Bipolar4LifeSupport

What Are Mixed Episodes in Bipolar Disorder?

Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed features experiences symptoms of both mood “poles” — mania and depression — simultaneously or in rapid sequence.

Who Gets Mixed Bipolar Episodes?

Virtually anyone can develop bipolar disorder. About 2.5% of the U.S. population has some form of bipolar disorder – nearly 6 million people.

Mixed episodes are common in people with bipolar disorder — half or more of people with bipolar disorder have at least some mania symptoms during a full episode of depression. Those who develop bipolar disorder at a younger age, particularly in adolescence, may be more likely to have mixed episodes. People who develop episodes with mixed features may also develop “pure” depressed or “pure” manic or hypomanic phases of bipolar illness. People who have episodes of major depression but not full episodes of mania or hypomania also can sometimes have low-grade mania symptoms. These are symptoms that are not severe or extensive enough to be classified as bipolar disorder. This is referred to as an episode of “mixed depression” or a unipolar (major) depressive episode with mixed features.

Most people are in their teens or early 20s when symptoms from bipolar disorder first start. It is rare for bipolar disorder to develop for the first time after age 50. People who have an immediate family member with bipolar are at higher risk.

What Are the Symptoms of a Mixed Features Episode?

Mixed episodes are defined by symptoms of mania and depression that occur at the same time or in rapid sequence without recovery in between..

Mania with mixed features usually involves irritability, high energy, racing thoughts and speech, and overactivity or agitation.
Depression during episodes with mixed features involves the same symptoms as in “regular” depression, with feelings of sadness, loss of interest in activities, low energy, feelings of guilt and worthlessness, and thoughts of suicide.
This may seem impossible. How can someone be manic and depressed at the same time? The high energy of mania with the despair of depression are not mutually exclusive symptoms, and their co-occurrence may be much more common than people realize.

For example, a person in an episode with mixed features could be crying uncontrollably while announcing they have never felt better in their life. Or they could be exuberantly happy, only to suddenly collapse in misery. A short while later they might suddenly return to an ecstatic state.

Mood episodes with mixed features can last from days to weeks or sometimes months if untreated. They may recur ,and recovery can be slower than during episodes of “pure” bipolar depression or “pure” mania or hypomania.

What Are the Risks of Mixed Features During Mood Episodes of Bipolar Disorder?

The most serious risk of mixed features during a manic or depressive episode is suicide. People with bipolar disorder are 10 to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, as many as 10% to 15% of people with bipolar disorder eventually lose their lives to suicide.

Evidence shows that during episodes with mixed features, people may be at even higher risk for suicide than people in episodes of bipolar depression.

Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, may help to reduce the risk of suicide.

People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.
What Are the Treatments for Mood Episodes With Mixed Features in Bipolar Disorder?

Manic or depressive episodes with mixed features generally require treatment with medication. Unfortunately, such episodes are more difficult to control than an episode of pure mania or depression. The main drugs used to treat episodes with mixed features are mood stabilizers and antipsychotics.

Mood Stabilizers

While lithium is often considered a gold standard treatment for mania, it may be less effective when mania and depression occur simultaneously, as in a manic episode with mixed features. Lithium has been used for more than 60 years to treat bipolar disorder. It can take weeks to work fully, making it better for maintenance treatment than for acute manic episodes. Blood levels of lithium and other lab test results must be monitored to avoid side effects.

Depakote is an antiseizure medication that also levels out moods in bipolar disorder. It has a more rapid onset of action, and in some studies has been shown to be more effective than lithium for the treatment of manic episodes with mixed features

Some other antiseizure drugs, such as Lamictal and Tegretol, are also effective mood stabilizers.

Antipsychotics

Many atypical antipsychotic drugs are effective FDA-approved treatments for manic episodes with mixed features. These include aripiprazole (Abilify), asenapine (Saphris), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon). Antipsychotic drugs are also sometimes used alone or in combination with mood stabilizers for preventive treatment.

Electroconvulsive Therapy (ECT)

Despite its frightening reputation, electroconvulsive therapy (ECT) is an effective treatment for any phase of bipolar disorder, including manic episodes with mixed features. ECT can be helpful if medication fails or can’t be used.

Treatment for Depression in Mixed Bipolar Disorder

Common antidepressants such as Prozac, Zoloft, and Paxil have been shown to worsen mania symptoms without necessarily improving depressive symptoms when depressive and manic symptoms occur together. Most experts therefore advise against using antidepressants during episodes with mixed features. Mood stabilizers (particularly Depakote), as well as atypical antipsychotic drugs, are considered the first-line treatments for mood episodes with mixed features.

Bipolar disorder usually involves recurrences of mixed, manic, or depressed phases of illness. Therefore, it is usually recommended that medications be continued in an ongoing fashion after an acute episode resolves in order to prevent relapses.

Treatment for bipolar depression has come a long way from the days (not so long ago) when patients were given sedatives and medications with numerous side effects. Today, mood stabilizing drugs are a mainstay treatment for bipolar disorder. Doctors may prescribe lithium, an antimanic drug, or an antipsychotic drug — or a combination of both — in order to alleviate symptoms of depression without triggering a manic episode.

While depression episodes are far more common than manias and have a tremendous effect on the lives of patients, there are only a few established treatments for bipolar depression.

What’s the standard treatment for bipolar depression?

Lithium and the anticonvulsants lamotrigine and valproate are mood stabilizers that are sometimes used “off label” as treatments for bipolar depression, although none of these has been established as an FDA-approved first-line treatment for bipolar depression. For many years, psychiatrists have traditionally added an antidepressant to a mood stabilizer if a mood stabilizer alone is ineffective; however, research shows that antidepressants are often not effective for bipolar depression.

A mood-stabilizing medication works on improving social interactions, mood, and behavior and is recommended for both treatment and prevention of bipolar mood states that swing from the lows of depression to the highs of hypomania or mania. According to the American Psychiatric Association (APA), lithium, lamotrigine, valproate, carbamazepine, and most atypical antipsychotic medications are approved by the FDA for treating one (or more) phases of bipolar disorder.

In some patients with bipolar disorder, a mood stabilizer may be all that’s needed to modulate the depressed mood. However, in bipolar patients who do not respond to one mood stabilizer, another mood stabilizer or an atypical antipsychotic is sometimes added to the treatment regimen.

Are antidepressants used to treat bipolar depression?

While antidepressants are effective treatment for people with major depressive (unipolar) disorder, antidepressants they are not always as effective for bipolar depression, and generally should not be given alone (monotherapy) in people with bipolar I disorder. When antidepressants are given alone to someone with bipolar disorder, there’s a risk the drug might ignite a manic episode in some patients. Knowing this, most doctors may avoid using antidepressants as monotherapy for bipolar depression.

A very large randomized study sponsored by the National Institute of Mental Health (NIMH) called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) showed that mood stabilizers alone produced a stable improvement only in about 1 in 4 people with bipolar depression, and surprisingly, adding an antidepressant to the mood stabilizer did not increase the chances for improvement. The STEP-BD study underscored the need to find treatments other than mood stabilizers or antidepressants for bipolar depression.

How are antipsychotic medications used in treating bipolar depression?

Studies have shown that some (but not all) antipsychotic drugs are in themselves effective treatments for bipolar depression. Seroquel and Seroquel XR are used for the treatment of depressive episodes associated with bipolar disorder. Another effective drug with rapid onset for the treatment of bipolar depression is Symbyax, a combination medication of the atypical antipsychotic Zyprexa (olanzapine) and the selective serotonin reuptake inhibitor (SSRI) Prozac (fluoxetine), an antidepressant. The atypical antipsychotic Latuda(lurasidone) is FDA-approved for use alone or with lithium or valproate for treating bipolar depression. These three drugs are currently the only FDA-approved treatments for bipolar depression.
These medications work by affecting brain receptors involved in mood and behavior, and helping to restore the balance of certain natural chemicals in the brain (neurotransmitters).

Your doctor will weigh the benefits and risks of the available medications to help you get relief from the bipolar depression without the risk of mania and/or drug interactions.

How do the CNS depressants help with bipolar disorder depression?

Central nervous system (CNS) depressants, which include the benzodiazepines, act on neurotransmitters to slow down normal brain function. CNS depressants are commonly used to treat anxiety and sleep disorders and may be an effective alternative or adjunctive therapy in some bipolar patients with acute mania.

Some commonly used benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium). These drugs all can be habit-forming/addictive and can cause sluggish thinking. They generally should be used only to treat agitation or sleep problems during the acute phase of the illness and not as long-term medications. They typically should be tapered off rather than stopped abruptly, in order to minimize the risk of drug withdrawal.

Is electroconvulsant therapy (ECT) a viable treatment for bipolar depression?

Guidelines from the American Psychiatric Association suggest that ECT is a reasonable alternative in those patients who may have suicidal ideation or psychosis. In addition, ECT may benefit women who are pregnant and suffer with severe bipolar depression or mania.

What about psychotherapy for help with bipolar depression?

Along with medications for bipolar depression, patients may benefit from ongoing psychotherapy. This one-on-one therapy combines interpersonal psychotherapy with behavioral techniques to help patients learn how to diminish interpersonal problems, stay on their medications, and normalize their lifestyle habits. The STEP-BD study mentioned earlier found that in addition to medications, adding a structured psychotherapy — such as cognitive behavioral therapy, interpersonal/social rhythm therapy, or family-focused therapy — can speed up treatment response in bipolar depression by as much as 150%.

How Is Depression Diagnosed?

Although very common, depression is often ignored or misdiagnosed and left untreated. Such inattention can be life-threatening; major depression, in particular, has a high suicide rate.

If you or a loved one have symptoms of depression, seek help from a qualified health care provider. Many primary care doctors diagnose and treat depression. Screenings for depression are now often part of a routine visit to your doctor. But if your symptoms get significantly worse or do not improve within four to eight weeks of treatment, ask your health care provider for a referral to a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms — and always if you have thoughts about death or hurting yourself or someone else — you should see a psychiatrist as soon as possible.

To diagnose depression, your health care provider will ask you questions about your symptoms and family history. You may be asked to fill out a questionnaire about your symptoms. You may be given medical tests to rule out other conditions that may be causing your symptoms, such as nutrient deficiencies, underactive thyroid or hormone levels, or reactions to drugs (either prescription or recreational) and/or alcohol.

What Are the Treatments for Depression?

The stigma depression carries drives many people to hide it, try to tough it out, or misuse alcohol, drugs, or herbal remedies to get relief. To effectively treat depression, it is important to seek care from a health care provider such as your primary care doctor or a licensed mental health professional. Both of these types of providers can help you get a correct diagnosis and develop a treatment plan. Many treatments for depression are available and typically include a combination of psychotherapy and medication.

Psychotherapy teaches patients how to overcome negative attitudes and feelings and helps them return to normal activities.

Drug therapy is intended to treat symptoms that are thought to result from abnormalities in brain circuits that regulate mood, thinking and behavior. It may take several weeks for an antidepressant to fully work to ease depression symptoms, so it’s important to stay on the medication.

As with any chronic illness, getting an early medical diagnosis and medical treatment may help reduce the intensity and duration of depression symptoms. It may also reduce the likelihood of a relapse.

Medication for Depression

The group of antidepressants most frequently prescribed today consists of drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors (SSRIs), the group includes Paxil, Prozac, Celexa, Lexapro, and Zoloft. Serotonin norepinephrine reuptake inhibitors (SNRIs) including Effexor, Khedezla, Pristiq, Fetzima, and Cymbalta, also act on serotonin and norepinephrine but in a different way than SSRIs. The drugs Brintellix and Viibryd affect the serotonin receptor (like SSRIs) but also affect other receptors related to serotonin function. Other antidepressants include Wellbutrin, a drug that appears to affect dopamine and norepinephrine regulation, and Remeron, which increases levels of serotonin and norepinephrine by a different mechanism than SNRIs. For children and adolescents, the SSRIs are among the best-studied and therefore often the drugs of choice.

The tricyclic antidepressants (TCAs), which have been used to treat depression since the 1950s, are another option, although they are apt to have more side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. TCAs include Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, and Trimipramine.

Because adolescents do not tolerate side effects well and tend to stop taking their medication, TCAs are not recommended for them as first-line treatments. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine, a TCA, so caution should be taken when this medication is prescribed to this population.

The third group of antidepressants, the monoamine oxidase inhibitors (MAOIs), like Parnate, Nardil, and the skin patch EMSAM, have also proved effective. MAOIs may sometimes work more quickly than the TCAs, but they require avoiding certain foods (such as aged meats and cheeses) and certain other medicines that can also affect serotonin or raise blood pressure. MAOIs are usually prescribed only if the SSRIs and the TCAs or other depression medicines that can be simpler to take fail to bring improvement.

Lithium carbonate, which is a drug commonly used for manic depression, is also sometimes used to treat depression in combination with an antidepressant. Today, atypical antipsychotics have become the most widely prescribed class of medications that are added on to an antidepressant after an incomplete initial response. Two in particular, Seroquel XR and Abilify, are FDA-approved as add-on therapy for antidepressants, regardless of the presence or absence of psychosis (delusions or hallucinations). However, atypical antipsychotics can have many possible side effects, including weight gain, changes in blood sugar and cholesterol, sedation, and abnormal movements.

Your health care provider can recommend the best medicine for you.

Psychotherapy for Depression

Psychotherapy is an important part of treatment for depression. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression.

Commonly used forms of psychotherapy are cognitive, behavioral, and interpersonal therapies.

Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively.
Behavior therapies concentrate on changing patterns of behavior.
Interpersonal therapies help you examine how relationships affect your moods.
Other Treatments for Depression

Electroconvulsive Therapy (ECT)

ECT involves the application of an electric current through electrodes on the head. These are not felt by the patient, who is asleep under general anesthesia. Although doctors are still uncertain exactly how ECT works, it is thought that by producing a brief seizure, a course of several treatments of ECT conducted over a few weeks can bring about relief from depression. Its techniques have been refined in the past 20 years in order to minimize side effects, such as memory loss, and today ECT is considered to be as safe, or even safer, than many drugs used to treat depression and for some people, more effective.

ECT is usually considered after a number of other options have been tried because it may require hospitalization and general anesthesia. It’s also considered if rapid results are vital, as with suicidal patients or those who refuse to eat or drink. ECT should not be thought of as a “last resort”; it is extremely effective and may work before other treatments have been tried and failed.
Usually given three times a week for two to four weeks, treatments generally involve 6 to 12 sessions and are sometimes followed by a gradual “taper down” in frequency over several weeks. Some people benefit from ongoing “maintenance” treatment over longer periods to prevent relapse when medicines alone may be ineffective.

Repetitive Transcranial Magnetic Stimulation (rTMS)

rTMS, which involves passing strong magnetic currents through the brain, is another option for treating depression. rTMS has been used effectively at times to treat major depression and depression that does not respond to other forms of treatment (treatment-resistant depression). However, to date, studies have not found rTMS to be as effective as ECT.

Vagal Nerve Stimulation (VNS)

VNS is used to treat select cases of severe or recurrent, chronic depression that does not respond to at least two antidepressant trials. This surgical treatment involves the use of a pulse generator implanted under the collar bone that sends out pulses of electricity to stimulate the vagus nerve in an attempt to affect the brain’s mood centers. It typically takes at least several months for VNS to begin to show a benefit for treating depression.

Exercise for Depression

Exercise should be a part of any therapy for depression. It improves blood flow to the brain, elevates mood, and relieves stress. Even if used alone, it can often bring favorable results. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20-30 minutes three to four times a week.

Nutrition and Diet for Depression

Because symptoms of depression can be exacerbated by nutritional deficiencies, a healthy diet is important. Eat a well-balanced diet. Some people have noticed an improvement of depression symptoms when they eliminated wheat, dairy, alcohol, sugar, and caffeine from their diets. But this is not proven to treat depression. You can try eliminating those foods one at a time from your diet and note whether your depression improves. It may help to keep a symptom diary. Quitting smoking is also advised.

Alternative Medicine for Depression

As with any alternative or complementary medicine, check with your health care provider before starting it, especially if you are taking other medications or treatments.

Herbal Remedies for Depression

Several studies show that the herb St. John’s Wort is as successful at improving symptoms of mild-to-moderate depression as prescription medications, often with fewer side effects. However, other reports show that the herb isn’t any better than placebo (or sugar pill) in treating depression. Although it is considered safe, St. John’s Wort can be potentially dangerous if taken with other antidepressants (especially SSRIs), including certain medications used for treating HIV, cyclosporine, a drug used in organ transplant patients, or anticoagulant drugs. It can also interfere with the efficacy of oral contraceptives and medications used for heart disease and seizures.

S-adenosyl-methionine (SAM-e), another herbal remedy, is also sometimes considered to be a useful treatment option for depression, although existing medical studies have not been conclusive about its effectiveness.

Although ginkgo biloba is typically used as an “alternative medicine” strategy that might help to improve memory and ease confusion, it has proven in some cases to work better than placebo for the symptoms of depression, and is approved by the German government’s Commission E for this purpose.

Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to consult your health care provider first. This is especially true if you are taking prescription medications for the same or other conditions.

Mind/Body Medicine for Depression

Many mind/body practices can be helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the Asian exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you and practice often.

Massage for Depression

Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed adolescents received massage therapy, their stress hormone levels changed, their brain activity was positively affected and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program. However, by itself, massage is not considered to be a proven or evidence-based treatment for depression.

Acupuncture for Depression

The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown it markedly lessens symptoms of depression. Acupuncture may be a viable alternative from therapy if you are unable to take antidepressants or have not found them helpful.

Traumatic events are a shock to the mind and body, and lead to a variety of emotions. Coping with grief takes time, help from others, and the knowledge that grieving isn’t easy.

Grief is an emotion that takes time to deal with, but you can get through it and eventually move on. Grieving is a healthy response to tragedy, loss, and sadness, and it’s important to allow yourself time to process your loss.

Coping With Grief: The Range of Emotions

Grief doesn’t just happen after someone dies. Any traumatic event, major life change, or significant loss — a rape, a divorce, even major financial losses — can cause grief. Throughout the grieving process, you may find yourself feeling:

• Guilty
• Sad
• Angry
• Fearful
• Disbelief or in denial
• Depressed
• Numb

Coping With Grief: Accepting It

“Don’t try to run away from it; rather, face it head on,” advises Sally R. Connolly, a social worker and therapist at the Couples Clinic of Louisville in Louisville, Ky. In more than 30 years of practice, Connolly has helped many individuals and couples deal with grief and various traumatic events.

“Acknowledge that something traumatic has happened and that it has had a profound effect on you,” Connolly advises. Give yourself time to grieve, but seek help when you need it.

Coping With Grief: Finding Help

You may want some time alone to process your thoughts and struggle with your grief, but it’s important to recognize when you need help from others.

“You might need more help if you find that, after some time, you are not able to get back to normal activities, you have trouble sleeping or eating, or have thoughts and feelings that interfere with everyday life,” says Connolly.

A grief counselor or other therapist may be able to help you cope with grief, and finally start to move past it. Getting your grief out in the open is an important first step.

“Talk about it with someone — a friend, family, a support group. Support groups can be wonderful,” Connolly says. There, you can relate to other people who understand your situation, and you can get advice on what helped them through their grief.

Of course, expressing your emotions doesn’t have to be done out loud. “Write about it,” suggests Connolly. Rather than allowing thoughts to swirl in your head, put them down on paper. This is a great way of getting out your feelings if you are shy or embarrassed about sharing them with another person.

Coping With Grief: Getting Closure

Closure is also an important part of coping with grief and may help you move through the grieving process.

“Depending on the event, developing a ritual to say farewell may be helpful. We have funerals when someone dies and they are a healthy step on the road to acceptance. Rituals can be helpful for other traumas as well,” Connolly says.

Coping With Grief: When Will I Feel Better?

There is no set timeline for grieving. And unfortunately, you may never completely get over your loss. But your loss shouldn’t keep you from enjoying life, even with occasional periods of sadness.

“Let yourself grieve as long as you need to. You do have to resume normal life, but know that it’s going to take a while,” says Connolly.

Look for small signs that you’re coping with grief and getting past it. “Happy times signal that you’re progressing,” she says. When you realize that you aren’t always dwelling on the sadness or don’t think about it as frequently as you once did, that means that you’re finally moving on — at your own pace.

Your mind and body need time to grieve after a traumatic event. If you deprive yourself of the grieving process, you may find that you have more difficulty accepting what has happened or that unresolved feelings and issues may flare up later on. Allow yourself to feel sad and even selfish; eventually you’ll find yourself feeling better a little bit at a time. Even though part of you may always feel sad about your loss, you’ll find yourself happy and laughing again one day.

A woman on ProjectBeyondBlue.com, my depression community, recently asked me this: “You exercise daily and eat the right things. You research and write this stuff for a living. But what about those of us who can’t get out of bed in the morning? What about when you are too depressed to exercise, eat right, or work. How do you simply get out of bed?”

The honest answer is that I don’t know.

My bed has never been a sanctuary. Not because I’m disciplined, but because I have very painful memories of my mother’s severe depression — her living in her bed — that I experienced as a grade-schooler. When I was much younger than my kids, I woke myself up for school, made my breakfast and lunch, and walked to school. When I returned to the house, around 3 pm or so, sometimes she was still in bed, oftentimes crying.

I don’t fault her for her depression — I have cried hours and hours in front of the kids and wish I could take back those memories. However, I promised myself somewhere in that pain that I would never use my bed as an escape, especially when I had young children. The thought of a pajama day even today makes me ill.

Therefore, I posed the how-do-you-get-out-of-bed question to my community and to an expert. Here’s what they had to say.

1. Be Depressed Upright (or Prepare For the Voices)

Robert Wicks, psychologist and author of the bestselling book Riding the Dragon, has debriefed professionals in Cambodia following years of torture and was responsible for the psychological debriefing of relief workers evacuated from Rwanda during the country’s bloody civil war. I figured he would be a good one to ask about the bed debacle.

“A depressed person did say to me, ‘I couldn’t do anything you asked in our last session. I was too depressed to get out of bed,’” Wicks told me. “I said, ‘Ah, that is my fault.  I should have cautioned you that those voices would be there and to respond by saying: Yes, I am depressed but I am going to be depressed outside. Activity and depression don’t like to live together.”

When I really don’t want to do something, I try my best to stop the cerebral activity known as thinking, put myself in automatic mode, and “just show up,” as a running coach once told me. Preparing in advance for these thoughts is also helpful, like Wicks said, so you won’t be taken off guard when they try to manipulate you to stay under the covers. And once your body is in motion, it is much easier to keep it in motion.

2. Just Make It to the Shower (or Break Things Down Into Tiny Steps)

My standard words of advice to anyone who is heading into the Great Hole of Depression is this: “Take it 15 minutes at a time. No more than that.” Because every time I do just that — think about only those things that need to be handled in the next 900 seconds — I breathe a sigh of relief and can sometimes even touch an edge of hope.

Michelle, from Project Beyond Blue, uses the same system to get herself out of bed. I thought her self-talk was worth passing on to others:

“What works for me on bad days is to break things down into tiny, tiny steps. So I started saying to myself, ‘I don’t have to go to work, I just need to get into the shower.’  Then, ‘I don’t have to go to work, I just need to eat some breakfast.’ Then, ‘I don’t have to go to work, I just have to brush my teeth.’  Then, ‘I don’t have to go to work, I just need to get on the train.’  It made me feel like I could back out as soon as something became too much, and I would usually end up at work by taking it slowly like this. It sounds insane and overly simple, but it did make a big difference for me when I struggled to get out of bed.”

3. Bribe Yourself

Laurie, from the community, gets herself out of bed by reminding herself how much better she’ll feel after coffee, and by recalling how much she loves to listen to music on her iPod on the ride in. Her wisdom reminded me of the tricks that Ben, my 85-year-old running buddy (I’m a slow runner), used to pull out to get me to jog 18 miles as we trained for a marathon. An hour or so before our run, he would plot out the course and hide bonbons and refreshments behind the trees every two miles. Toward the end, when I didn’t think I could run any further, all I had to do was visualize the watermelon Jolly Ranchers at the next stop. And I wondered why running made me gain weight.

4. Get a Reason (or a Purpose)

I apologize in advance for the irate comments this point will probably provoke: “You think it’s my choice to be depressed?” “You think I’m in bed because I don’t have a reason to get up?” Well, no. I know of people with psychomotor impairment who literally cannot get out of bed without help. However, I also know that most of the people who responded to this question — how to get out of bed — told me that they needed something to do to get them vertical in the morning. Even though they hatehaving to get up at some ungodly hour five times a week for a job they don’t love, they are glad they have the job, because their work gives them the structure that is critical to their recovery.

When my mom was trying to climb out of her darkness, a therapist recommended she get a job — any kind of job — to get her mind off of her sadness. So she became a hostess at nice restaurant, and worked the late breakfast and lunch shift. I believe that was the beginning of her healing process. I know it made for much happier kids. It doesn’t have to be a 9-to-5 stressful job, of course. Agreeing to look after an elderly neighbor or take care of a friend’s pet, or volunteering your time at the Boys & Girls Club can give you a sense of purpose that demands rising from your bed.

Join the conversation “Getting Out of Bed in the Morning” on Project Beyond Blue, the new depression community.