What can recent research tell us about how to treat depression?

In 2010 the Journal of the American Medical Association (JAMA)  made head-line news when it published research which concluded that whilst anti-depressants were effective in helping those with severe depression, they were no better than a placebo in treating mild to moderate depression.

Anti-depressants such as SSRIs (Serotonin Re-uptake Inhibitors) are widely used to raise the level of serotonin in the brain and this, in turn, is thought to alleviate the symptoms of depression. However, only about half the patients who take SSRIs appear to be helped by them, and then it takes at least three weeks for any effects to be felt.

So the following questions were asked* - if increasing the amount of serotonin in the brain was the answer to depression, why didn't these SSRIs help everyone who took them?  And if a lack of serotonin in the brain was the reason we get depressed, why wouldn't the pills work immediately?

One possible answer was thought to be that, in cases of mild to moderate depression, it was the placebo effect that was really helping patients not the SSRIs.

But that can’t be the whole story, as anyone who has suffered from depression - however mild - will tell you. It also doesn’t explain why the pills take three weeks to become effective in the case of severe depression.

The neurogenic hypothesis of depression suggests that the reason SSRIs work for severe depression is that in these cases the drugs promote the growth of new neurons - and it takes three weeks, because that's how long it takes for the brain to start making new neurons and creating new neural pathways.

This neurogenic hypothesis challenges the old neurotransmitter (serotonin is a neurotransmitter) explanation. In the new explanation, it is the creation of new neural pathways which ultimately frees people from the grips of depression and also explains why depression is so intractable for those who have it and can't seem to shake it off. Old patterns of behavior (i.e., pre-existing neural pathways) get reinforced in depressed people in the same way that new patterns of behaviour get formed: with repetition. Whilst old behaviours go over old ground - again and again and again - new behaviours, on the other hand, create new neural pathways and it is these that can help forge a path out of depression. Cells that fire together wire together.

We are what we repeatedly do; happiness, then, is not an act but a habit.

with apologies to Aristotle

The ability of the brain to forge new neural pathways is what is known as neuroplasticity . To illustrate plasticity, imagine making an impression of a coin in a lump of clay. In order for the impression of the coin to appear in the clay, changes must occur in the clay -  the shape of the clay changes as the coin is pressed into the clay. Similarly, the neural circuitry in the brain must reorganize in response to new experience or sensory stimulation - it’s a physical process - grey matter can actually shrink or thicken; neural connections can be forged and refined or weakened and severed .  

Brains are designed to change. It's what allows us to cope with the ever-changing world around us. So anything that restricts our brains ability to change would be a major hindrance to personal growth and our own survival. And it turns out that one of the things that inhibits the growth of new neurons in the brain is stress. In effect, chronic stress limits neuroplasticity in the brain. And as a result, unrelenting stress can have a major impact on our mental health and influence a whole host of psychological disorders including depression. But in order to benefit from our brain's ability to change, the depressed person must force him or herself to do new things and participate in new activities every day.

Charles Darwin (1809-1882) knew this a long time ago when he wrote:

"My mind has changed during the last twenty or thirty years... Now for many years I cannot endure to read a line of poetry… I have also almost lost any taste for pictures or music… My mind seems to have become a kind of machine for grinding general laws out of large collections of facts...

If I had to live my life again I would have made a rule to read some poetry and listen to some music at least once every week… The loss of these tastes is a loss of happiness, and may possibly be injurious to the intellect, and more probably to the moral character, by enfeebling the emotional part of our nature."

We seem only now to have caught up with him.

So what can we do to help ourselves?

Just as we create flexibility in our bodies by stretching physically, so too we can create flexibility in our minds by stretching mentally. Every day we have the opportunity to exercise our flexibility. We can do this in small ways such as taking a different route home from work or changing the ways we do routine tasks – just doing things differently. On a larger scale, we can learn a new language or learn to play an instrument. Doing unique, random, different, and sometimes ridiculous things is a good way to exercise the mind and promote new ways of thinking about the world around us as well as alleviating any symptoms of depression by markedly refusing to reinforce negative experiences by forging alternative pathways. 

“A mind that is stretched by a new experience can never go back to its old dimensions.”

Oliver Wendell Holmes (1841-1935)

As those of you who took part know, we have recently undertaken a Happiness Habits Experiment to see whether repeating between one and six simple activities that are correlated with well-being, daily, for three weeks, raised people’s happiness levels and became embedded as habits. We’ve had very positive results and will be bringing you the full report in a few days time. Watch this space.

* see Jim Porters blog for more

**I am not in any way suggesting that people who are on anti-depressants should come off them except under the guidance of their doctor - what I am suggesting is that there are alternatives which can compliment drug treatment and that should certainly be considered as a first option in cases of mild and moderate depression before resorting to drug treatment. 


Posted by Annabel

International Women's Day; Women's Mental Health

“Women are drawers of water, hewers of wood, labourers, preparers of food, bearers of children, educators, healthcare providers, producers, and decision-makers. Although they are central to caring for families and communities, to production and reproduction, they are accorded unequal status. Throughout the world they are overworked and undervalued. Their subordination makes it more difficult for them to cope with the demands made upon them whether of a physical, social or emotional nature. Woman are more vulnerable than men to sex exploitation and violence, to poverty and malnutrition, to environmental degradation, to chronic diseases which are often exacerbated by pregnancy and lactation, and to the debilitating effects of harmful traditional practices.”

This was the opening of the Preface to the World Health Organisation’s 1993 report into Psychosocial and Mental Health Aspects of Women’s Health. 18 years later, the same still holds, though there is a growing understanding of these issues and more work being done to attempt to right the inequalities.

It is quite clear, though, that "gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. Gender differences occur particularly in the rates of common mental disorders - depression, anxiety and somatic complaints. These disorders, in which women predominate, affect approximately 1 in 3 people in the community and constitute a serious public health problem." (World Health Organisation)

MIND’s factsheet on Women and Mental Health gives us the following statistics about women’s mental health in the UK, taken from a variety of sources: 

• ·     Recorded rates of anxiety and depression are one and a half to two times higher in women than in men.
• ·     One study showed that 57% of those attending emergency departments for self-harm were women.
• ·     13 to 15% of new mothers experience postnatal depression.
• ·     Women in custody have a high level of psychological disturbance – 78%, compared with 15% in women in the general adult female population.
• ·     Nearly two-thirds of women on remand have a diagnosis of depression. More than 40% have attempted suicide before entering prison. More than twice as many have an eating disorder compared with women in the general population.
• ·     One in four women will experience intimate partner (domestic) violence (IPV) in their lifetime. Depression affects nearly half of women exposed to IPV, and post-traumatic stress disorder (PTSD) affects almost two-thirds.
• ·     90% of the 1.6 million people in the UK who have an eating disorder are female.

 Another WHO report demonstrates the international and cross-cultural phenomenon of women’s vulnerability to depression, anxiety, psychological distress, sexual violence, domestic violence and escalating rates of substance use, which affect women to a greater extent than men across different countries and different settings. “Pressures created by their multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse, combine to account for women's poor mental health. There is a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental health problems in women. Severe life events that cause a sense of loss, inferiority, humiliation or entrapment can predict depression.”

Williams and Miller report that “Gender inequality in society leads to differences in the life experiences of men and women, which affect mental health in different ways. Gender inequality is described as a system that tends to give more advantages to men in terms of employment, status and ownership. Women are much more often expected to look after others in the home or in society, often doing work that is undervalued and unpaid or poorly paid.”

The Geneva report of the WHO agrees that “Some risk factors for mental health problems affect women more often than men. These include gender-based violence, social and economic disadvantage, low income and income inequality, low or subordinate social status and rank, and major responsibility for the care of others.”

For some women, family life may contribute to mental distress. Many women have primary or sole care of children, and women are more likely than men to take on caring responsibilities (e.g. for older family members). Women also tend to work in part-time jobs, and are over-represented in low paid occupations and sectors such as teaching and care work. Williams finds that the low social status traditionally associated with domestic and caring work can damage feelings of self-worth, while the stresses of overwork, extensive responsibilities and feeling undervalued can damage women’s mental health. While the extent of gender-based disadvantages varies according to social class and ethnicity, it has been argued that women bear the brunt of reconciling paid work with family life.

Research also shows that there are three main factors which are highly protective against the development of mental problems, and especially depression. These are:

• having sufficient autonomy to exercise some control in response to severe events.
• access to some material resources that allow the possibility of making choices in the face of severe events.
• psychological support from family, friends, or health providers

Women around the world are less likely than men to have the first two, but hopefully number among their armory against mental health problems the support of family and friends.

And Pilgrim has found that women in the UK receive more services than men for mental health problems at the level of primary care, though this difference is less at the level of secondary care (specialist and hospital treatment). It is difficult to know whether more mental health problems are diagnosed in women at primary care level because they seek help more often than men, or because they actually experience more distress.

Either way, women's place in society the world over - their central role as carers of young and old,  their lower economic status and perceived value compared to men, their difficulties in balancing working and domestic life and their greater vulnerability to violence - negatively affects their mental health outcomes. This is mitigated by supportive relationships with friends and family and a willingness to seek help for problems - but it is not enough. Greater equality for women will bring improved mental health: a number leading charities brought together by Annie Lennox are working towards it under the banner of We Are Equals.

Posted by Lucy

More at:

http://www.who.int/mental_health/prevention/genderwomen/en/

http://www.mind.org.uk/help/people_groups_and_communities/women_and_mental_health#_ednref13

Williams, J. and Miller J., 2008, ‘Gender inequality and the mental health of women and men’, in T. Stickley and T. Bassett (eds) Learning about mental health practice. Chichester, Wiley: 381–400.

Astbury, J., 2001, Gender disparities in mental health. Mental health. Ministerial Round Tables 2001, 54th World Health Assembly. Geneva, World Health Organisation

Pilgrim, D., 2010, ‘Mind the gender gap: mental health in a post-feminist context’ in: Kohen, D (ed) Oxford textbook of women and mental health. Oxford University Press, Oxford

Perrons, D., 2009, Women and gender equity in employment, Institute for Employment Studies.  

Williams, J., 2005, ‘Women’s mental health’, in: Tew, J (ed), Social perspectives in mental health: developing social models to understand and work with mental distress, Jessica Kingsley Publishers, London

 Department of Health, 2002, Women’s mental health: into the mainstream, DH, London

Choosing To Be - Lessons in living from a feline zen master

This deceptively simple narrative dextrously weaves a tale of survival and renewal around an introduction to meditation and a conversation with a cat (or feline zen master).

I have to admit this last aspect made me a little wary as I started to read; I'm neither a cat lover nor a fan of literary anthropomorphic cuteness (at least not in adult books). However, what Kat Tansey achieves through this device is to seamlessly embed a discourse on meditative practice within her personal chronicle; to underscore the intense loneliness of the depressive with almost zero human interaction; and to create two likeable, entirely "human" characters who add depth, not cutesiness, to her journey.

This account takes us through (the aptly named) Kat's passage from high flying career woman to debilitated chronic fatigue syndrome sufferer and depressive. Her suicidal thoughts are presented without drama and the painful monotony of mental and emotional struggle without self-pity. Equally, her heroic and painful steps back to wellness are depicted with self-deprecating and often humorous honesty and the revelatory "conversations" with Poohbear come across as unaffected and authentic.

Choosing To Be (a clever title, evoking Hamlet's soliloquy as well as the Buddha's teachings) is structured around the "lessons" of meditation under the technical headings of Ordinary Mind, The Hindrances and Buddha Mind, which make it an easy-to-follow and inspirational guide book. The fact that Tansey has also written an absorbing memoir with the flair of a fiction writer, however, draws you effortlessly through her story and makes the learning seem incidental - until you reach the end and realise that the tale of a woman, a cat and a kitten has reminded you that there is a better way to live, and how to do it

Review by Lucy

How to be happy - tips from recent research

It appears that people suffering with mild to moderate depression focus too much on the bad and the sad*, and that socially anxious people tend to remember negative rather than positive experiences*. When trained to shift their attention, both groups experienced a major improvement.

In the case of the research on depression, sad faces seemed particularly attractive to people with mild to moderate depression, whereas non-depressed people found neutral or happy faces more attractive. The question is whether the increased attention paid by depressed people to unhappy or sad themes is simply a byproduct of depression or might it be a cause?

Researchers looked at the question of whether biased attention towards sadness plays a maintaining role in depression and, more specifically, they looked at the question of  whether modifying the attention for sadness, by training participants to shift their attention toward neutral stimuli, could reduce depressive symptoms.

The study provided evidence for the first time that training attention away from unhappy or sad stimuli to neutral stimuli reduces depressive symptoms. In addition, these effects lasted beyond the duration of training. Perhaps most notably, these results provide additional evidence that, rather than being by-products or symptoms of depression, attentional biases towards sad themes play a causal role in the maintenance of depressive symptoms.

These findings worked with people with mild to moderate cases of depression, and those are also the people for whom anti-depressants often don’t work. Since we are all prone to episodes of mild depression, it may well be worth remembering to keep a tab on the amount of attention you pay to sad or unhappy events - and try to stop yourself.

In the study that looked at people who suffer from social anxiety, results showed that socially anxious individuals more easily forget socially positive words and experiences than do non-anxious individuals. It’s not that socially anxious individuals have fewer positive experiences than non-anxious individuals, it’s just that they appear not to recall them as readily.

Martin Seligman’s research is worth noting here. He found that the habit of writing down Three Good Things that went well each day increased happiness and decreased depressive symptoms for six months after the single week of testing.

So if you can get into the habit of writing Three Good Things that went well, and reasons - preferably to do with you - why they went well, even if you only manage it twice a week, you’ll have clocked up over Three Hundred Good Things that have happened to you in a year.

The first and last Steps of The Real Secret "Choose to be Happy" and "Smell the Roses" give you Habits that promote focusing on the positive and have been shown to raise happiness levels. Get your copy from Amazon.com or Amazon.co.uk in paperback or Kindle



* Tony T. Wells and Christopher G. Beevers (2010) Biased Attention and Dysphoria : Manipulating selective attention reduces subsequent depressive symptoms Cognition and Emotion, Vol. 24 (4)
* Chi-wen Liang et al., (2011) Absence of a positive bias in social anxiety: The application of a directed forgetting paradigm" Journal of Behavior Therapy and Experimental Psychiatry, Vol. 42 (2)

Post by Annabel