The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time

by Alex Korb

Serotonin—improves willpower, motivation, and mood Norepinephrine—enhances thinking, focus, and dealing with stress

Dopamine—increases enjoyment and is necessary for changing bad habits Oxytocin—promotes feelings of trust, love, and connection, and reduces anxiety GABA—increases feelings of relaxation and reduces anxiety Melatonin—enhances the quality of sleep Endorphins—provide pain relief and feelings of elation Endocannabinoids—improve your appetite and increase feelings of peacefulness and well-being

Go for good enough. Worrying is often triggered by wanting to make the perfect choice or by trying to maximize everything. When buying a used car, you want one that is cheap, reliable, safe, sexy, the right color, and fuel efficient. Unfortunately, no single option is likely to be the best in all those dimensions. If you try to have the best of everything, you’re likely to be paralyzed by indecision or dissatisfied with your choice. In fact, this kind of “maximizing” has been proven to increase depression.9 So don’t try to make the most amazing dinner; start out by just making a good dinner. Don’t try to be the perfect parent; just be a good one. Don’t try to be your happiest; just be happy.

Putting emotions into words—however hokey that sounds—actually rewires your brain circuits and makes you feel better.

Why does it seem like when you’re running late, you always hit the longest red light in the world? And, of course, there would be a big rig and pedestrians getting in the way. But the real question is, why is my brain focused on the big rig that made me almost miss my exit and not on the fact that there was hardly any other traffic? Why did I get annoyed at the pedestrians even though they didn’t actually get in the way? Why did I notice the red light and not the three green lights I had just driven through? Sometimes it seems like the whole world is conspiring against you, like life is full of disappointing events, missed opportunities, and harsh circumstances. Maybe, for you, it feels that way all the time. But guess what? It’s not some cosmic conspiracy, just a by-product of your brain circuitry.

Interestingly, our emotion circuits are more easily activated by the negative, which means that most people need to experience numerous positive events for every one negative just to come out even.

All of this means that to be happy in our daily lives, we need a high ratio of positive to negative. And it turns out, after considerable study, that ratio is three to one.

Notice what you notice. You can’t control the random bits of information that pop into your head. But you can start to notice your biases. When you get annoyed that you’re stuck at a red light think, Oh, that’s interesting. I noticed this red light, but I didn’t notice the last green light I made.

Similarly, during actual painful stimulation, people with depression had greater increases in amygdala activity than nondepressed people. Their brains had a more emotional response to the pain. And the more helpless they felt, the greater the brain’s emotional response. Furthermore, they had decreased activation in the region of the brainstem that produces painkilling endorphins, so their brains did not try to suppress the pain as much. They also had decreased activity in the ventral anterior cingulate and prefrontal cortex, which meant that the pain had a greater impact on their optimism circuitry and lowered their ability to think rationally about the situation. Thus, if a depressed person and a nondepressed person both burn their hand on the stove, the depressed person is more affected by the pain. The brain’s response to pain is one reason that people with chronic pain are more likely to develop depression, and vice versa.

One study looked at the effect of using medication to boost serotonin or norepinephrine. After a week, neither medication significantly increased overall happiness, but they both caused increased attention to positive events and decreased attention to negative ones.33 While this study was conducted on healthy volunteers, it suggests how antidepressants help with depression. They don’t necessarily directly improve mood,

To combat pessimism, you can strengthen the brain circuits responsible for optimism. The first step is to simply imagine the possibility of positive future events. You don’t have to believe they will happen, just that they could happen. It’s possible you could find true love tomorrow. It’s possible that you could find a better job. It’s possible that things won’t turn out in the worst conceivable way. Recognizing that good things are possible activates the lower (ventral) anterior cingulate.35 Importantly, the ventral anterior cingulate helps regulate the amygdala, so admitting the possibility of good things helps control the brain’s negative bias.

Figure out your triggers. It is much easier to avoid temptation than to resist it. If you know what triggers a particular habit, sometimes you can get rid of that habit simply by removing that trigger from your life. For example, Billi realized he was watching too much television, and the trigger was seeing the television set itself. So he moved it out of his bedroom, and now he doesn’t have a problem watching too much television. As another example, if you don’t want to buy cookies, don’t walk down the cookie aisle at the supermarket. Seeing all those delicious baked goods will release dopamine and push you toward buying them.

If you were a caveman, your impulses wouldn’t be such a problem. Life would be pretty simple. If something tastes good, you eat as much as possible, and if something feels good, you do it as much as possible. Nowadays, though, there are too many easily obtainable pleasures, which hijack dopamine in the nucleus accumbens and create a tendency to act for immediate gratification. It becomes even more problematic in depression, because there’s less dopamine activity in the nucleus accumbens. First, that means things that used to be enjoyable no longer are. Second, with reduced dopamine activity, the only things that motivate the nucleus accumbens are things that release lots of dopamine, such as junk food, drugs, gambling, and porn. All these impulses mean your actions are guided only by what’s most immediately pleasurable, which is not usually good for you in the long term. And while most impulses are easy to recognize, the most insidious bad habits are often routines.

Habits are formed because every action activates a specific pattern in the dorsal striatum. Each time you follow the same path, it becomes more and more defined in your brain—in other words, the neurons in the dorsal striatum are wired together more strongly. In addition, each time you activate that brain pattern, it becomes easier to activate the next time. So pretty soon, it’s nearly impossible to create a new path—all your brain wants to do is follow old tracks.

The important thing to understand about a pattern in the dorsal striatum is that once it’s there, it’s pretty much there for good. That’s why you never forget how to ride a bike. This is one of the reasons that bad habits are so hard to change. You don’t actually eliminate old habits—they just get weaker as you create newer, stronger ones. Furthermore, once habits are in the dorsal striatum, they no longer care about pleasure. Sure, they usually first get in there because your nucleus accumbens is motivating you to do something, but once a habit is really engrained, it no longer requires the nucleus accumbens to motivate it. That’s also how addictions work. Addictions start out as pleasurable impulses in the nucleus accumbens. But over time, the nucleus accumbens stops responding, and the addictions no longer feel pleasurable. But because they are engrained in the dorsal striatum, you feel compelled to have another drink or another cigarette anyway. Because of these changes in dopamine, addictions increase your risk of developing depression, and depression increases your risk of developing an addiction. Another downward spiral.

Stress causes dopamine release in the dorsal striatum,2 which automatically activates your coping habits.

Our coping habits are not the only habits triggered by stress. In fact, stress biases the brain toward any of our old habits over new actions.3 The dorsal striatum says, “Let’s do it this way, because we’ve always done it this way.” And the prefrontal cortex says, “But that won’t help us get where we want to go.” Meanwhile, the nucleus accumbens says, “Ooh, that cupcake looks delicious.”

Stress changes the dynamics of the conversation. When you’re calm and relaxed, your prefrontal cortex is pretty good at getting its way. But the more anxious or stressed you get, the more the power shifts to the dorsal striatum and nucleus accumbens. That’s why you might be doing fine on your diet until you get in a fight with your significant other. Or you might be exercising regularly until family drama raises its ugly head. When stressed, you usually act out your most deeply engrained routines or become a victim to your impulses. Take a deep breath. When you start to feel antsy or compelled to act on a bad habit, take a deep breath. Let it out slowly, then take another deep breath. Repeat as necessary. As we’ll discuss more in chapter 9, long, slow breathing calms the brain’s stress response.

Our large prefrontal cortex is what separates us from other animals. Pretty much all other animals live their lives by impulse and routine, but we humans have the capability to overcome that through willful action. In this case, “willful” means we consciously and deliberately “put on the brakes” to stop acting out a habit. Willful actions are enacted by the prefrontal cortex, and inhibiting impulses requires proper serotonin function in the prefrontal cortex. Unfortunately, you don’t have an unlimited supply of serotonin. Each time you inhibit an impulse, it makes it harder to inhibit other impulses. Resisting impulses is like fighting an army of zombies with a limited number of bullets. Eventually you’ll run out.

In mountaineering, if you’re stuck in a bad situation and you don’t know the right way out, you just have to pick a direction and go. It doesn’t have to be the best direction; there may not even be a best direction. You certainly don’t have enough information to know for sure. So if you start down a path and end up at a cliff, you’ll just have to pick another direction from there. Because guess what? In a dire situation, you can’t be certain of the right path; what you do know is that if you sit there and do nothing, you’re screwed.

Make a good decision, not the best decision. When trying to make a decision, we tend to focus on the relative drawbacks of each option, which often makes every decision seem less appealing.1 Nor do we usually have enough information to feel confident in the decision—the world’s just too complex. But remember, it’s better to do something only partly right than do nothing at all. Trying for the best, instead of good enough, brings too much emotional ventromedial prefrontal activity into the decision-making process.2 In contrast, recognizing that good enough is good enough activates more dorsolateral prefrontal areas, which helps you feel more in control.

Once you make a decision and create an intention to solve a specific problem, the potential solutions are highlighted in the brain in a similar way.

We don’t just choose the things we like; we also like the things we choose.

People are often at their best when working toward a long-term, meaningful goal that they believe is achievable, like earning a degree or getting a promotion. That’s because not only is dopamine released when you finally achieve a long-term goal but it’s also released with each step you make as you move closer to achieving it. Having a goal also allows the prefrontal cortex to more effectively organize your actions. And most importantly, achieving the goal is often less important to happiness than setting the goal in the first place.

Create specific long-term goals. Start by thinking about your values and what’s important to you. Write down at least one or two specific goals that you could achieve that align with what’s important to you. A specific goal has a clearly defined benchmark of success, so at some point in the future you will know definitively whether or not you have achieved it. Do the goals on your list inspire or motivate you? If not, think harder about some different goals. If you have found some specific, meaningful goals, do you believe you can achieve any of them? If not, break them down into smaller goals that you believe may be achievable. For example, if the goal of finding a job seems too daunting, try setting a smaller goal of sending out two resumes a week, or spending ten minutes every day look for a job online.

Deciding Creates Perceived Control You may not make all the right decisions, but they will be your decisions. And the mammalian brain works much better when it has some control over the world than when it doesn’t. Indecisiveness is part of the downward spiral because it enhances your feeling of being out of control.

The important thing here is not actual control, but perceived control. Making decisions may not increase your actual control over a situation, but it will likely increase your perceived control. And when you increase your perceived control, you increase your confidence, mood, and future decision-making capabilities.

Deciding Helps Make More Decisions As I neared the end of college, I had a hard time deciding what I wanted to do with my life. This indecisiveness became insidious—soon I was having trouble deciding what I wanted to do for the summer, and then simply what I wanted to do that weekend. When you’re stalled and paralyzed, things feel out of your control. But the good news is that you don’t have to start with the big decisions. You can start small. Choose what to have for lunch, or what television show to watch. Research shows that decisiveness in one part of your life can improve your decisiveness in other parts of your life.22 Pick one thing, go with it, and don’t question it. When you exercise a muscle, it gets stronger, and the exercise makes it easier to work out the next time. Similarly, every time you make a decision instead of procrastinating, worrying, or acting impulsively, you strengthen your decision-making circuit for the future. Of course, if you run five miles, your muscles become fatigued, and a sixth mile is going to feel a lot harder than the first. The same with decisions—if you have to make a lot in a row, the decision-making circuit gets fatigued and your brain falls back into indecisiveness or impulsivity. But that’s okay. Just like with exercise, you’re training your brain for the future, and the next time you need to make a decision, that sixth mile will feel easier—you’ll have set the stage for an upward spiral.

Write down your worries. As we’ve discussed, worrying disrupts sleep because it activates the prefrontal cortex—and so does planning. If you’re worrying or planning while trying to fall asleep, write down your thoughts. Get them out of your head and onto a piece of paper and be done with it.

Improve Your Sleep Hygiene Studies show that knowledge about sleep hygiene improves sleep hygiene practices, which in turn improves sleep quality.37 So just by reading this chapter, you’re on the right track. And here are some more concrete tips to prepare your brain for a great night’s sleep. Sleep for eight hours straight. Most people need about eight hours of sleep. In general, the older you are, the less sleep you need. In college, you need about eight hours and twenty-four minutes. By the time you start drawing Social Security, you might need only seven. The important thing is to sleep in one continuous block (seven hours plus a one-hour nap is not the same). So don’t take regular naps. And if you consistently get quality sleep, you won’t even feel that you need them. Use your bed/bedroom for sleeping. Don’t do work in bed or in your bedroom. Don’t surf the Internet. Don’t watch television. If you use your bedroom only for sleeping, your brain associates your bed only with sleep, which will induce sleepiness like Pavlovian conditioning. Of course, it’s also okay to have sex there (some might say more than okay). Create a routine for preparing for sleep. Do it every night—a ritual to separate yourself from the rest of your hectic day. Your prefrontal cortex, in particular, needs to wind down, so if you’re doing everything at sixty miles per hour and then plopping into bed, you may have difficulty falling asleep or getting quality sleep. A bedtime ritual might involve b...

Medical residents have to deal with long hours, late nights, difficult patients, and the fear that they’ll make a mistake and accidentally kill someone. In short, they’re stressed. On top of that, in order to become full-fledged doctors, they have to spend months studying intensely to pass their board-certifying exam. In short, they’re extra-stressed. To study the effects of chronic stress, researchers in Portugal performed fMRI scans on a stressed group of residents who had just spent three months studying for their board exam and compared them to a control group of residents who had no exam.5 The study found that stressed subjects acted more out of habit than intention. They kept making the same choices, even when those choices were rewarded less and less. Not surprisingly, the increased habitual behavior was caused by changes in processing within the habitual dorsal striatum. In addition, the stress caused the decision-making orbitofrontal cortex to actually shrink. The subjects were studied again six weeks later, after they’d gotten a chance to relax—and indeed, their dorsal striatum activity had returned to normal, as had the size of their orbitofrontal cortices. Stress biases the brain toward old habits over intentional actions, which is one of the reasons it is so hard to change coping habits—the things we do to deal with stress. One of the problems with coping habits is that if you don’t do them, you stay stressed. And if you try to suppress a coping habit, you’re ...

Accept That You Won’t Be Perfect In a commencement address in 2012, author and graphic novelist Neil Gaiman made the keen observation that “if you’re making mistakes, it means you’re out there doing something.” Changing habits does not require that you make zero mistakes; in fact, mistakes are almost inevitable. As I said above, habits are created by repetition, that is, by practice. You continually practice your habits, the same way LeBron James continually practices his jump shot. Because it’s practice, it makes sense that you’ll make mistakes—lots of mistakes, particularly in the beginning. Old habits persist because of striatum activity. Fortunately, when you want to create a new good habit, like going to the gym or eating healthier foods or even just taking a shower to start your day, the prefrontal cortex can override the striatum. The problem is that the prefrontal cortex can only override it insofar as it’s paying attention, and it’s impossible for your prefrontal cortex to be eternally vigilant. It has a lot to do and only so many resources for paying attention. When you stop paying attention because of distraction or stress, the striatum takes over, and you don’t realize it until you’re halfway through that pint of Cherry Garcia. Resolve to change. Making a resolution to change is more effective than simply wanting to change, and dramatically increases your chance of success.7 Being specific in what you want to change helps make it more achievable. For example, “...

Think about how your life would improve. How would your life be better if your bad habit was gone? In a study on alcoholics, subjects were asked to use this type of thinking while looking at pictures of alcohol. Focusing on how life would be better reduced activity in the dorsal striatum and nucleus accumbens.14 Reducing alcohol-related routines and impulses prepared them to change their drinking habits.

Productive Procrastination Maybe you want to go to the gym, or you have a project due at work or some chore to do around the house. Despite the fact that the deadline is approaching, you just can’t work up the energy or motivation. And the more you procrastinate, the more anxiety you feel. Trying to force yourself to do a project when you have no energy or motivation is akin to sitting in your car and trying to change directions without first stepping on the gas. Sure you can sit there and turn the wheel, but nothing happens. The key is to start driving. The same can be true of things you need to do. Procrastinating by checking Facebook or watching terrible reality-television shows—or by even doing nothing at all—is like sitting in your car playing with the steering wheel. It won’t get you anywhere. Instead, just start doing something productive—anything productive—even if it’s not the thing you’re supposed to be doing. Wash one dish in the sink. Put on your shoes. Send one work email. Do anything that’s on your to-do list that needs to be checked off, even if it’s not anywhere near the top. It still needs to get done, and it keeps you moving forward. Once you start being productive, dopamine is released in the striatum and parts of the prefrontal cortex. Suddenly you’ll have more energy and motivation to do the thing you really need to do. It’s perfectly fine to procrastinate a little; just try being more productive in your procrastination.

The brain changes its activity based on what the body is doing. Even actions as simple as changing your posture, relaxing your face, or slowing your breathing can have dramatic effects on your brain activity and, subsequently, your stress, your thoughts, and your mood.

Changes in posture are reflected by changes in neurohormone levels. One study from Harvard found that standing or sitting in an open, expansive posture increases testosterone and decreases the stress hormone cortisol.14 These changes in neurohormones likely contribute to the other effects of confident postures described above. The take-home message is that if you’re feeling doubtful, keep your chin up, stand up straight, and stick out your chest. It will help you be more decisive and internalize positive thoughts, and it will give you more energy.

Change Your Breathing Breathing is your most important bodily function, and like all basic functions (eating, sex, etc.), it is closely tied to the limbic system. People with breathing problems have a much higher risk of developing depression.18 Changing your breathing is a powerful tool for creating an upward spiral, because it is one of the quickest ways to change your emotional state. Take a deep breath. When anxious or overwhelmed, slow breathing can help. Breathe in slowly through your nose while counting slowly to six (or even eight). Pause for a couple seconds at the top of your inhalation and then exhale slowly through your nose for the same count. Different types of breathing have different effects on the body and the brain. A study from Sweden showed that a combination of different breathing types (slow, fast, and superfast) increases feelings of optimism and decreases feelings of depression, anxiety, and overall stress.19 Breathing affects the brain through signals carried by the vagus nerve. Not only does the vagus nerve send signals down to the heart, as mentioned earlier, but it also carries signals up into the brain stem. Vagus nerve signaling is important in activating circuits for resting and relaxation, known as the parasympathetic nervous system. The parasympathetic system is the opposite of the sympathetic nervous system, which controls the fight-or-flight instinct. Slow breathing increases activity in the vagus nerve and pushes the brain toward parasym...

Write a detailed thank-you letter. Think of someone who has been especially kind to you—a friend, a teacher, a coworker—whom you’ve never properly thanked. Write a letter thanking this person, being specific about what he or she did that affected your life. Then schedule a meeting, maybe over coffee or a drink, and deliver the letter in person. Don’t tell the person what the meeting is about; let it be a surprise. This form of gratitude can have a long-lasting effect. One study showed that after writing and delivering a thank-you letter, people had increased levels of happiness even two months later.3

Ask for help. Sometimes when you’re feeling crappy, it’s hard to focus on—or even remember—happier times. If you’re having difficulty remembering happy events, talk to an old friend, look at photographs, or read older entries from your diary. This is another reason to keep a gratitude journal; it’s something to look back on when things get tough.

Gratitude Improves Activity in Dopamine Circuits The benefits of gratitude start with the dopamine system, because feeling grateful activates the brain stem region that produces dopamine.8 Additionally, gratitude toward others increases activity in social dopamine circuits, which makes social interactions more enjoyable.

Keep a gratitude journal. Take a few minutes every day to write down three things you’re grateful for. To make it a better habit, try doing it at the same time every day. If you can’t think of three things, just write one. If you can’t think of even one thing, just write, “I’m grateful for the food I ate today” or “I’m grateful for the clothes I’m wearing.” Even if a situation is 90 percent what you don’t want, you can still be grateful for the other 10 percent.

Gratitude Boosts Serotonin One powerful effect of gratitude is that it can boost serotonin. Trying to think of things to be grateful for forces you to focus on the positive aspects of your life. This simple act increases serotonin production in the anterior cingulate cortex.9 The same study that found this also showed that remembering sad events decreases serotonin production in the anterior cingulate. Thus, remembering positive events has a twofold effect: it directly increases serotonin and indirectly keeps you from remembering negative events. Gratitude Improves Sleep Gratitude is a great way to start an upward spiral, because it can improve your sleep—and we know from chapter 7 how important that is. A Canadian study took a group of college students with insomnia and asked them to keep a daily gratitude journal for a week.10 This simple intervention led to improved sleep, reduced physical problems, and less worrying. Even in people with chronic pain,11 gratitude improves sleep and reduces anxiety and depression.

Be grateful when you wake up. When you wake up in the morning, try to think of one thing you are looking forward to that day, even if it’s just breakfast.

The Difference Between Fishing and Catching Once, while at a Boy Scout camp, I saw an old scoutmaster heading down to the lake with a rod and reel. A couple hours later, as he was walking back, I asked him how the fishing was. “Great,” he responded. “How much did you catch?” I asked. “I didn’t catch anything,” he replied, adding, “It’s called ‘fishing,’ not ‘catching.’ ” You can’t always find something to be grateful for, but just because you can’t find it doesn’t mean it’s useless to look. It’s not finding gratitude that matters most; it’s remembering to look in the first place. Remembering to be grateful is a form of emotional intelligence. One study found that it actually affected neuron density in both the ventromedial and lateral prefrontal cortex.19 These density changes suggest that as emotional intelligence increases, the neurons in these areas become more efficient. With higher emotional intelligence, it simply takes less effort to be grateful. With gratitude, it is often the searching, the looking, the fishing for gratitude that activates the circuitry. You can’t control what you see, but you can control what you’re looking for. Sure, finding something to be grateful for is an added bonus, but it’s not the only thing.

Be around people. Downward spirals are more likely when you’re alone. If you start to feel your mood sliding downhill, try going somewhere where there are other people around, like a library or coffee shop. You don’t need to interact with others; just being in the same physical space can help. Humans are a social species—we evolved to survive with each other, and our brains are healthiest when we interact with and feel connected to others. That means that when we feel disconnected, the consequences can be devastating. Fortunately, research has clearly demonstrated that interacting with others—and not just friends and family but strangers too (and even pets)—can reverse the course of depression. Social interactions change the activity of numerous brain circuits and neurotransmitter systems. Talking, physical contact, or even just being near other people can decrease stress, pain, anxiety, and depressive symptoms, and it can increase calmness and happiness.

The Trouble with Other People The poet Emily Dickinson once wrote, “It might be lonelier without the loneliness.” She famously kept to herself and yet was scared of being alone. This apparent paradox is common, because the people who most yearn for closeness are often the most sensitive to rejection. Whether you have depression or not, other people can often be a source of stress and anxiety. Our brains are wired to care what people think about us, which is why feeling judged or rejected is so distressing. In fact, as demonstrated in an fMRI experiment, social exclusion activates the same circuitry as physical pain.1 In the experiment, participants were scanned while playing a virtual ball-tossing game with two other players. They were told the others were real people, but in fact, it was computer controlled. At first the “other players” played nicely, sharing the ball with the participant. But at one point they stopped sharing, only throwing back and forth to each other, ignoring the participant. This small change was enough to elicit feelings of social exclusion, and it activated the anterior cingulate and insula, just like physical pain would. We avoid social exclusion for the same reason we avoid touching a hot stove: it hurts! Reflecting on rejection. We often experience something as rejection when it’s really just a misunderstanding. For example, maybe you leave a message for a friend, and he or she doesn’t call you back. It’s easy to assume the intention was to hurt...

Depression Disrupts the Neurochemistry of Love and Trust When it comes to love and intimate relationships, one neurohormone gets more press than anything else. Its name is oxytocin and it’s often called the “love hormone.” Oxytocin is released during light caresses and sex, when someone shows they trust you, and sometimes simply during conversation, which increases feelings of trust and attachment for others. Oxytocin also decreases feelings of stress, fear, and pain.

Unfortunately, in depression, the oxytocin system is out of sorts. Some studies say that people with depression have more oxytocin, and other studies say they have less. While this seems paradoxical, oxytocin levels influence—and are influenced by—different subtypes of depression,4 reflecting the idea that each individual’s specific neural circuits interact to create a unique instance of depression. So while the studies aren’t exactly clear, the easiest way to understand it is to say that the whole oxytocin system is just out of whack. The proper biological term is dysregulated. In depression, oxytocin isn’t always released when it should be, and it’s sometimes released when it shouldn’t.5 In addition, the brain’s response to oxytocin isn’t always on target.

In addition, people with depression are more likely to have a particular gene for the oxytocin receptor that causes decreased confidence in social relationships and an increased need for approval.9

Stressful situations are almost always easier to deal with when supportive people are present.