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EF Skills and Depression

Recent experiences have shown me that there is likely a connection between Executive Functioning (EF) deficits and mental health conditions like depression. Science has known about this link for some time, as described in this article. What interests me about EF skills deficits is how they impact treatment.


As a Psychologist, a big part of my job is diagnosing and treating mental health conditions. I primarily use a strategy called Cognitive Behavior Therapy (CBT) to both think about and treat depression. My job is to develop a theory of what is happening to my client, communicate this idea in a way they can understand, and suggest things to do to make the depression decrease or go away. Over the years I have mastered how to think and communicate about depression, but the treatment side remains something of a wildcard. Recently I have been thinking about the people I work with who are on-board for treatment but can't seem to do the things that research and experience say will decrease the frequency and intensity of their symptoms. One major obstacle I have encountered is EF skills deficits. Here's how EF skills factor into depression treatment.

Medication

Medication is the most common treatment for depression. Even though I do not (cannot) prescribe medication, I do coordinate with medical doctors and provide the rationale and behavioral support for medication compliance. Medication has two major flaws in the treatment of depression. First, its effects are most prominent in the first couple of weeks or months of treatment. After that medication is no longer the most effective treatment for depression. Second, medication only works when you take it as prescribed. A major obstacle for my clients in taking medication as prescribed is remembering to take it. I help my clients create routines and habits around medication compliance.

Exercise

Research is unrelenting in its praise of exercise for the treatment of mild to moderate depression. In most cases, exercise is as effective as medication for treating mild to moderate depression. Despite the nearly magical properties of exercise for depression (and a host of other health and mental health issues), most people do not exercise. Clients report many EF issues as reasons for not exercising.

  • cannot find the time

  • exercise is boring

  • it's too expensive

  • forgetting

  • exercise is exhausting and results in sore muscles

  • they don't like to sweat

The reasons are endless and most of the issues people bring up have a solution that requires good EF skills.

Journaling

My friend the copyeditor bristles at the use of the word journaling because it's not an actual word. "Writing in a journal" is what it's called, according to her, but my industry calls it journaling. Therapeutic writing has great outcomes for addressing the cognitive symptoms of a host of mental health issues, especially depression. Journaling is supposed to be especially effective if you handwrite in a paper journal. My clients report losing their journal or not knowing where to buy one, losing pens and pencils, forgetting to journal, having low motivation to journal, or sitting down to journal and having their mind go blank or feeling like there's nothing to journal about. Again, all of these experiences and roadblocks require EF skills to move forward.

Socializing

Some of the causes and symptoms of depression are part of their treatment. For instance, some people can become depressed because they are isolated, or feel like they cannot bear to be around people because they are depressed. Socializing can be amazingly effective for symptom relief, but in many cases, socializing can have a huge EF burden on the front end. Planning a get-together with a friend is a very complex activity for most of my clients because it requires not only knowledge of one's schedule but knowledge of the friend's schedule as well. In addition, there is planning around travel, length of time spent together, figuring out what to do when together, and working it all into two pre-existing schedules. It is not uncommon for my clients who want to use socializing as a way to treat depression to start by learning how to use a calendar and figuring out the best means of communicating with a friend. These are both basic EF skills that require training and practice.


This list could easily go on and on, but the above is a good survey of the more effective treatments for depression. To my colleagues, I say that you must have a plan for addressing EF skills deficits in the treatment of mental health issues including depression. Simply telling people to exercise is no longer meeting the standard of care, in my opinion. To people struggling with depression and feeling like they're not making much progress, I would recommend looking not just at the treatments but also the planning and organizing that goes into implementing treatments. For instance, effective use of a calendar or to-do list might make a noticeable difference in intervention efficacy.

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