Depression

DEPRESSION TEST

By Dr. Stephen Last

In its lay use, the term “depression” is used to convey a whole range of emotional and psychological states – unhappiness, low mood, misery, apathy etc. Indeed, many use the term interchangeably with any and all of these words. The psychiatric profession uses the term “depression” in a more specific way. To differentiate the lay and psychiatric use, it may be useful to use the term “clinical depression” to denote the condition recognised by psychiatrists. This differentiation is significant for several reasons.  To be “depressed” at times is to be human; to be “clinically depressed is (to the psychiatrist) to be mentally unwell. It is for the clinically depressed that doctors and psychiatrists prescribe medication. Finally, it is on clinically depressed patients that these medications are trialled to determine efficacy.

To determine if a patient is clinically depressed, the psychiatrist will interview them face to face. Typically this interview lasts somewhere in the region of one hour (for an initial assessment – follow up interviews tend to be shorter). The majority of this interview will focus on the patient’s current symptoms (see below), the remaining time being used to look for so-called “risk factors” for clinical depression. Thus they will ask a number of questions covering areas such as the patients childhood, time at school, family life, occupational history, physical medical history, alcohol and other drug use, past psychological and emotional difficulties, and the patients current social situation (occupation, relationships etc). In addition, whilst talking with the patient, the psychiatrist will also be conducting a “mental state examination”. That is, they will be observing the language and behaviour of the patient (the tone, volume and speed of their speech, their dress and demeanour, the presence of any abnormal facial or bodily movements etc).

The diagnosis of “clinical depression” will be made on the basis of the patient’s current     psychological and emotional symptoms – relevant symptoms are listed below.

1. Low or depressed mood.

2. Lowered energy levels and increased tiredness.

3. Lack of interest in and pleasure from usual activities (“apathy”).

Symptoms 1-3 are usually present in all cases of clinical depression. Other symptoms that are also frequently found include:

4. Lack of concentration.

5. Sleep disturbance (typically waking early in the morning).

6. Low self-confidence.

7. Hopelessness about the future.

8. Reduced appetite, often with associated weight loss.

9. Thoughts of suicide.

10. Feelings of guilt.

The symptoms will usually be present for at least two weeks for the diagnosis to be made. It is to be noted that these symptoms are typical of a depressive episode but are not exclusive. Some clinically depressed patients suffer from agitation and an inability to sit still, others will sleep excessively. Furthermore, the psychiatrist will often grade the diagnosis (mild/moderate/severe) depending on symptom severity.

The treatment prescribed for a clinically depressed patient will depend on their particular symptoms, their general health, their personal preferences and other factors. Typically, severe cases will be prescribed medication and will be monitored closely  - some may require hospitalisation, particularly if suicidal. Moderate and mild cases are usually offered antidepressant medication and/or possibly some form of “talking therapy” (if it is available).

There is a wealth of information concerning antidepressants available from GP surgeries, mental health units, pharmacies, books and the Internet. As such, I will not discuss them further, save to say that they’re not everyone’s choice of treatment.

Many patients prefer the “talking therapies”. Such therapies vary enormously in their scope and intensity. The traditional psychotherapies (e.g. psychodynamic psychotherapy) can require a patient to attend weekly sessions for many years. Others, such as relationship or bereavement counselling, are less formal and much briefer (e.g. weekly sessions for six weeks). The last decade has seen a growing interest in the so-called “cognitive therapies” such as Cognitive Behavioural Therapy (CBT) and Neuro-Linguistic Programming (NLP). These modern therapies have good evidence of effectiveness when compared to the older style talking treatments, and treatment periods are shorter. However, they are not “magical cures” and require significant effort and contribution from the patient – a case of “you get out what you put in”. Once the patient has mastered the techniques explained in the sessions they will be able to use them throughout their life, hopefully preventing any recurrence of their symptoms.

Unfortunately, access to the talking therapies is limited in the NHS, with long waiting lists typical and some therapies not available at all.

Philosophy, Mental Health and Depression

By Karen Hastings

“I think therefore I am” – Renee Descartes (1640)

It is a beautiful summers day and you are walking in the countryside. In a clearing to your right you see a cherry tree, the red fruit peeping from under the lush green foliage. You walk up to it. You touch it, feeling the rough bark under your fingertips. You can hear the breeze rustling the leaves, and smell the odour of the fruit. You take a cherry and pop it in your mouth, savouring the sweet juice as it floods over your tongue.

But does the cherry tree exist? You can see it, hear it, feel it, smell and taste it’s fruit – but this is not enough. You may be hallucinating, or asleep and having a particularly vivid dream. How would you know?

You wouldn’t. All our experience of the world and “reality” is governed by our five senses (I leave aside any discussion of a “sixth sense”). These senses are our only connection with the world outside our selves. A blind person has no visual contact with the outside world; somebody with a severe cold has little taste or olfactory contact with the outside world. And these senses are basically biochemical machines designed to send information to our brain. For example, the eyes collect and focus reflected light onto the retina (at the back of the eye). Receptors in the retina convert this light into electrical impulses (this electricity is produced by chemicals in the receptors). These electrical impulses are then fired along a network of nerve cells to the brain. The brain, another very complex mass of interconnected nerve cells, analyses these impulses – their strength, their rate, their pattern and frequency – and generates an internal picture based upon them. It is this brain-generated picture that we “see”. It is a similar case with the sensation of touch. Receptors in our skin are stimulated by physical contact and produce electrical impulses that are sent to the brain – what we “feel” is the result of the brain’s analysis of these impulses. And so on for taste, smell and hearing.

So the tree that we saw, felt, heard, smelled and tasted isn’t actually “out there” in the world – it is in our brains. More accurately, it is the brains image or impression of the tree constructed from the impulses it receives from our senses. Whenever our brain received this particular pattern of impulses from the senses, it would construct an image of a tree – colour, shape, smell, taste, touch and sound – whether or not a tree was actually there.

There is little controversy in stating that our brains can be deceived. We can block the path of the electrical impulses as they pass from the sense receptors to the brain – this is the case with local anaesthesia, where a patient can watch as his appendix is removed without pain. Or we can interfere directly with the brains analysis of the sense impulses – a drunken person is aware that he has fallen over, but it doesn’t hurt (until the next day!). And we don’t need alcohol or drugs for this deception to occur – at some point, most of us have believed, albeit briefly, that we’ve seen or heard or felt something that has turned out to not be there.

It was this sort of reasoning that led Descartes to question the very existence of a world outside our selves. In light of modern science, Descartes is questioning the existence of a world outside our brains (our bodily sensations such as feeling hungry or having an aching leg are also mediated by our senses). In these terms, our own bodies are considered as part of the outside world. If all we see, hear, touch, feel and taste in the outside world is but a representation in our brains, and this representation is based on information from our senses, and these senses can be deceived, then we can never be sure that the outside world exists. Descartes talked of the possibility of us being hypnotised by a demon who is tricking us into believing we are moving around in a world with trees, houses, other people etc when in fact we’re locked in a dungeon somewhere. The film “The Matrix” provides a technological alternative.

So we can’t know if the outside world exists – it could all be in our brains. But in that case can we know that anything exists? Thankfully, yes. We can be sure our thoughts exist. How? Because we think them. There seems no way that we can be deceived about our thoughts existing – in the very act of having a thought, that thought exists. The thoughts may be based on deceptive information from the senses, but they are still real, they still exist. It is difficult to conceive of deceiving someone into believing they have thoughts when, in fact, they don’t. You need to have thoughts to be deceived.

So we can safely say that our thoughts definitely exist! Descartes moved on from this “rock of certainty” and went on to “prove” the existence of the outside world. Unfortunately, this further “proof” is highly suspect and relies on the notion of a beneficent and all-powerful God – but then Descartes was writing on behalf of the Catholic Church! Most modern philosophers discount this extension of his theory, but they do still accept his earlier reasoning -  “I think therefore I am” has stood the test of time. If we are being pedantic, Descartes quote is better rendered as “There are thoughts” – just because I experience thoughts doesn’t mean they are mine! But this isn’t as memorable as the original.

So what has all this got to do with mental health? Well, if the outside world doesn’t exist as such and all we have is thoughts, then (potentially) the world is what we think it to be. I’m not saying we can change things dramatically. It would take a lot of effort to “create” a thought-world where trees can talk and people fly by flapping their arms – for this to be “real” one would have to interact constantly and consistently with trees and people as though they could do these things. Rather, I am talking about how our thoughts and feelings can “colour” our experience of the outside world (I am using the terms “thoughts” and emotional “feelings” interchangeably here). Depressed people (i.e. people with depressed or depressing thoughts!) experience the world differently to others. They see colours less vividly, food can seem tasteless and unpleasant, and harmless everyday situations can appear threatening. They predict bad consequences from actions and events where others see only benefit. A depressed persons world is very different to a happy person’s, but to an observer they will seem one and the same.

A person with depressive thoughts who is looking to “get better” has three courses of action open to him.

Firstly, he can accept the “medical model” of mental illness and depression. This model sees the brain (rightly) as a complex neuro-chemical structure, and postulates that depression and other psychological illnesses are due to defects or malfunctioning in this system. The brain, when examined anatomically, consists of millions of various cells, each of which is in turn composed of smaller structures. When these structures are examined in turn, they are found to consist of chemicals (as does all physical matter). The medical model thus presumes that it is a defect or malfunctioning of these chemicals that adversely affect the brains cells, leading in turn to the malfunctioning of the brain and finally a “malfunctioning” of thinking – depression or whatever.

On this model, the course of action is clear – correct the malfunctioning of the brain. This is done using drugs that enter the brain and interfere with the cells chemical structure and functioning.

This all makes perfect sense. Unfortunately, there is a vast gulf between the theory and the practise. Medical science just does not know enough about the brain at present. There are numerous different cell types, numerous different chemicals in and around these cells, and numerous different interactions and connections between each cell and the others. No test has been developed that shows which chemicals/cells/connections are malfunctioning. The best that the scientists can do is make an educated guess as to those chemicals/cells/connections seem likely to be defective, and choose drugs that act on these. The initial guesses (based on drugs that were found in the 1950’s - by accident!) are still the main focus of research today. The result is predictable – a large number of different drugs that work seem to work sometimes and not at others and have side effects (because they are also affecting perfectly healthy cells). This is likely to remain the case for the foreseeable future.

A second course of action for the depressed person is to change the outside world i.e. their circumstances. This makes perfectly good sense. If you are feeling depressed because you hate your job or your relationship, then change it. If you feel depressed because you’re overweight, then diet. Of course, this is rather flippant. If it were that easy to do, people would just do it. And it must be acknowledged that depression often saps the will and motivation to change just these sorts of situations. Further, many situations cannot be changed by our own actions – the loss of a loved one, poverty, ill health, war, famine etc. The outside world can be very resistant to change.

The third course of action takes a leaf out of Descartes book. We are what we think – a depressed person is no more and no less than someone with depressed thoughts. If they stopped having depressed thoughts, then the depression disappears. It is possible for people to be happy, or at least content, even in the direst of circumstances. Most of us have known people face up to unpleasant and distressing events with resilience and even cheerfulness. We say they are “naturally happy” or are “positive people.” One can also say that they think “happy thoughts” or think “positive thoughts.”

Perhaps they were born like that. Or perhaps they learnt to think like that as they grew up (I believe this is more likely). Either way, though, they enjoy life a lot more than many of us. But this needn’t be the case – if we can learn to think a little more like them, learn to think in a more pleasant, positive way.

It seems unlikely that depressed people are “born like that”, just as it is unlikely that happy people are “born like that.” Even the wackiest psychiatrist will hesitate to diagnose a baby as depressed! Young babies can’t think as we do – and they can’t have depressed thoughts. As they grow, their thinking abilities develop under the influence of their parents, siblings and peers. Patterns of thought are developed, ways of thinking, with each person having their own particular patterns, unique to them. By the time adulthood is reached, these patterns are likely to be “ingrained” in us, to the point where we’re not even aware of them – we automatically process situations, events, and interactions with others in terms of these thought patterns. The thoughts we actually think (and are aware of) are the results of this processing. Therefore, if this processing is “set wrong” (e.g. if it constantly produces thoughts that are depressive), then psychological problems are likely to follow.

This is the basic theory on which are based the cognitive therapies for psychological problems. With the prompting and guidance of the therapist, an individual is taught to examine his or her thinking patterns, searching for maladaptive and detrimental ways of thinking. This is not an easy task – the patterns are usually “automatic” (like a habit) and the individual is likely to be unaware of them initially. An important task for the therapist is to elucidate these “faulty” patterns. These can then made explicit to the individual, and the first steps taken towards challenging these ways of thinking. The aim of the cognitive therapies is to minimise or remove entirely the identified faulty patterns, and for the individual to learn more adaptive and helpful ways of thinking in their place. A successful therapy can change a persons life forever – when a person no longer automatically thinks depressive thoughts, they are insulated and protected from becoming depressed in the future.

One of the original cognitive therapies developed is Cognitive Behavioural Therapy (CBT). This is still widely used, particularly in the NHS. It has proven efficacy in a wide range of psychological conditions such as depression, anxiety, phobias, and post-traumatic stress disorder. Treatment consists of one-hour sessions with a therapist on a one-to-one basis, typically having one session a week for between six to twelve weeks.  CBT are intensive talking therapies that require a significant commitment from the client. Aside from the actual sessions, they will often involve the client reading additional material and monitoring and recording their behaviour and thoughts in every day life. As with most things, the more the client puts in, the more he’ll get out.

THE TREATMENT OF DEPRESSION

By Dr. Stephen Last

Depression (also called depressive illness or clinical depression) is a common condition, affecting up to 20% of the adult population in their life times. Many go untreated. Of those that do seek help, the GP is usually the first port of call. He or she will assess the severity of the symptoms and recommend the appropriate course of treatment.

Depression is commonly ranked in terms of severity – mild, moderate or severe. Severe cases are relatively rare and will usually be referred on to the local psychiatric teams. Mild and moderate cases common and will normally be treated by the GP, at least initially. Failure to improve in these cases may precipitate referral to specialist care for advice and treatment.

The treatments available for mild and moderate cases of depression fall into two main categories – drug treatments and “talking” treatments. GP’s commonly prescribe medications in the first instance. The reasons for this will be discussed towards the end of this article.

Antidepressant medications were first discovered (by chance) in the 1950’s and 60’s. Medications designed to be used for very different (physical) conditions were found to be effective in depressed patients. These first antidepressants, such as Amitryptilene and Imipramine, are called the Tri-Cyclic Antidepressants or TCAs (named after their chemical structure). Trials have shown them to be about 70% effective in relieving the symptoms of depression. The effect is not immediate, typically taking 4 to 6 weeks. This effectiveness is to be compared to the placebo tablets used in the trials. Placebos are non-active tablets given to patients to correct for the positive “psychological” effect of taking any tablet, whether the tablet is effective or not. The placebos (e.g. a sugar coated pill) are typically effective in 50% of cases! It is also worth noting that observation studies of depressed people show that around half improve “spontaneously” (i.e. without any treatment at all) after a short period.

So the TCAs are more effective than placebo’s. If you gave a TCA to ten depressed people, around seven would be improved after six weeks; giving a sugar pill to the same number, around five will be improved after the same time period.

Unfortunately, TCAs have significant side effects. Patients commonly feel sedated, put on weight, suffer dry mouth and constipation, and have slowed reflexes. Importantly, TCAs are very dangerous in overdose – a significant consideration in those patients who feel suicidal.

Over the ensuing decades, pharmaceutical companies in the area of antidepressants have conducted much research, and many new drugs have appeared on the market. The main focus has been on producing “cleaner” drugs, drugs that are effective but do not possess all the side effects of the TCAs. This has largely been a success. The newer drugs, such as the Selective Serotonin Reuptake Inhibitors (SSRIs) e.g. fluoxetine (Prozac), do indeed have less side effects. This appears due to their method of action – SSRIs effect only 1 or 2 of the brains neurotransmitters, the older drugs can affect 3 or 4. And they seem to be as effective as the TCAs – but they are not more effective. It is one of these newer antidepressants that GP’s typically prescribe for their patients. These drugs are amongst the most widely prescribed medications in the West.

But what of those who don’t improve – the 30% who don’t get better? Or those who suffer severe side effects? The GP may change the dose of the drug, or switch to an alternative drug, or refer the patient on to the psychiatric services. Other patients may not want to take medications for their psychological or emotional difficulties at all.

This group of patients would seem well served by the “talking therapies” such as counselling, psychotherapy, CBT and NLP. In mild and moderate cases of depression they seem at least as effective as antidepressants, and without the side effects. Further, through these therapies, patients are encouraged to examine their problems and difficulties in detail, allowing them to actively participate in their resolution rather than simply taking a tablet every day. Ideally this leads to the patient acquiring strategies and ways of coping with difficulties in their lives that will enable them to not only resolve these difficulties in the present but also prevent their re - occurrence in the future. Effective talking therapies have the potential to remove patients from recurrent cycles of depression. The drug treatments are effective for only as long as they are taken – potentially a lifetime.

Given that talking therapies are an effective treatment for depression and their lack of unpleasant side effects, why aren’t they offered more often by the GP? A big consideration here is cost – antidepressants are undoubtedly cheaper than employing a therapist. Secondly, it is quicker and easier for the GP to write a prescription for an antidepressant than it is to think and consider which therapy may best help the patient. Finally, there is huge economic interest in the prescribing of these medications. Pharmaceutical companies make huge sums of money from these drugs. They spend a considerable sum (more than they actually spend on researching and developing the drugs!) on advertising and promoting their particular brands to the medical profession. The GP is under both time and economic constraint, and a tablet billed as a “wonder cure” can be very appealing.

None of this is the fault of the GP. The NHS has well publicised money problems, and decisions about which treatments are cost-effective are constantly being made (the pharmaceutical industry lobbies these decision makers also). The result is the situation as it stands – drugs are prescribed, other therapies aren’t. This isn’t a situation exclusive to mental health – back pain and other injuries are typically treated with painkillers, when physiotherapy or a similar treatment may well be better for the patient.

Talking treatments for depression are generally not available on the NHS or, if they are, there is likely to be a lengthy waiting list. This is a result of economic decisions, not a shortage of trained practitioners. One has only to look in the phone book to see numerous highly qualified and experienced therapists ready to help. Unfortunately, the NHS’s priorities lie elsewhere. This is a frustrating situation for both patients and therapists.