||Live Chat about the best methods of dealing with Depression
On 13 November 2002
All in the Mind held a debate about the best methods of coping with Depression. This was followed by a live web chat. Thanks to everyone who sent in questions for Dr Raj Persaud and his guests, Dr Alan Cohen and Dr Clare Stanford.
We had a great response - there just wasn't time to answer them all. Read the full transcript below.
Q: Sarah: How do I tell whether I am depressed or just unhappy?
A: Raj: Clinical Depression as opposed to unhappiness is usually accompanied by problems sleeping, loss of weight, loss of appetite, loss of sense of humour, increased irritability and loss of pleasure from those things you used to enjoy. Depression is usually referred to in the scientific community as a mood which has remained unchanged for over two weeks. Most of us feel down from time to time but if you have not perked up at all in over two weeks then its time to consider you might have a problem that requires professional intervention.
Q: Andy: If a series of traumatic life events has caused depression, then I fail to see how boosting the levels of serotonin in the brain can help you come to terms with the these traumatic events. What value are antidepressants in this type of depression?
A: Clare: There's a common misunderstanding about serotinin, namely that increasing its levels will do the trick. In fact anti-depressants increase the activity of serotinin in the brain, which is quite different. It's interesting that the bio-chemical effects of chronic anti-depressant treatment resemble key changes found in the brain after severe or repeated stress. One influential theory is that anti-depressants mimic the bio-chemical changes needed to tolerate stress. Obviously, this is uncertain as yet. But at least it's a start when trying to make sense of how anti-depressants influence mood and behaviour.
A: Alan: I don't understand the connection between mind and brain. However, Professor Susan Greenfield has written extensively, and in English, and you may find it interesting to read some of her work.
Q: Anon (female): As a twenty-one year old year who recently suffered from clinical depression for over a year, and am proably still recovering I would like to ask why no-body on the panel mentioned the 'personality' of the suffer? I survived serious virual encephilitis aged thirteen, recovered quickly from acute pychosis aged eighteen and fought back from the depths of despair in the last year. The drugs - Seroxat, Prozax and Venaflaxine - did help, as did the therapy, but I think my fighting spirit helped as well.
A: Raj: You are absolutely right that personality is vital and partly explains the genetic component of depression. A neurotic or obsessional personality is known to be particularly vulnerable to depression. Perhaps the key issue is to be aware of how your personality predisposes you to psychological difficulties and learn how to manage your personality. Your fighting spirit is excellent but there is some evidence that 'problem solvers' like yourself get upset and low when they keep trying to solve what in fact is an unsolvable problem. Early cognitive appraisal of whether your problem is really solvable or not would be vital in the case of your personality type. The good news is when your problem is solvable you will do better than the more resigned personality types out there.
Q: Joanna: I take a daily antidepressant, Efexor. I'm with Prof Wolpert - they have truly saved my life. However I would like to take a break from the tablets to have another baby. If I do need to go back on an antidepressant during the pregnancy I don't think Efexor is recommended. Does anyone know what the current thinking is on this, or what other drugs are regarded as fairly tried and tested (I know nothing is 100% safe).
A: Raj: NHS Direct can offer drugs advice, or speak to your GP
Q: Jill Shuker: I am director of a branch of Samaritans in West Sussex. I do not understand why GP's do not feel able to suggest to their patients that they may use samaritans at any time as a listening service. I have volunteers waiting to take calls.
A: Alan: the primary care trust in West Sussex would look forward to receiving your call and using your service. There is a broader issue of who may use the services like the Samaritans and that requires good communication and education within primary care services. The organisation that manages communication and education is the local primary care trust and in this particular case I'm sure they would welcome a call from you.
Q: Alastair Gibson: I have been on fluoxetine (Prozac) 20mg for 13 months and feel that I need to continue on this treatment for the foreseeable future. Is there a time threshold on the effectiveness of the treatment and are there alternatives to this medication
A: Raj: The Americans who have more experience with Prozac than we do in Britain believe in prescribing higher doses and for example there are some people running around in the US on 80mg of Prozac a day. I wonder if you might want to consider upping your dose if you want to get a better result from your Prozac. Obviously you should do this after consultation with your doctor (80g is probably a bit high and you should increase your dose cautiously). In my experience Paroxetine is another very good anti-depressant though usually you need to take this at night while Prozac you usually take in the morning. Buspirone is another medication that you can take with your prozac and has been shown to enhance the effect of anti-depressant medications, as has lithium has. I find buspirone an excellent enhancer.
Q: Jack: I have been on Lustral for 17 days. I feel a little better but tired. Do ytou think I will continue to feel tired and will I feel even better if I persevere? What about coming off them>? The doctor said approx 6 months? Might I have horrid withdrawal symptoms?
A: Alan: The tiredness should resolve and you should feel better if you perservere. The duration of treatment is usually negotiated between doctor and patient, but certainly six months would not be unusual. Withdrawal symptoms with Lustral are unusual.
Q: Marty Farrow Can depression be learned?
A: Clare: This is a very interesting question. There's a good evidence from pre-clinical studies that uncontrolable and unpredictable stress produces changes in behaviour, and bio-chemical changes that are prevented by anti-depressant drugs. This syndrome is called learned helplessness. Whether it has any firm links with learning per se is not certain.
A: Alan: The question is from whom might the individual have learned the depressive symptoms; the presumption is that depression is in part nature and in part nurture. I just wish we knew which and in which proportions.
Q: Sarah: I've suffered with depression for the last 10 years , I have been prescribed various drugs and various talking therapies (all of which helped mildly) but the best thing that worked for me was to find out everything I can about this illness and as a result I have a psychology degree! Have you found this to be a common way of approaching mental illness?
A: Raj: Many many psychologists and psychiatrists started out because they were interested in the way they were different from others. It has to be said what is intriguing is how bad many psychologists and psychiatrists are at preventing psychological difficulties in themselves. I believe this is because they haven't investigated thoroughly enough the group of people who experience severe stress but never go to see a psychiatrist or psychologist and are therefore very resilient. I believe psychologists and psychiatrists should study resilience more - but instead they seem preoccupied with illness that has already started. You can learn a lot from this but perhaps we could learn even more from the resilient.
Q: Ann Legg: Just very briefly....why are none of your speakers addressing the well known and hugely researched gut-brain connection?† Are they aware of the research paper published this year by Kaplan and Popper on the benficial effects of mineral and vitamin supplementation in bi-polar illness?† Nutrition is a fundamental tool in recovering all aspects of health yet...why do the medical profession not question this missing aspect in their education?
A: Clare: the link between food and mood is really interesting and scientists are doing more and more research in this area. So far there is no certain benefit between in treating bi-polar disorder with mineral and vitamin supplements. However, it's well known that uni-polar depression can get much worse if you remove certain amino acids from the diet. There's certainly a lot of work to be done in this area but it will be a long time before it can be used with confidence in the clinic.
Q: Jayne: My husband suffers from recurrent bouts of depression which take the form of withdrawal from any interaction with me and limited interaction with our children. How best do I handle this? Do I make him interact or leave him to come out of it? It makes me feel very low too? How can I cope with it?
A: Raj: I don't think you should force a depressed person to interact when they don't want to - is your husband on good medication for this? The key is to find activities they want to do that involve a bit more social interaction than they would otherwise do. Another key issue is to get to the bottom of why they are getting depressed - what are the triggers? People sometimes don't talk because there are things they want to say but feel would be pointless expressing - could you take a stab at guessing what those might be and you yourself bring them up. I hope you are yourself getting enough support in this difficult situation.
Q: Mrs Williams: Why is there so much mental ill health amongst GP's? One local GP is obsessed that patients' symptoms are 'all in the head'. She cannot listen to what patients are saying; she's off in her fantasy world such is her obsession with her personal opinions. In her surgery, she also uses unqualified and unfit people as 'counsellors' and even worse 'psychotherapists' who use NHS patients as objects for their training. This particular GP is dangerous.
A: Alan: My advice is that you change your doctor and speak to your local primary care trust about your concerns.
Q: Jeff: in view of continuing adverse media reports on use of ssri's, especially prozac, what advice you you give a worried user?
A: Clare: Donít stop your medication and if you have any worries go and see your doctor and your psychiatrist. So far media reports are anecdotal.
Q: Craig: I am a mental health nurse and I often wonder why exercise, fish oils, st.john wort, CBT and family work is not invested in or used at all. Evidence Based Practice, should mean we are using these options?
A: Alan: You are correct that social prescribing and alternative prescribing may be effective for example, the evidence that exercise is good for depression is very strong whereas the evidence on St John's Wort is very poor. CBT and family work has an extensive evidence base. I'm sure that the NICE guidelines when they're published will set out the evidence base very clearly.
Q: SJB: Under what circumstances should Seroxat not be prescribed?
A: Raj: I happen to find in my clinical practice that Seroxat is a good anti-depressant, however there is some good recent evidence that if pregnant mothers are given Seroxat the baby who is subsequently born is more likely to suffer from withdrawal reactions compared to other SSRI medications. I suspect pregnant mothers should not be given paroxetine in the first instance. Sometimes an important contraindication for many anti-depressants is if a person has a history of going 'high' as some anti-depressants can make a sufferer from mood swings go high.
Q: Tessa Blackburn:
I have suffered from depression since 1996 or maybe before. Initially I coped with this through counselling, which helped but really only kept me sane rather than anything more. I eventually went on to taking Seroxat which didn't do much and then in 2001 started on Venlafaxine; throughout this time I still attended counselling. In February 2002 I was diagnosed with Under-active Thyroid and began treatment, and after referals to an NHS psychiatrist increased Venlafaxine intake. I now am a lot better than I was! I still have set-backs but am more able to cope with how I feel and react to things, and how I manage my depression. The point I am trying to make is that there is invariably more than one thing that will help a person contend with depression as often there is more than one reason for it. Rarely in life does one thing cause or lead to another thing with nothing else impacting on it.
A: Clare: It's certainly true that there are several medical conditions which are known to increase people's vulnerability to depression. But these are fairly well-known and your doctor should be aware of the need to screen for these problems. In your case, and under-active thyroid could be an obvious risk factor, but would be easy to confirm with blood tests. The difficulty is that depression, as you say, could have more than one origin in the brain and that's much harder to look for and find. Research in this area is at a very early stage but at least we now have a wide range of different sorts of treatments, so that if the first doesn't work, your doctor can try another. It's hit and miss therapy, but getting better all the time. The important thing is to consult with your doctor.
Q: Anna Stuart: Do you think that depression can be handled by using one's common sense and that this can merely depend on your level of intelligence and confidence in knowing how to handle stress triggers in life - e.g. cleverly knowing what to avoid to protect yourself from making mistakes and disappointments i.e. are self-preservation techniques used exclusively by people who are naturally intelligent - and therefore are less intelligent people at a significant disadvantage in avoiding depression?
A: Raj: Actually there is some evidence that amongst adolescents the more intelligent get more depressed because they worry more and this is because they think harder and more realistically about the future. Perhaps the key issue in preventing depression isn't academic intelligence but something called emotional intelligence and even practical intelligence which Professor Sternberg based in the US is a pioneer of. There is also some evidence that the happy suffer from positive illusions about life. Maybe you can't be realistic and happy - you have to choose what you are going to go for in life.
Q: Hilary Wheat, RMN:
Tukes is a drug-free treatment centre based in Wales, offering help to people from throughout the UK, who have an obsessive-compulsive dependency. We include depression within this, but differentiate between those experiencing a severe Ďpsychoticí depressive episode and those with chronic melancholia.
The approach we use is based on the 12 Step self help philosophy and Reality Therapy. We treat depression as a dependency. A way of coping with uncomfortable feelings on which someone becomes reliant. We see it as a vicious circle of uncomfortable feelings, fear, loneliness, sadness, anger, leading to an avoidance of certain situations or responsibilities - going to work, caring for children, shopping, getting out of bed, washing etc, which then further reinforces the uncomfortable feelings and results in a reduction of self worth and self esteem.
Questions for Debate:
1. Do the Panel agree that prescribing anti-depressant medication may actually delay a person from seeking to change an unhealthy situation, as the medication (initially) reduces the uncomfortable feelings that are necessary to promote change?
2. I am concerned by the tendency among some therapists to offer prolonged psychotherapy but maintain the client on an anti-depressant throughout this time. Do the Panel agree that this process will prevent effective counselling taking place, for isnít the very aim of anti-depressant medication to alter our mood and thus make effective and accurate sharing of feelings impossible?
3. "Life is difficult" (Scott Peck, 1978). The longer health professionals seek to deny this fact by the excessive prescription of anti-depressant medication, thus protecting their clients from the responsibilities that living involves, the more at risk we are of having a somatised society, devoid of life-enhancing feelings and experiences. Do the Panel agree?
A: Clare: There is certainly a theory that drugs can subsitute for what we call toughening up. They could also make unpleasant environments more tolerable. Neither of these are necessarily bad for you but they may not help you much either. In either case, drugs are manipulating or mimicking adaptive processes which are going on in the brain all the time.
A: Alan: I think it is important to distinguish between the obsessive compulsive dependency and depression as you do in your introduction. So far as anti-depressant medication prescribed for people with depression is concerned, I think that in the early stages of depression when negative feelings are at their most powerful, people need the benefit of anti-depressants to allow them to feel motivated to make the long-term life-style changes that are needed. Obsessive compulsive disorder is different and the evidence suggests that anti-depressant medication may not be helpful in all cases.
Q: Michelle Shipworth: What do the panellists think about social therapy? I'm thinking of Durkheim's classic study on suicide - where he pointed out the relationship between suicide rates & type of religion & social support systems.
A: Raj: An interesting discovery by Durkheim and sociologists who followed him was that at times of war suicide rates go down in a society - it was even suggested that going to war served some kind of therapeutic function. It could be that at times of war people bind together against a common enemy. It does indeed seem that how bound people are to their neighbours, friends, family and spouses is a crucial resistance factor in helping prevent and even treat depression. The problem with social therapy is that depressed people isolate themselves, plus others find depressed people more difficult to socialise with than the non-depressed. I agree with social therapy but the key issue is how to implement it and how to persist with it in the face of serious depression. I suspect one needs different treatments at different stages of a depressive illness and that social therapy might be introduced after the drugs have started to work. Depression Alliance have a useful website and information on local groups which might help with social therapy. Group Therapy is also a form of social therapy and the Institute of Group Therapy have a strong interest in this area.
Q: Dr David Bramble MD:
Freud, like many clinicians personally tested his own treatments. In doing so with pharmaceutical strength cocaine, there is considerable evidence that he became chronically addicted to this agent and its effects upon his brain (particularly its withdrawal in his notorious self-analysis) significantly influenced his bizarre sexual theories of the origins of our psychic ills, including depression. One must be wary of historical postmortems but would we have psychoanalysis without cocaine, a drug so well known to produce depression?
A: Raj: Many clinicians have tried drugs they shouldn't have, often in the spirit of discovery, often just in the spirit! I think Freud got a lot wrong but he also got a lot right - in particular when people persist in behaviour that makes no obvious sense to themselves and which they consciously try to resist but can't, in other words where unconscious or pre-conscious forces may be at work.
Many thanks for your interest in All in the Mind - keep listening and do send us your suggestions for future programmes.
Q: Patrice Gladwin:
For thirty years I have been instructing individuals in the simple, natural mental technique of Transcendental Meditation. This involves no counselling, belief or change of attitudes and behaviour. Rather, the mind settles to its own inner stillness while the metabolic rate drops to a level deeper than sleep. My experience has been that depression in all of its forms is helped and often dramatically alleviated by accumulating effects of the TM experience.
A: Clare: Your comments on TM are most interesting and the fact that it relieves your depression should be investigated to see whether other people can be helped in the same way.
I have manic depression, apparently. Is really medication necessary for that? I dont like therapy either actually - I suppose spontaneous recovery is out of the question?
A: Raj: I think the evidence is that of all the different types of mood problem - manic depression is the one that most strongly responds to mood stabilising medication like lithium or sodium valproate. After a few years of this treatment many people can take a break and may not need to return to taking medication again. The wonderful thing about mood stabilising medication is that there are well worked out blood levels and this can be monitored so that the dose is absolutely right for you. It means a blood test every few months or so. There is a new cognitive behavioral therapy for manic depression and this is being pioneered at The Maudsley Hospital - more info should be available at their website
Q: Joy G: Are you aware of recent work on the psychobiology (mind body systems) of depression, in particular the importance of REM sleep in breaking the depression cycle?
A: Raj: Yes, you are right that sleep seems to be a major factor in depression - we know that sleep disturbance is one of the most sensitive indicators of the earliest signs of depression. An early treatment for depression which is still sometimes used today is sleep deprivation therapy where you go without sleep for many many hours, even days and this seems in some patients to help kick start a recovery from depression. There is also evidence that the quantity of REM sleep is linked to depression and that there is REM rebound around the beginnnig of the time of recovery from depression.
There is more information on sleep on several websites including the websites linked to sleep journals. Try the Maudsley Hospital and Institute of Psychiatry website
Q: Jenny Baines:
Isn't there any way of finding out more accurately which treatment is most likely to succeed? My husband began to develop depression around the age of 18. You name it, he's had it in terms of treatment, and he reckons working it out together helps most, although I'm not allowed any input into his treatment, of course. He watched our son carefully for signs, only to find our eldest daughter developed depression at the age of 17. We now have two out of four children on Seroxat. Nobody seems to want to connect the three of them, and I would like to know why, when it seems quite likely that an inherited deficiency occurring at that age had affected them all. Surely this is important in determining treatment?
Your question is very appropriate as unfortunately we can't answer your question! In part, it's because the information doesn't exist and in part even if it did exist, it would be very hard to interpret the evidence on an individual basis. Let me give you an example: if the evidence showed that 99 per cent of people with a chest infection respond to anti-biotics, it's impossible to decide whether you're in the 1 per cent group, or the 99 per cent group. Clearly in your case, Jenny, it would appear that there is a familial or genetic basis to the illness. I suggest that you speak to your GP or your psychiatrist for further information. It may also be helpful to speak to either of them about local carers' groups which may be able to give you more information.
A: Raj: I agree with you and find it puzzling that no clinician is willing to see or even think about your family in its entirety. You might want to consider changing your GP or your specialist. An important point is that in my experience if one medication works for a member of your family suffering from depression, often the same medication should be tried for another member of your family suffering from the same problem. This seems to have been already worked out by those involved in treating your family. However, I do strongly suggest that some sessions where your whole family is seen in its entirety might be very useful. There is an Institute of Family Therapy in London who have a website and who might be able to recommend a local family therapist.
Q: Lizzie: I had a baby 9 months ago....I am back at work full-time and am beginning to feel that I'm being stretched in all directions. I do have a supportive husband who is away sometimes - at weekends too. I used to lead a very independant life before the baby and was quite sporty. Now I feel that I'm looking at my old life through a window and often end up crying, feeling almost a bereavement for my old life, even though I love my daughter to bits. Do you think I should seek medical intervention such as Prozac or do you think this feeling will go away by itself?
Dear Lizzie, thank you for your email. I do think that you should speak to your GP or your health visitor about how you feel. Your feelings are not unusual and almost always resolve eventually. However, talking to your health visitor or your GP may speed up that resolution. There are also a number of websites that may be helpful to help you understand post-natal depression which would be a label to use for how you feel.
Q: Samantha Hilling:
If discussion is more useful to those suffering from depression, (i) how long should one attend such sessions and (ii) is it not better to attempt to answer 'why?' you feel the way you do through a psychotherapist rather than have a counsellor merely listen even though the former is significantly harder to be referred to and expensive?
A: Alan: The answer to both your questions depends on the individual and the character of their depression. There are some individuals to answer "why" and there are some that do not. Part of the assessment prior to treatment, is to understand what the individual wants to gain from treatment.
Q: Gill Hartley:
Is St John's Wort safe to take to help with SAD?
There's no evidence that St John's Wort when taken on its own is harmful but it should never be taken in combination with any other medicines (even those you can buy over the counter). It should be safe to take it to treat SAD, but the preferred treatment for SAD is "light" therapy, which seems to help many people. You should be able to find out about this treatment from your doctor.
Q: Amanda Sewell: I've recently been diagnosed with bipolar disorder ( type 2) - don't have any acute mania , but get mood disorders of intense activity and on-going persistent depression. I'm now 57, and have suffered from this disorder, largely untreated for 40 years. The psychiatrist at my local hospital has put me on Tegretol Retard (600 mls), one dose to be taken at night. I find it quite to be very stabilising, but can't resist taking Cipramil (20mls) during the day as a 'top-up'. Does this counteract the Tegretol's effects. Am worried about long-term side-effects of both these drugs. Thank you for the very interesting programme.
A: Alan: Yes, there is no liklihood of inter-action between Citalopram and Tegretol (Carbamazepine). However, both may sedate and this effect may be added if you take both. I would certainly avoid alcohol if you're taking either of these medication. So far as the long-term side-effects are concerned, the doctor who prescribed the medication probably told you that you need to have regular blood tests to check the level of Carbamazepine in your blood and a check that the blood hasn't changed as a consequence of the medication. These are usually done every three to six months. If you want more detailed information, you can access the British National Formulary website where you will find all the information that doctors have access to.