Depression #4: The road to recovery

Thankfully, and with support, there are many ways to tackle depression, starting with simple lifestyle changes, through talking therapies and anti-depressant medications. In this, the 4th and final post from our series by Dr Stephanie Hughes, we learn about the options available.

Lifestyle Factors

Improving sleep patterns
Many patients with depression describe difficulty sleeping. It is important that this is taken seriously, as things always seem so much worse without adequate sleep – and problems can multiply and assume huge proportions in the wee small hours of the morning, when everyone else is dead to the world. Sticking to a proper “sleep hygiene” routine is key to managing sleep; one of the worst culprits is the bluish light which is emitted by many devices such as tablets, phones, laptops etc. Bedtime use of devices such as these will convince the brain that it is daylight, and keep people awake. Avoiding caffeine is pretty obvious, but avoiding eating too much before bedtime is also important. People often believe alcohol will help them to sleep, but in fact it interferes with sleep and stops people from getting the high-quality sleep that refreshes and restores, so is best avoided. Establishing a good sleep routine is crucial, so patients should be advised to stick to the same bedtime and getting-up time, as well as avoiding naps.

Regular exercise
Taking regular physical exercise can also help sleep, and is great for overall health generally as well as being thought to help depressive symptoms specifically – group exercise is better than exercising alone.

Non-Drug Treatment for Depression
Sigmund Freud published his work “Mourning and Melancholia” in 1917, which was probably the first modern psychological theory of the psychological causes, as well as potential psychological treatments, of depression – and many of the best-known and most commonly used psychological therapies are derived from Freudian principles. There are several therapies which are recommended by NICE for the treatment of depression, and evidence suggests that psychological therapies and medication combined are more effective than either one alone. 

Cognitive Behavioural Therapy (CBT) can be very useful indeed at managing depression. Unlike counselling, CBT does not involve detailed discussion about past events, but rather concentrates on attending to and correcting negative thought patterns – over time, these negative thought patterns can become a habit and almost automatic, and chronic negative thinking can actually distort reality and make depressive symptoms worse. Depressed patients often show signs of so-called “minimisation”, which means that they concentrate on the negative aspects of their life while not giving enough emphasis to the positives – this in itself leads to further lowering of mood. The mantra of CBT might be summarised as “changing the way you feel by changing the way you think”, and it takes practice, but it’s definitely worth it – there is plenty of evidence that it works.

CCBT is a computerised form of CBT and is offered via on-line web-based programmes such as MOODGYM or Beating the Blues. These programmes ought to include a full explanation of how CBT works, and be done over 9-12 weeks to get the best effects. Patients with moderate or severe depression really ought to have face-to-face CBT with a trained therapist, rather than on-line, but for patients with less severe symptoms the computerised therapy can be very helpful and easy to access. Guided Self-Help is a CBT-based approach which may also be used to help patients with depression, and is a problem-focused therapy.

Behavioural Activation is also an evidence-based CBT-based therapy, and it approaches some of the behavioural symptoms of depression (avoidance, withdrawal and rumination) as learned behaviours which can be “un-learned,” and therefore the negative spiral of depression can be reversed by increasing engagement in meaningful activity. Depressed patients often reduce their participation in activities they once enjoyed, and may employ “escape” behaviours to avoid having to interact with the outside world (for example, by staying in bed for much of the day) – these in combination reduce the potential for the patient to have rewarding and positive experiences, and this in turn leads to further negativity of thought, worsening depression and yet more avoidance and inactivity. Behavioural Activation seeks to put a stop to this, by scheduling increased engagement of the patient with meaningful activity, even if the patient is feeling unmotivated, unhappy or otherwise not in the mood to take part. This might be summarised as “changing the way you think and feel by changing what you are doing”.

Mindfulness techniques can be very helpful in the management of depression, too. Mindfulness is one of the most important developments in mental health in the last twenty years - its use as a psychological treatment for depression has been comparatively recent, but is definitely effective. Mindfulness is based on Buddhist traditions, and centres around awareness and acceptance of feelings, thoughts and experiences. Patients are taught to become consciously aware of their sensory experiences and any thoughts that are going through their mind, as well as focusing their conscious attention in ways which are beneficial. Patients are also taught to accept, in a calm and non-judgmental way, what they are experiencing. Many people with depression live either trapped in past problems or overwhelmed with future anxieties – neither is helpful. Mindfulness teaches patients to connect with the present moment, or to “be present in the now”, and to observe and affirm their thoughts, feelings and sensations; this practice has been shown to be highly effective in the treatment of depressive illness.

Counselling is another sort of psychological therapy useful in the treatment of depression, that encourages a patient to talk about their problems in a confidential and “safe” environment. A counsellor is a specially trained therapist who is trained to listen with empathy, and to help the patient deal with any negative thoughts or feelings that they might have; counsellors don’t usually give advice, but will be respectful of the patient’s perspective and will facilitate exploration of difficult feelings. The aim of counselling is to help the patient deal with and overcome issues that are causing psychological pain, by developing an insight into the issues and some strategies to manage them. Counselling involves acknowledging and expressing emotional pain, and talking about difficult issues – it can sometimes seem as though this makes the situation worse to begin with, but perseverance over several sessions with a counsellor whom the patient trusts can yield very good results over time.

Psychodynamic Psychotherapy is a therapeutic process based on psychoanalysis and which aims to help patients understand their problems, and help to alleviate their depression symptoms, by increasing their awareness of their “inner world” and the effect that this has on relationships past and present. It centres around the notion that our unconscious minds “hold onto” painful emotions and memories which are too difficult for our conscious minds to process; people then develop defences, such as denial or projection, to stop the painful emotions and memories from surfacing, and these defences often do more harm than good. Psychodynamic psychotherapy encourages the patient to unravel and release their suppressed emotions and memories, and to make changes to the ways in which they behave.  

Interpersonal Psychotherapy (IPT) is another psychological treatment for depression, which is based on the idea that psychological symptoms of depression, such as low mood, can be caused by difficulties in relationships as well as having negative effects on the quality of those relationships. It covers conflict, and ways to start relationships and to keep relationships going. Closely related to IPT is couple or relationship therapy, which aims to help couples with their relationship and to manage the aspects of depression which may stem from emotional difficulties arising from problems within their relationship.

Electro-convulsive therapy (ECT) is a treatment for severe depression which involves sending an electrical current through the brain to induce an epileptic fit. No-one knows exactly how ECT works, although the therapeutic benefit probably comes from the fit rather than the electricity. ECT is done in hospital, under a general anaesthetic, and with the use of a muscle relaxant to stop the body from convulsing during the epileptic fit. Its effects are very rapid, and so benefit can be conferred straight away. There are risks of memory loss following ECT treatment, and it is usually reserved for patients who are profoundly depressed (possibly life-threateningly so – for example, actively suicidal or not eating or drinking due to depression) and who have not responded to the pharmaceutical and psychological treatments mentioned above.

Antidepressant Medication
Patients’ attitudes to antidepressant medication vary widely. It’s certainly not the best thing for everyone; the National Institute for Clinical Excellence (NICE) recommends that antidepressant medication be reserved for patients with moderate to severe depression, or those who have been depressed before or have had low level symptoms for a long time. This is because antidepressant medication works best in people with greater severity of symptoms – in people with mild depressive symptoms it doesn’t really work any better than “placebo” (a “dummy” medication that helps people feel better because they believe it will), and all medications have the risk of side effects, so a sensible approach to the potential benefits measured against the potential risks needs to be taken.

The most commonly prescribed antidepressant medications are serotonin-specific reuptake inhibitors or SSRIs. Examples of these include citalopram, sertraline, fluoxetine, and paroxetine, and there’s really not much to choose between them when it comes to how well they work. These medications work by allowing the levels of the body’s own natural serotonin to build up, by stopping it from being broken down as quickly as it usually is. SSRIs start working pretty quickly, and patients should expect to start to feel better within a matter of days (in fact, people often feel better almost immediately, but this is almost certainly due to the feeling of relief that they get from having talked about their problems with someone who cares, and having been given some treatment, rather than the treatment itself – added of course to the magic “placebo effect”!). The medication is considered to have “worked” if the symptoms are 50% better – but it would be entirely reasonable to hope for a more complete return to health.

SSRIs are pretty well tolerated by most people, and, crucially, are more safe than other classes of antidepressants when taken in overdose (accidental or deliberate – the risk of deliberate overdose in depressed patients, either as a genuine suicide attempt or a “cry for help”, must always be considered by the prescribing doctor). However, just as with all drugs, they have side effects – the commonest side effects of SSRIs as a class of drugs are headache, tummy upset and sexual problems. SSRIs can also cause low sodium and bleeding from the digestive tract, so doctors will always want to know about any other medications that you are taking that might worsen these risks and, if you’re taking something like ibuprofen long-term, you might not be able to take an SSRI. A very rare but serious condition exists, known as Serotonin Syndrome, where patients on SSRIs or other medications affecting the levels of serotonin in the brain can experience shaking, sweating, confusion, high blood pressure and muscle jerks. This is not usually seen in standard antidepressant dosing regimes, and is more likely to occur if patients are taking more than one treatment at the same time.

The commonest cause of antidepressants “not working” is that they are not being taken as prescribed. It is very important to follow the dosing instructions carefully, and to trust your doctor’s advice. The tablets are effective at what they do, but won’t do you any good if they are still in the blister pack on your bedside table – or still on the pharmacist’s shelf! If the medication genuinely has had no effect at all after a month, your doctor may decide to try you on a different sort of antidepressant – it is not best practice to keep increasing the dose of a drug that isn’t working, or to add in more different drugs on top. Combination antidepressant therapy is prescribed from time to time, but usually only under specialist supervision. Reasonable second choices of antidepressants after SSRIs have been tried might include venlafaxine (a serotonin and noradrenaline reuptake inhibitor or SNRI), mirtazapine (a noradrenergic and specific serotonergic antidepressant or NASSA), or a tricyclic antidepressant (TCA) such as lofepramine. These “second choice” antidepressants have more troublesome side effects than SSRIs, but, as they work differently, they may sometimes be used as a first choice treatment depending on the exact symptoms the patient is suffering from.

Hopefully, patients will respond well to their antidepressants, and, after some time, they may wish to discuss stopping their treatment. A common mistake is for patients to stop their medication as soon as they are feeling back to normal. This is an unfortunate mistake, as relapse of symptoms is very common if treatment is stopped too soon. Doctors will usually recommend staying on the same dose of antidepressant medication for at least six months after returning to health, or sometimes even longer. This is very important to make sure that people stay well, and don’t experience their mood crashing back down again. Patients may be advised to reduce their medication dose gradually when they are coming off the treatment – while SSRIs are not addictive, people can often suffer from some withdrawal symptoms when they stop them (especially if they stop suddenly) which include not only headache and tummy upsets but also feeling flu-like, dizziness, getting pins and needles, feeling anxious and having poor sleep. These withdrawal symptoms aren’t dangerous and don’t last, but are best avoided by a gradual stepping down of the medication.

Herbal treatments including St John’s Wort should be regarded with caution
Some people are interested in herbal treatments for depression, and you may have heard of St. John’s Wort. This is an extract of the plant Hypericum perforatum and it has been used for centuries for the treatment of depression – it can be bought over the counter at health food shops, herbalists and community pharmacies. It is not available on prescription in the UK as it is not licensed as a medication – people often assume that herbal treatments are safer than pharmaceuticals, but this is a misguided belief. Nobody really knows how St. John’s Wort works (it has at least ten active ingredients), and it is impossible for doctors to be confident in its preparation techniques and strength. More worryingly, St. John’s Wort has known serious interactions with many prescribed medications including the contraceptive pill, blood thinning medications and anti-epileptic medications. Best practice is for doctors to advise against its use.