a special forum organized by KL Buddhist Mental Health Association (BMHA) with the theme, "Understanding Depression with Kindness." It was a very informative and inspiring forum. Dr. Phang Cheng Kar (psychiatrist & president of BMHA) explained that depression is more than just occasional low moods it’s a serious psychological illness! Among the main common symptoms of depression are persistent feelings of sadness with crying spells, tiredness, and loss of interest in doing things. More serious symptoms include suicidal thoughts or taking one’s own life.

Dr. Phang stressed that just like physical illness, patients who have depression can use antidepressant medication to treat their depression effectively. Antidepressants are non addictive and safe. However, effective treatment of depression should be individualized and include non medication strategies. Thirty minutes of daily exposure to sunlight can brighten up mood. Regular exercise, (e.g. brisk walking at least three times a week, 30 minutes each time) stimulates the production of feel good chemicals in the brain. Healthy eating habits with balanced nutrition are important. Moderate coffee consumption (not more than two to three cups a day) may be helpful to boost energy (provided that you don’t have anxiety symptoms, are able to tolerate coffee, and don’t take it at night). Food rich in omega fatty acids, e.g. fish, soy milk, canola oil are nourishing for the depressive brain. Counseling and more specialized psychotherapy, (e.g. cognitive behavior therapy CBT) are also helpful. Last but not least, friends and family support is extremely important. Dr. Phang ended his sharing by giving a meaningful quote, "If you have depression, it doesn’t mean that you ’ re weak it probably means that you’ve been strong for too long."

It’s crucial for patients with depression to 'ACCEPT' their illness with kindness and seek professional help. This message was echoed by all the three special guests, who had experienced the dark moments of depression, and shared their experience in the forum. Venerable Kumara (Buddhist monk and meditation teacher from Sasanarakkha Buddhist Sanctuary) explained that, from a Buddhist perspective, the root cause of depression is mental defilements like craving and aversion. In this state, the wholesome qualities of the mind, such as confidence, energy and wisdom, are weak. Hence, it’s very important to increase the wholesome qualities. In line with this, BMHA has developed "3G-Gratitude," which is a card game for cultivating these beautiful qualities.

The moderator, Ms. Low Mi Yen (clinical psychologist) then invited three specials guests, all sisters who had gone through depression to share on how they discovered their illness, coped with it, with support from their friends and family.

The first Sister (Jasmine) shared that she started off with mood swings, crying most of the time and having suicidal thoughts. She was referred by her general practitioner to a psychiatrist for

further assessment. She was given questionnaires to answer and went through a thorough interview. Both 'tests' showed that she had depression. The second Sister (Yin Hun) had a negative personality since young. She had a few times subjected herself to self injury. But due to a lack of awareness, her family members didn’t send her for treatment. However in 2004, when she had a very strong urge to end her life, she was finally admitted to a psychiatric ward for treatment. Even though she realized that she had had repeated low moods since she was 15 years old, she never sought professional help. She tried to cope by reading motivational and religious books. However all was in vain. "Please get professional help early!" emphasized the Sister Yin Hun who is on treatment for Bipolar Depression.

Even now and then, she has unpleasant thoughts and feelings. She is aware of them and reminds herself, "I must keep myself busy with work, e.g. jogging and charity work. The bad feeling will come and go eventually." Another Sister said that after learning techniques in MINDFULGym (a local mindfulness based stress reduction and wellness program), she is more mindful of her

thoughts, is able to think positively, and response wisely to problems in life. MINDFULGym is a mindfulness based stress reduction and wellness program organized by BMHA.

As for the last Sister, it began with poor concentration in doing things, loss of interest in activities that she used to like, excessive fear without reasons, reluctance to talk, sad and moody feelings.

Ms. Mi Yen explained that a lot of people cannot accept the fact that they have depression. This is worsened by social stigma and wrong views about depression. Kindness from friends and family members is therapeutic and it facilitates acceptance. We also need to understand that acceptance isn’t an on-off switch - it’s a gradual process. People may need to go through stages of shock or disbelieve, anger, and blame before final acceptance. Venerable Kumara added a witty remark to that, "If you cannot accept, at least accept that you cannot accept."

When asked how they wish they can be supported by their friends and family, they said, "a listening ear and smiling face." A physical touch with care, e.g. holding hands, hugging, a pat on the shoulder also mean a lot to them.

In short, kindness, friendship, listening ears are all very meaningful to people suffering with depression; be kind to them and slowly guide them out from the darkness of depression.

"People surrounding them must be kind and understanding to them. They don’t choose to be like that, e.g. lack of energy, slow in thinking, not motivated, not productive. The worst thing to tell a person with depression is, 'Why are you so lazy!?" Why do you have to do that to me?! (ignoring the fact that 'laziness' is part and parcel of the illness)," reminded Dr. Phang, championing the voice of his patients.

A member of the audience shared her own experience, "Loving ourselves doesn’t mean that we ’ re selfish. We must love ourselves first; then we ’ re able to love others better. Ms. Mi Yen affirmed her view by adding a comment by Ajahn Brahmavamso (Buddhist meditation monk), "When we have worked too hard and are tired of holding a bottle for so long, we should put it down, even for a few minutes; it’s always easier when we take it up again be kind to ourselves."

Another asked if a patient with depression is suited to practice meditation. Dr. Phang said meditation is only suitable for those with mild depression. For those with severe depression (e.g. suicidal,

hearing voices, extremely restless), meditation isn’t suitable; stabilization with medications and family support are more important at this phase of the illness. Venerable Kumara shared that for people with mental illness, such as depression, it’s better to meditate while walking, as it’s easier to practice awareness that way. They can also do that in daily activities, e.g. sweeping the floor, exercising, washing. It’s important that we don’t use meditation as an avoidance strategy to run away from life’s problems, stressed Ven. Kumara.

Yet another asked if depression is genetically inherited. Dr Phang said, "Yes," but it isn’t an unavoidable condition. That is why some people with a family history of depression don’t get it. There’re many things that we can do to influence gene expression and prevent depression. Related to that, someone asked Venerable Kumara whether depression is due to past kamma? "If you ’ re referring to something bad you did in the past life, I honestly don’t know. What we experience now is a result of past conditions. We can't change that. What's important though is how we relate to what is happening now. That's the new kamma that would make all the difference. For example, if we regard depression with kindness, then that's good kamma; that is a condition for the healing of depression," commented Venerable Kumara.

It’s so inspiring to see several members of the audience openly sharing their journey through depression they’re so courageous!

By the end of the forum, the shadows of depression were transformed into a melody of kindness, hope and wisdom it’s truly wonderful. I am so grateful for the opportunity to attend this forum. Thank you.

Reported by Sis. Chew Poh.

Inspirational sayings by the forum speakers:

Things may not get better, but I can always learn to cope better. - Yin Hun –

Acceptance isn’t pleasant; it’s acknowledging what’s happening – that’s kindness. Venerable Kumara

We’re not alone in coping with depression. There’s a light at the end of the tunnel - don’t give up. Jasmine

Acceptance isn’t an on off switch it’s a gradual process. - Low Mi Yen

I’m grateful to depression – it makes a better me. Chwee Fang

Having depression doesn’t mean that you’re weak; it probably means that you have been strong for too long. Dr. Phang Cheng Kar

When depression is recurrent

Mindfulness-based Cognitive Therapy

Depression can be recurrent (happening repeatedly). Each episode of depression increases a person’s chances of another episode by about 15%. Therefore, the more episodes of depression you have, the more likely you’ll get another relapse. Mental health professionals are working hard to find ways to deal with recurrent depression. One of the promising ways is through Mindfulness based Cognitive Therapy (MBCT), which was developed by Professor Dr. Mark Williams and his team at the Oxford University. MBCT is based on ancient wisdom of mindfulness (originated from contemplative traditions especially Buddhism) and state of the art research in cognitive behavior therapy (CBT). MBCT has been shown to reduce the risk of relapse by half in those who have had 3 or more episodes of depression. This is an outline of some principles and exercises used in MBCT.

1. Paying attention to the here-and-now: It means trying to give full attention to whatever that we’re doing. This is important as when the mind isn’t anchored in the present-moment experience,

it tends automatically to ruminate about the past (guilt content) or future (worrying content) which is vulnerable to depression relapse. Strategies to cultivate here-and-now awareness include:

a) Labeling – mentally naming and giving full attention to our activities, e.g. ‘typing,’ ‘eating,’ ‘walking,’ ‘thinking,’ ‘talking,’ ‘sweeping,’ ‘checking e-mails.’

b) Sensing giving full attention to our sensory experience, e.g. seeing, hearing, smelling, tasting, touching.

c) Beginner’s mind – experiencing life with an attitude of a beginner, as if seeing things through fresh lenses and thinking of it as once in a-lifetime experience, e.g. eating chocolate slowly, with full attention and as though tasting it for the first time.

2. Mindful walking: It involves paying full attention to the process of walking: 1. Labeling the movements of the legs, “Left…right…left…right,’ and 2. Noting the sensations around the feet and other parts of the body (e.g. wind brushing against the skin). Besides benefiting physical fitness, this is very helpful for overcoming bodily restlessness and to slowly calm the mind.

3. Breath as emotional anchor: Mindfulness of breathing involves repeatedly bringing gentle awareness to our breathing, “Breathing in, I’m aware than I’m breathing in. Breathing out, I’m aware that I’m breathing out.” This trains the mind to be less scattered and more present or calm, which is very useful during emotional storms Breathing is a useful mindfulness ‘tool’ as it’s with us wherever we go (we can’t go anywhere without it).

4. Body scan and awareness: It involves repeatedly bringing gentle awareness to the physical sensations (e.g. heat, tightness, tiredness, pain) in different parts of the body (e.g. chest, neck, head, hands, legs, stomach, back), and noting them with kindness, acceptance, and a sense of curiosity (beginner’s mind). This is useful in several ways: 1. It helps to disentangle ourselves from our thoughts; won’t be so easily sucked into the drama of negative thoughts. 2. It breaks the conditioned link between body sensations and thinking (e.g. feeling physically tired which triggers negative memories). 3. It helps us to be more aware of our ‘thinking-feeling’ as body sensations are mirror to our thoughts and emotions sort of a natural bio-feedback device.

5. Mindful awareness of thoughts: In recurrent depression, the problem is usually not so much of the sadness which is brief and

‘normal’ (part and parcel of life). It’s more of how our mind reacts to the sadness with aversion, “Oh my God, It’s back again!” “What’s wrong with me?!” “Why can’t I just get over this?!” “Come on, move on lah!” “I shouldn’t be like this!” “Shit, I should have tried harder!”

Such kind of self critical thoughts can easily suck us back into the depression ‘black hole.’ Mindfulness of thoughts involve mentally stepping back and looking at the thoughts from a distance with kindness – like watching birds and clouds passing through the sky.

In the process, one realizes that thoughts are just creations of the mind which can be distorted. With that realization, we can respond to situations wisely, instead of reacting impulsively, and end up with full blown depression relapse.

This is the Chinese character for ‘Mindfulness,’ with sub characters of ‘now,’ ‘heart/compassion’ and ‘home’ all representing important values for healing of depression.

For further information on MBCT, you may refer to the book, “The Mindful Way through Depression: Freeing Yourself From Chronic Unhappiness,” by Mark Williams, John Teasdale, Zindel

Segal & Jon Kabat-Zinn. In Malaysia, similar mindfulness-based therapy is available at Sunway Medical Centre http://sunwaymedical.com/doctor/dr-phang-cheng-kar/ FREE online MINDFULGym courses by Dr. Phang Cheng Kar for stress reduction, good health, and

Jasmine’s Journey of

A Journey Of Recovery

I first shared about my depression (Journey of Depression) in the book “I’m Still Human Understanding Depression with Kindness,” co-authored with Dr. Phang in 2012. Now, in 2020, it’s my 10th anniversary of living with depression. I’m grateful that Dr. Phang invited me to share my experience further in recovering from depression (Journey of Recovery). I dedicate this book to all who are struggling with their mental health. By the power of my sharing, may they be free from mental suffering and live happily.

OMG – It’s Never Easy

The journey of recovering from depression is challenging. In the process of healing, I underwent many episodes of depression relapse. I was tired and frustrated as I battled with the illness. At times, I doubt whether I’m on the right path to improving my mental health. However, I’m glad I learned wiser ways in handling mood swings with each relapse. The American professor and creator of the Mindfulness-based Stress Reduction (MBSR), Dr. Jon Kabat Zinn, said, “You can't stop the waves, but you can learn to surf.” Our mission in recovery is learning to surf the waves of emotional storms and stay afloat to live meaningfully. If we manage our triggers, thoughts, and feelings properly, we can ride the waves with ease and be happy.

More Than Just Depression

Besides episodes of low mood, I often had excessive worries, panic attacks, mood swings, and sometimes visual hallucinations of a little girl saying negative things (critical and suicidal). Oh no! It’s terrible enough to have depression. You can imagine the hell I went through with the additional anxiety and psychotic symptoms. I started to have many worries, especially about whether I will ever recover from my mental difficulties. “No worries, things will get better, slowly, but surely,” I repeatedly consoled myself.

It’s Scary – Panic Attacks!

Due to excessive fears and worries, I had several panic attacks. I still remember clearly the first time I had a panic attack. It occurred on a quiet night when I was ready to go to bed. I suddenly had difficulty breathing, chest tightness, numbness in hands and fingers, and a fast heartbeat. It was like having a heart attack, and I felt like I was going to die. My family sent me to a hospital accident and emergency (A&E) department for a check up. The medical officer said it was not a heart attack; there was nothing wrong with me, and I could go home and rest. The next day, I contacted my psychiatrist. I described what had happened, and from there, I finally understand what a panic attack is. Even though I encountered various disturbing symptoms related to depression, I want you to know - depression is treatable. So, please don’t give up. There’re many effective treatments for depression nowadays. Please seek professional help earlier for a better outcome.

Ouch! – Invisible Pain

We often hear from people who suffer from depression that you won't understand how painful depression is. Yes, depression is PAINFUL! You can't fully understand it unless you also suffer from the same illness. The pain is invisible; it appears in the forms of disturbing thoughts and feelings instead of physical injuries like broken bones. When you're feeling depressed or anxious, you'll typically believe, "I'm useless," "I'm a failure," "I'm hopeless," "I'm a burden," and so on. The mind is bleeding, and it's very damaging to self esteem and mental health. People don't readily understand depression compared to physical diseases like cancer. You're not alone. I know it's intense suffering. But please remember; it's not that you're terrible, it's the illness that makes you feel horrible. You're not bad; the condition makes you feel bad.

Don't Delay - Seek Proper Treatment

Even though depression is common, people often delay seeking professional and medical help. The main reasons are the lack of understanding of depression and treatment options, social stigma on mental illness, and a person's denial of the disease for various reasons. Over the years, I've seen many people who procrastinate treatment, resulting in immense suffering. The longer the illness is left untreated, the more it damages our physical health, self-esteem, relationship, and productivity. That also means it's harder to recover when one is ready for help. Even if it’s late, never mind, it's okay. It’s better to be late than never. Get help now, follow the recommended treatment plan, and life will be brighter.

Is It Just Emotional Flu?

Some people call depression "emotional flu." Unfortunately, the treatment for depression isn’t as simple as just taking flu or fever medicine, and you recover within a week. There're many causes and conditions for a person to develop depression. Therefore, it's essential to have a proper understanding of our illness. I’ve come a long way to explore and understand the factors that contribute to my depression, e.g. low self esteem, high expectation, family issues, lack of self-compassion, and nonassertiveness. I’ve realized, besides taking antidepressant medications, you'll need a holistic treatment plan that includes talking therapy, relaxation and mindfulness training, a healthy lifestyle, and the right family and friend support. The comprehensive treatment takes time. There's no short cut for deep healing. Without this understanding, it's tough to have a real improvement in therapy.

Trust Me –

Medicine Is Very Important!

Medicines for the brain and nerves play a vital role in my recovery. It's an integral part of my treatment plan besides psychotherapy and family support. The antidepressant medications help stabilize my mood before we can proceed with other therapy methods that focus on addressing the underlying emotional issues. People with depression often have the dilemma of taking medicine, including myself. It’s natural to be concerned about any medication's side effects, such as weight gain, dependence, and drowsiness. Never believe what you read on the internet blindly. If not, you'll be very confused and worried, like what happens to many people. Instead, find a caring and patient doctor, discuss your

concerns, and find medicines that suit you the most.

If you’re already taking an antidepressant, never stop consuming it or reduce the dose without discussing it with your doctor. This practice prevents withdrawal symptoms, recurrence, or worsening of the ailment.

Have I Recovered?

On many occasions, out of concern, my close friends asked, "Have you recovered from your depression?" My answer to them is always, "YES, but I'm still on medication." They don't seem to agree that I've recovered from depression. To most people, recovery means a person is entirely well and no longer needs any treatment. This belief is logical, but it doesn't apply to chronic and severe types of depression, like the one I'm having. I have a different and more realistic definition of recovery. Recovery means I can move on with my life, perform my daily routines with medicine's support. I can learn new things to upgrade myself and share my experience to benefit others. It's good enough. After all, numerous…

people with chronic physical conditions like high blood pressure, high cholesterol, diabetes also take medicine for the long term, even some for a lifetime. I don't have to be free from medications to be free from depression. That's how I befriend my illness. I like the word "befriend" instead of "fight" depression, which reminds me of the value of gentleness and kindness in relating to depression.

Small Is Beautiful - Set Small Goals

When we're in the zone of depression, it's typically hard to do anything, even a simple task. When I was severely depressed, to bathe every day was pretty challenging for me. There were times when I didn't shower for the entire week. So, don't expect too much from yourself with heavy responsibilities, e.g. disciplining the children, managing the household, making a crucial decision like changing job or divorce. Else, you'll be disappointed and hate yourself more and more. Try to kick-start the day by doing simple activities, e.g. brush your teeth, water the plants, feed the cat, make the bed. The satisfaction from accomplishing the smalls goals will charge up energy for more actions on the to-do list. In this way, gradually, you'll be more in charge of your life and feel good about yourself.

A Mindful Attitude

Practicing mindfulness, which I've learned from the MINDFULGym program, becomes my daily mind-body workout. It's nice to cultivate the ability to relate to our experience with an attitude of kindness, a beginner's mind, and wisdom. Being mindful, I'm aware when a depression relapse is coming. I can recognize my negative thought patterns. Once identified, I'll usually do the mindful body stretching and breathing exercises to help me relax. Then I'll relate to the negativity with a mindful attitude:

Kindness: I gently acknowledge, accept, and embrace all the unpleasant emotions with compassion. "The most important thing to do is self-care," I continuously remind myself. I've learned not to

fight with the feelings but befriend them with a beginner's mind and wisdom. Beginner's mind: I try to see my difficulties with empathy instead of harsh judgment. Like the clouds passing through the sky, I let the mental chatter come and go when they're ready. I remind myself that thoughts aren’t necessarily facts, and they're impermanent. That's how I apply "social distancing" to my 'infected mind' to keep myself safe. Wisdom: Nobody likes to have painful experiences. But they teach us valuables lessons. I've learned that everything happens for a good reason. The reasons might not be apparent now. But with time, we'll discover and cherish them. The problems in life are like fertilizers for our growth. When there's no mud, there's no lotus, as Zen master Thich Nhat Hanh says. sketchesinstillness.com

Live In The Present Moment

Since my secondary school days, I often hear people say, "don't overthink, live in the present moment." It's true, but I didn't fully understand its practical use until the recovery phase of my depression. To 'live in the present moment' means purposefully paying attention and be grateful for any positive experience, no matter how trivial it might be. This effort helps to build positive emotions. It also means to relate to ourselves with kindness; in thought, speech, and action, when we encounter any negative experience. Living in the present moment makes me happier and more resilient. It's a lovely way of life.

It’s OK Not To Be Okay

Low self-esteem and lack of self-compassion are among the main contributory factors for my depression. In the past, I like to criticize and blame myself. I felt so much hatred for myself, as I thought I was a failure in life. Thinking in this way is unhelpful for my recovery. I started to learn ways to love, trust, and appreciate myself. I realize that being kind to myself is more than treating myself with love and compassion. It's also learning to make peace with my past mistakes and forgive myself. I got up from where I fell and transform imperfection into meaningful lessons that I can share with and benefit others. “Real beauty doesn’t lie in perfection, but in embracing and accepting imperfection,” says meditation teacher Ajahn Brahmavamso. So, It's OK not to be okay. Just be kind to yourself and stay hopeful.

It’s Time For ‘Me-Time’

The concept of 'me-time' was so alien to me. It took me a long time to comprehend that me time is self care time instead of moments of selfishness. I hope you can likewise resolve this misconception that leads to a lot of inner conflicts. This reminder is vital when you're a responsible and conscientious person, like me. Nowadays, it's easier for me to take me time without feeling guilty. I ensure I give myself sufficient time being alone to refresh, reboot, and recharge. The freedom to be alone gives me time to do things that I like, which generates joy. It also gives me the space to contemplate the true meaning and purpose of life. Me-time, I love you.

Gyming The Mind & Body

I try to maintain an exercise routine to keep my mind and body healthy. My regular mind-body fitness plans consist of mindfulness practice (body stretching and breathing), chanting, loving-kindness, and gratitude meditations. Occasionally, I will run on a track mill while enjoying inspirational movies or listening to uplifting music. Regular exercise helps to increase dopamine, serotonin, and endorphin levels in the brain and body. These natural feel-good brain chemicals are useful for enhancing feelings of well being. It's also helpful to do something meaningful or passionate to us, such as gardening, keeping pets, playing music, making handicrafts, and doing voluntary service. Sometimes, it can be tough to find things to do and hold the energy to accomplish an activity. My experience tells me that we need to push ourselves and experience some tension if we want to recover from depression. Try to 'just do it' even if we don't like it, for a better future.

Accept, Adjust & Move On (AAM)

No matter how strong we are, we have our vulnerable moments in life. It's easy to feel helpless and hopeless if we don't have the skills to cope with obstacles. The 'AAM' (Accept, Adjust & Move On) is an indispensable tool for me to befriend depression and strengthen resilience in my recovery journey. Accept: I recognize and acknowledge challenges connected to my depression with kindness (e.g. soothe myself with mindful body stretching and breathing). I try not to beat myself up when triggered.

Adjust: I adjust the way I perceive things for a clearer understanding of a problem. Seeing things from different perspectives often helps in finding creative solutions.

Move On: I learn to let go/let it be if I can't solve an issue. Not everything has a solution, and worrying is pointless. It's good enough when we don't make things worse. We can then channel our energy for other things that are within our control.

When I'm emotionally stuck, I try not to push myself too hard to 'AAM.' I give myself permission to stay with the unpleasant thoughts, memories, and feelings for a while. In the process of ‘resting’ (non struggling), I often see things with greater clarity and learn new lessons.

It’s better to light a candle than to curse the darkness

- Chinese Proverb -

Mental Immunity 5 Mindful Vitamins

When our body immunity is low, we take Vitamin C or other supplements. As for me, when my emotional immunity is down, I take the '5 Mindful Vitamin.' The mental vitamins are positive mental attitudes that help me handle adverse situations.

I'm not alone: Instead of feeling shameful or isolated, I remind myself that they're other people with a similar experience whom I can seek advice.

It could have been worse: Instead of feeling overwhelmed, I remind myself that whatever hardship that happened isn’t that bad or could have been worse in many ways.

What I can I do now? Instead of wasting time worrying or regretting something, I remind myself to focus on what I can do to make things better.

What have I learned? Instead of resenting people or events that caused afflictions, I remind myself to learn something useful from the experience.

This will also pass: Instead of holding on and magnifying problems, I remind myself that all unpleasant feelings and situations are impermanent.

sketchesinstillness.com

A Gratitude Visit

Every year, I pay a visit to Dr. Ong, the family doctor who first diagnosed me with depression and referred me to Dr. Phang for further treatment. This year, 2020, is no different. Since the last time I visited his clinic was a year ago, I was concerned I couldn't recognize the roads to the place well. Nevertheless, I decided to travel without GPS support. I wish to revisit the memories intertwined with the journey when I first sought help for depression.

As I drove along, I became familiar with the roads, sceneries, and painful recollections. Yet, I felt peacefully detached as many things had changed for the better over the years. It reminded me about the Buddha's teaching of impermanence. I'm glad that the distressing

event's memories are still there but diluted and colored with new happy ones.

The moment I stepped into the clinic, Dr. Ong welcomed me with a smiling face. He's a kind and compassionate doctor who shares the Dharma with me for deep healing. This year I visited him with wholly grateful and joyful hearts. It's unlike the past years, whereby I still had unfinished sadness. In this encounter, I related an incident to Dr. Ong regarding my visit, a year ago, to the place that I attempted suicide. Out of expectation, I broke down and cried profusely. I never thought I had such an intense memory about the occurrence.

Here's what Dr. Ong explained to me inspirationally:

"Some people will purposely revisit places associated with sadness. It's a kind of therapy that enables a person to courageously confront feelings of sadness, guilt, fear, and so on. It's okay that you have unpleasant feelings or thoughts while going through the process. Your emotions along the journey to visit me have transformed over the years. The experience is part of our growing pain, and it helps with gradual letting go of the past. Emotional anguish lessens as time passes. This year, you have finally conquered your trauma. That's very good. Time is the best healer."

Even though our meeting was short, it was therapeutic for me. It's like a vaccine to raise my mental immunity. I left Dr. Ong's clinic with immense gratitude. Thank you for everything you have done for me, Dr. Ong. I also never forget to thank myself for not giving up on my life and continuing to be a better person. sketchesinstillness.com

Be Grateful To Be Happy

Life with depression is tough, but I'm grateful for everyone and everything I have. I make an effort to count my blessings every day. I keep a gratitude diary to pen down three good things that happen in a day. Initially, it was quite challenging to think about good things. We tend to remember adverse events more easily; happy memories require more effort to recall. I like the exercise called 'Google-WWW-Yahoo,' which I learned from the MINDFULGym program. It's an exercise to train your mind to pay attention to the positive things in life and cultivate gratitude. How to practice this exercise? Firstly, try to 'Google' (mentally search or recall) '3W's' (what went well) every day and 'Yahoo' (rejoice or celebrate) the good things in life. Once you get in the habit of doing this daily, you'll notice it's easier to find happy things to be grateful for. This is because your mind automatically begins to think with gratitude.

Voluntary Service - I'm Not Alone

I sincerely appreciate the opportunity to do voluntary service at the KL Buddhist Mental Health Association. Along with the voluntary service, I’ve gained a lot of knowledge about mental health through talks and training programs. I learned techniques for relaxing the body, relieving mental stress, cultivating mindfulness, and nurturing a positive mindset. In sharing those methods, I met many people and realized that depression is a common human experience. I discover that it benefits my mental health by assisting others, as I feel I'm useful and needed. Life becomes meaningful when I get to honour my suffering by sharing the lessons to aid others.

Don’t Give Up, Be Hopey!

The tips I mentioned, coping strategies, and exercises are beneficial for my recovery from depression. I hope my sharing can help you to manage your depression better. It's OK if you find the approach not suitable for you. That's very normal as there's no one size-fits-all way for depression recovery. Don't give up. There’s light at the end of the tunnel. My sharing is just a guide to lighten your depression. It would be best if you always discussed with your therapist or doctor to decide what suits your conditions. Thank you for spending your precious time to read about my journey of recovery. May you be well and happy.

Further reading on depression

• Depressed Little Prince http://www.depression.edu.hk/en/home.html

• Beyond Blue https://www.beyondblue.org.au/

• Blue Pages https://bluepages.anu.edu.au/

• Black Dog Institute https://www.blackdoginstitute.org.au/resourcessupport/depression/

• Depression – National Institute of Mental Health http://www.nimh.nih.gov/health/topics/depression/index.shtml

• WedMD - Depression Slideshow http://www.webmd.com/depression/slideshow depression overview

• The Mood-Gym – Online CBT for Depression https://moodgym.anu.edu.au/welcome

After rain there’s a rainbow,

After a storm there’s calm,

After the night there’s a morning,

After an ending there’s a new beginning

Anonymous

Acknowledgement

I would like to thank the following online services for providing the use of photos and graphics in this book:

• Pixabay http://pixabay.com/

• MorgueFile http://www.morguefile.com/

• Wikimedia Commons http://commons.wikimedia.org/wiki/Main_Page

• Open Clip Art Library http://openclipart.org/

• FreeFoto.com http://www.freefoto.com/index.jsp

• Illustrations by Francois Lange https://www.sketchesinstillness.com/

• Cover image (cat & duck) Licenced by https://www.123rf.com/ &

Sis. Lilian Thong for suggesting the name of the book, Sis. Looi Sow Fei for language editing service, reviewers for valuable feedback for improvement.

DONATION

The publication of this book for free distribution is made possible through the kindness and generosity of the following donors. By the power of this goodness, may all beings be well and happy.

Anonymous • Ang Yoke Seng • Andrine Chan Mei Yoong • Anudeep • Brickfields Maha Vihara • Ban Yok Fong • Barbara Yen & Bro. Wuan • Bro. Yeoh & Family • Caren Yong • Chin Kong Meng • Chow Mun Wai • Chandra Malar • Cheong Lin Hi • Chai Lee lee • Chua Chong Hock & Family • Chew Poh & Family • CY Kow • Chuan Boon Teik • Chua Ah Hua • Chong Yi Leng • Chong Siew Ling • Chai TY • Chan Kah Yein • Chan Yoke Keng • Cheak Sook Kun • Doris (Sentul Clinic) • Dato’ Jeff Yap & Datin Nicole Ting Yap • Eddy Loh Wai Mun • Emelia Kam • Florence Ng & Sisters IMO Mr. & Mrs. Ng Soon Swee • Foo Fatt Mee & Family • Foon Kien Poo • Goh Sho Ring • Gan Poh Yan • Grace Lim Yew Min • Gaik Siew • Hon Lee Keow • Hooi Hooi & Family • Hamidah • Hoh Li Jiun & Hoh Li Yun IMO • Lau Foong Choo • IMO Phang Ah Keong & Family • IMO Chooi Ah Wah • IMO Sit Su Ling • IMO Kee Liang Chor • IMO Lim Swee Hin • IMO Phoon Choy & Aw Ah Feng • IMO Chin Kim soon & Hiew Wei Yuen IMO of Chin Kim Soon & IMO hiew Wei Yuen • IMO Mr. Au Yeong Thoong Kong • IMO Low Geok Fei • IMO Lau Geok Lian • IMO Bobby Yap • Irene Ang & Family • Juliana Oo • Joie Lee • Jessica Lee • Jasmine Choong • Jasmine & Family • Jaspal • Jenny Ong • Kemmy Chew & Vince Ng • Kathyrn Geh • Katherine Loo Kian Mei Ming & Family • Lee Teeng Teeng • Loh Hock Sun & Family • Liang Wei Fung • Lim Eng Bee • Lau Ah Tee • Lee Suan Seng • Leong Lai Kah • Lau Hong Mui • Lau Hui Ling • Lau Phaik Lin • Lau Ron Hsein & Lau Yi Ling • Lawrence Lim • Lee Oi Choo • Lilian Thong • Han Sheng • Han King • Han Huang • Lee Yoot Khuan & Kids • Lin Jik Khoong • Lim Li Lian • Lim Chin Chin • Low Khoon Hwa & Family • Loh Hooi Khin • Lum Peck Woon • Mittas from Singapore • Mimi Wong & Family • Mah Li Chen • Mrs. Tay Kim Soon • Mita, Nitha, Thana & Vicnes • Mr. & Mrs. Tan & Family • Mudita Yin Fan & Family • Nalanda Buddhist Society • Ng Peng Seng & Family • NLWong • Pearly Toh & Family • Pun Chee Kent • Quah Siew Chin • Quah Poh Lean • Rob & Ling Moult • Rose Cho • Sentul Buddhist Temple • Soo Yuet Yeng • Siew Fay & Family • Soh Lai Sim • Stuart Chua Yu Tang • Satpal Kaur • Soo Lay Khim • Tuen Foo Fat • Tan Joo Sin & Family • Tan Chee Eng • Tham & Family • Teoh Guan Huat • Turning Point • Tee Ee Chien & Family • Wong Bee Mi • Wong Yan Kuiw • Wong Mei Ying • Yeoh Lee Quan • Yeoh Ah Tu • Yeok Kim Yeok • If the names are erroneously spelt or omitted from the donor list, I sincerely apologize for the oversight. I will ensure it’s rectified in the next reprinting, should the errors be made known to me (klbmha.info@gmail.com). All excess funds received for this book shall be used for reprinting. If you wish to support future reprints of this book, you may bank in the donation to KUALA LUMPUR BUDDHIST MENTAL HEALTH ASSOCIATION (Maybank, account number: 5144 7702 2950) with an email and attached bank slip to me (klbmha.info@gmail.com).

A brief introduction of BMHA: http://www.klbmha.com

Kuala Lumpur Buddhist Mental Health Association (BMHA) was established on 1/3/2010 to promote mental health in the Buddhist community through Buddhist psychology and Buddhism-influenced psychotherapies.

Objectives of BMHA:

• To provide guidelines on principles, standards and ethics for the application of Buddhist wisdom for mental health.

• To promote positive mental health in the general community with emphasis on psycho spiritual well being.

• To support its members in self-care and continuous professional development in counseling and psychotherapy.

• To collaborate with other organizations in providing mental health education and service.

• To facilitate research related to mindfulness and other psycho-spiritual principles of well-being.

Books, CD’s & online resources

by the same author

1. No Worry Lah, Be Happy: A Medical Student’s Motivational & Inspirational Guide. http://issuu.com/pckar/docs/dwbh FREE

2. Don’t Worry, Be Healthy A Buddhist Guide for Health & Healing Volume I & II. http://tinyurl.com/dwbhealthy FREE

3. Progressive Muscle Relaxation Made Clear & Simple.

• Video https://youtu.be/o93rxliG bY FREE

• Book http://issuu.com/pckar/docs/pmr FREE

4. JOM Lah FIKIR: A Guide On Transforming Your Thoughts For Happiness http://tinyurl.com/jomlah fikir FREE

5. NOW Who Wants To Learn MINDFULGym? 12 Mindful Tools For Stress Reduction & Wellness https://payhip.com/b/YHGq

6. Contentment as an Antidote for Depression Audio CD http://tinyurl.com/contentment-depress FREE 7. Mental Illness, Spirits or Charm? Audio CD (FREE) https://soundcloud.com/zhen_phang/sets/mental illness spirits or 8. Garden of Mindfulness: Audio Guided Mindfulness Practice for Relaxation & Wellness - FREE https://soundcloud.com/phang cheng kar/sets/mindful gym

9. iMINDFUL-Gym DVD: 8 Mindfulness-based Lessons for Stress Reduction & Wellness FREE http://mindful gym.blogspot.my/2014/06/i mindfulgym course.html

10. 3G GRATITUDE: Card Game for Cultivating Happiness https://www.mindfulgymalaysia.com/mindfulgym gratitude workout2