Wednesday, 3 October 2012


There is no shame in this. I have tried to tell myself that over and over. Many people who have been unemployed for a while feel depressed and despondent. And that's without the history I have. I've made it a year without giving up, persisting in my job hunt, making myself healthy, hanging on to a sense that it will be alright. But the demons have finally caught up with me. My depression is out of control. I've had my ups and downs over the past year but this time it's unmistakable. I'm constantly exhausted, and I feel almost permanently nauseous, if not dizzy. I don't sleep for long at night, and when I sleep, I have vivid dreams - not necessarily nightmares, but they're not good dreams - and wake up covered in sweat, feeling almost more exhausted than before I slept.

I've tried to explain it away by talking about PMT and then a 'reaction to my flu jab', which at the time felt sensible. Sometimes being depressed feels like being poisoned. But I'm rapidly realising that the truth is that my body and mind are shattered. Gwyneth Lewis talks about depression being your body's way of telling you that the way you are living is simply not working. It's unsustainable. Applying for unpaid positions I don't want and not getting them, slogging through applications only to have them be totally ignored, and continuing to pretend I know what I'm doing, that I know what I want to do, has finally become too exhausting to bear. Something has to give.

But the shame I feel in admitting that is hard to ignore. Having people like me who claim JSA being consistently portrayed as scroungers, or lazy, unappreciative spoiled kids with no real worth ethic is not helping with that but it's not the only reason. Shame is almost always a big part of depression. I feel ungrateful. I blame myself. I vividly remember trying my absolute best to pretend not to be depressed in my last relationship, and the guilt was unbearable. I poured every ounce of energy I had into pretending to be what he wanted me to be - happy, normal, whatever - and it was a train wreck. I became more and more desperate and it only made the rift between us greater. The more I tried, the needier I became, and the more aware I was that it was never enough to make up for the fact that I was unwell.

It's time to heed my own advice and accept that this is not my fault, in fact I've done remarkably well to keep going this long. I've tried everything I should have - eating well, exercising, getting myself out of the house, calling my friends, making plans to look forward to - but it's not enough any more. I need help. I need space to re-think my next steps in my life and I need acceptance from the people who love me,

Thankfully I already have that last one. I could not be more grateful.

Monday, 1 February 2010

Treatment for Unipolar Depression

I realised today that I have addressed the physiology, causes, definitions, etc of depressive disorders, but not very much about how they are treated, so I shall address that problem in this post. There are a lot of different treatment options for people with mood disorders. The same treatments won't necessarily work for everyone, and many people find that a combination of two or more different approaches is best for them. This post explores treatment options for those diagnosed with Depression (Major Depressive Disorder). Treating Bipolar Disorder is somewhat different and will be dealt with separately, although the sections about therapy and looking after your mental health apply to bipolar patients as well. So with that said, I'm going to try and take you through step-by-step.

Finding a doctor
The first doctor you should see if you think you are suffering from depression is your GP. Many people find this step to be the most difficult, because they fear that their doctor won't take them seriously. Although each doctor is different, depression is the most common ailment that GP's deal with, so the majority will be experienced in looking for symptoms and giving you any advice or information you need. A few tips on going to your GP:
  • Make an appointment in advance, so that you have time to prepare. It should preferably with a GP you are familiar with and whom you trust, but if you are feeling desperate and need help ASAP then tell the receptionist this. Most practices have emergency appointments within 24 hours for problems needing immediate attention.
  • Think about what you're going to say. Write down how you've been feeling, for how long, and what you want out of the appointment. E.g. 'I've been feeling really low for the last few months, and I want to know if you think I might be depressed'.
  • Make a note of any questions you want to ask the doctor in advance so you don't forget them.
  • If you're nervous, ask a friend or family member to go with you for emotional support. Most GP's will welcome this, because often people you know well have a more realistic understanding of how your mood is affecting your life than you do yourself.
If the first doctor you see doesn't take you seriously, don't give up. Try another GP. It's not always easy to find a sympathetic doctor whom you feel comfortable with, but when you do find one, they are immensely helpful, so it's worth sticking with it. You can search for a GP near you on the NHS website.

Mental Health Professionals
If your GP feels that you are suffering from a mental illness, the logical next step is usually to refer you to an NHS specialist mental health service in your area, where you will be allocated a keyworker, who assess your needs and co-ordinate your care plan. They will then refer you to whichever mental health professional(s) suit your needs. I've summed up the different types below, with the most qualified professionals at the top.
  • Psychiatrist: Doctor who specialises in prescribing psychiatric medication, diagnosing psychiatric disorders and assessing patients level of risk to themselves or others. Everyone who takes psychiatric medication should see their psychiatrist regularly, so that the psychiatrist can check on how the patient is responding to the drug, and if necessary adjust their dosage or change or stop their medication.
  • Clinical Psychologist: Specialist psychologists, trained to give clinical therapy to patients either individually or in groups.
  • Community Psychiatric Nurse: Usually visit patients in their own homes. Offer support, make sure the patient is taking their medication correctly, and talk to the patient's family, to help them understand and cope with the illness.
  • Occupational Therapist: Help patients with practical and occupational difficulties. E.g. help patients set goals for themselves, take better care of themselves etc.
  • Psychotherapist: Therapist with an interest in a particular form of psychotherapy, which they offer to patients either in individual sessions, group sessions or a mixture of the two.
  • Counsellor: Has a degree or diploma in counselling - i.e. helping people identify and talk through their problems to help them cope better with them.
Mental health teams also include social workers, although they are employed by social services rather than the NHS. Although specialist mental health services are the ones recommending and providing treatment, your GP will still oversee your primary care and usually you will have to see them regularly to see how you're doing and to get your medication etc. So now, on to the actual treatment options.

Therapy is probably the most common treatment for depression, because although medication can help alleviate some of the symptoms, it doesn't treat the underlying psychological problems. Nor can it teach the patient how to manage their illness and prevent relapses. People with Bipolar Disorder should also receive some kind of therapy, although sometimes their psychiatrist will fill this role as opposed to an actual psychotherapist or clinical psychologist. There are many different kinds of therapy, and there isn't any hard evidence to suggest that one is better than another, so a lot of the time finding the right therapy is a case of trial-and-error. Here are some of the different kinds of therapy:
  • Psychodynamic Therapy: Based on Freud's psychoanalysis, psychodynamic therapies work around the theory that mental illnesses are caused by unconscious desires, conflicts and traumatic experiences in very early life. Therapy works by uncovering the original problem and working through it. The patient voices their thoughts as they occur to them without censoring them, and the therapist analyses this for signs of repressed memories, thoughts, fears and conflicts. Psychodynamic therapy is an intensive, long-term treatment, and is often criticised for being time-consuming, expensive and for ignoring a patient's immediate problems in preference for unconscious past conflicts.
  • Cognitive Behaviour Therapy (CBT): Works around the idea that mental health problems are not caused by negative events, but rather how the person distorts the meaning of those events through self-defeating thought patterns and negative beliefs. The therapist's job is to help you to identify and correct these negative patterns of thinking and behaving. CBT has widely been shown to be at least comparable to drug treatments in treating all but the most severe cases of depression. The advantage of CBT is that it is a short-term treatment which also helps prevent relapse in the long-term.
  • Interpersonal Therapy: Focuses on interpersonal relationships. The therapist helps the patient to learn to communicate better and develop good interpersonal skills, which improves their relationships to other people.
  • Humanistic-Experiential Therapy. Centres on the idea that we have both the freedom and the power to control our own behaviour and influence our own lives. The main goal of therapy is to increase the patient's self-awareness, self-acceptance and self-fulfilment, which may be frustrated by irrational tendencies, dehumanising mass society and existential anxiety. There are various types of therapeutic approaches:
    1. Client-centred Therapy aims to create a psychological climate in which the patient feels unconditionally accepted, understood and valued as a person, so that they can explore their true feelings and accept anger, hate and unpleasant thoughts as a part of themselves.
    2. Gestalt Therapy teaches patients to identify feelings they have been blocking off and hiding. It is often done in group therapy, but the focus is always on one person at a time, with the group and therapist offering insight into the individual's life which they are not accepting.
    3. Existential Therapy encourages patients to acknowledge and accept their own mortality, and that their existence is a coincidence, not the result of fate, destiny or a divine will. Although there is a tragic element to this, it celebrates the freedom of the individual (as opposed to the 'herd mentality' of mass society) and encourages free expression, similar to the French concept of 'joie de vivre'.
  • Integrative therapies: Types of therapy which combine different aspects of different kinds of therapy. E.g. 'Cognitive Analytic Therapy', which involves some analysis of early traumas and the impact those have on the individual's life, but with a cognitive behavioural approach. I.e. Repressed early experiences, family dynamics in infancy etc can affect an individual's mental health, but in the sense that they cause negative and self-defeating beliefs, which can be changed.
  • Couples therapy and Family therapy. Pretty much self-explanatory.
Psychiatric drugs are an essential part of treatment for some sufferers of depression. The most common drug treatment is the use of antidepressants. Antidepressants should only be used in cases of severe depression, or moderate depression which has not responded to psychological therapy and lifestyle changes. There are two reasons for this. Firstly, recent research has shown that unless you are very severely depressed, antidepressants do not work any better than placebos. Secondly, like any drug, antidepressants can have unwanted side-effects. In particular they are associated with an increase in suicide risk, so unless the patient is severely depressed, the risks of antidepressant drugs outweigh the potential benefits. You can find a guide to 'what you need to know' about antidepressants in this post.

Antidepressant treatment is usually offered in addition to psychological therapy, not instead of it. As for which antidepressant is right for you, it is impossible to tell. Basically it's a case of trial-and-error. In young adults and teenagers, psychiatrists will usually begin antidepressant treatment by prescribing fluoxetine (Prozac), due to its relative safety compared with other drugs it is the only one approved for treating under-18's, who are at an increased risk compared to adults of committing suicide as a result of antidepressants. In adults, citalopram (Celexa) is often the first drug prescribed. Whichever particular drug it is, SSRI's are generally the first line of treatment for unipolar depression. Most doctors begin by prescribing a very low dose and gradually increase it until it's high enough to work. If after 4-6 weeks you don't feel any better, your doctor will usually increase your dosage further.

If after a couple of months you are still experiencing symptoms, or if you can't tolerate the side-effects of the antidepressant there are several options. Your psychiatrist can switch you to a different SSRI or to one from a different class of antidepressants, or they can suggest that you add a second medication to supplement your current one. If you responded partly to the first drug, it makes sense to try a different SSRI or add another medication to it. If you didn't respond at all, it's probably more sensible to switch to a different class. This process continues until you the drug or combination of drugs which works for you, and which you tolerate well. Psychiatric patients sometimes call this the 'med-go-round'. It can be frustrating, and the side-effects can sometimes be unpleasant, but ultimately for the severely ill it's a worthwhile process, because the right drug (or combination thereof) can help you turn your life around.

Electro-Convulsive Therapy (ECT)
ECT has a bad reputation because it has a history of being abused by doctors to punish or control uncooperative patients but when properly administered, ECT is actually a very safe, effective treatment. In fact the only form of treatment available for:
  1. Those who have not had an adequate response to other forms of treatment
  2. Pregnant women for whom drug treatment may be problematic
  3. Those who have medical conditions which are contraindicative for antidepressant therapy
  4. Bipolar patients who have not responded to pharmacological treatment
It is usually administered bilaterally. That means that electrodes are placed on either side of the head. Brief electrical pulses of either high or low intensity are then passed from one side to the other for up to about 1.5 seconds. Anaesthetic is used so that the patient in unconscious throughout the procedure, and these days muscle relaxants are always used to stop the violent convulsions which ECT is sometimes known for. Psychiatry has come some way since One Flew Over The Cuckoo's Nest, people.

The advantage of ECT over other treatments is that it produces dramatic improvements almost immediately. However, ECT is still controversial. Many people are understandably uncomfortable with the idea of passing electric current through a person’s head, particularly because nobody is sure why it actually works. It remains a last-resort treatment because it carries potentially serious side-effects such as short-term and long-term memory loss, disorientation and confusion. Plus, although improvement can be drastic, it is usually temporary. The NHS says that "The NICE recommendations are that ECT should only be used with caution, and that a balance of risks and benefits for each individual should be made. Doctors are called on to keep strictly to guidelines on consent and encourage the involvement of both carers and ‘advocates’ who speak on the patient’s behalf." (NHS website)

Alternative Therapies
Some people choose to try alternative, holistic treatments instead of the conventional ones. My personal opinion is that unless you are only mildly depressed (i.e. NOT clinically depressed), this is a bad idea. Alternative therapies can be complementary to conventional treatments, but they are not a replacement for medical help. Listen to your doctor and always ask his or her advice before opting for an alternative treatment. Some examples are:
  • St. John's Wort: an unlicensed herbal medicine used to help alleviate mild to moderate depression. While some clinical trials have found positive results, there is considerable variation in the preparations of St. John’s wort available over the counter, and one does not necessarily work as well as another. It is essential to consult your GP and/or psychiatrist before taking St. John's Wort, or with any herbal medicine, because they can have serious interactions with a large number of commonly used medications (e.g. warfarin). St. John's Wort should never be used alongside an antidepressant drug.
  • Expressive therapies which encourage artistic expression as an emotional outlet, e.g. art therapy, drama therapy, dance therapy, writing therapy, music therapy.
  • Hypnotherapy
  • Acupuncture
  • Aromatherapy
  • Etc.

Looking After Your Mental Health
Looking after your general physical and mental health on a day-to-day basis is an essential part of treating and living with depression. For some people with mild to moderate depression, these things alone can be enough to make you feel better. The Mental Health Foundation suggests 10 ways you can look after your mental health:
  1. Talk about your feelings with friends and family. Just being listened to can help you feel less alone.
  2. Be Active. The NHS recommends that exercise be a part of treatment for everybody who suffers from depression. It lifts your mood, alleviates stress and improves your self-esteem. Ask your GP about exercise referral schemes in your area.
  3. Eat Well. Even if you don't feel like eating due to depression, try to eat three balanced meals a day and make an effort to include a variety of fruits, vegetables, protein etc. For more information, visit the Feeding Minds webguide
  4. Drink Sensibly. Don't drink to feel better. Overall it actually makes you feel more depressed. Always ask your doctor if it's okay before you mix your meds with alcohol. Stay within your daily limit.
  5. Keep in touch. Isolation makes depression worse, and support from family ties can make you feel cared for and included, plus they can offer advice if you need it.
  6. Ask for help. If you're struggling, talking to a therapist, counsellor or people in a support group can help. Ask your GP or psychiatrist to refer you. For a list of organisations which run support groups for people with depression, click here.
  7. Relax. Ask your GP about relaxation techniques, or try yoga or meditation, or just do whatever relaxes you, either with a friend or alone. Disaster movies work great for me. Some support groups and mental health charities run relaxation classes you can go to. You can also download relaxation podcasts from the Mental Health Foundation. Finally, if you're having problems sleeping, talk to your GP.
  8. Do something you're good at. Find an activity you enjoy, or learn a new skill. Achieving something boosts your self-esteem, and concentrating on something you love doing distracts you from negative thoughts or feelings.
  9. Accept who you are. Recognise and accept your flaws as part of you, but try to focus on what you can do well and what you like about yourself.
  10. Care for others. Looking after your friends, a pet or volunteering for a charity are all good for your self-esteem because it makes you feel valued and needed. But don't take responsibility for a pet unless you are absolutely sure you have the time and money to care for it properly. If you do decide to get a pet, please consider adopting from a rescue center. Your love will be even more valuable to a rescued animal. Find out more about volunteering at the do-it website.

1. The section about looking after your mental health borrows and paraphrases from the guide 'How to look after your mental health', which is a copyright of the Mental Health Foundation. Parts of it reproduced here are done so on an educational, strictly not-for-profit basis according to the Copyright, Designs and Patents Act 1988, and remain the intellectual property of the MHF.
2. As always, crazymeds
3. NHS guide to treating depression
4. Personal experience.

Thursday, 22 October 2009

Friends & Family: Understanding Depression

If one of your friends or a family member has depression, it can be a real struggle. Mental illness doesn't just affect the person with the illness, but everyone around them too. If you've never been there yourself, you will never completely get it. But there are some things I can tell you which may help you understand a little better, and some advice on how you can help.

Depression is neurological. When a person suffers from depression, their overall brain activity is significantly reduced, and this accounts for a lot of the symptoms which outsiders can find frustrating or confusing. So concentrating, paying attention, keeping up with a conversation, remembering to do things, etc, are suddenly completely overwhelming. It's like having the energy sucked right out of you. It's a neurological disturbance. It's essential to understand that.

There are no quick fixes. It's tempting, in this day and age, to think that somebody can take a pill and all's well again, but recovering from depression is like recovering from a really badly broken limb (as Jerod Poore points out at crazymeds). It's not like a sprain where you just need some ibuprofen and to keep the pressure off it. Your bones need to be re-set and then put in a cast for a while. You need some serious painkillers to get any sleep at all, and in the long-term you need lots of physiotherapy and follow-ups. Medication can help improve the symptoms of depression, but it's not a cure-all. For a severe or prolonged depressive illness it can take years to recover. It's okay to find this frustrating, but try not to take it out on the person who's depressed. It's not their fault.

Depression affects the way you think. Depressed thinking, by definition, is so negative that it interferes with a persons normal functioning. It happens in all sorts of situations and it becomes a downward spiral, where negative thinking causes negative behaviour. You withdraw from social situations because you think "what's the point? nobody likes me" and you stop doing things you used to love because you think "I'm crap at it anyway." None of this is rational or normal, but it's an unavoidable part of the illness.

You're not a therapist. Don't forget that you can't make it all better and you definitely can't be their therapist. The ill person has to tackle this themselves, with the help of a trained professional. You'll have a much easier time if you accept that. There are no magic words, and no advice you can give which will make it all better. Yes they may be being irrational, but it's not your job to point those things out. That stuff hurts coming from a friend in a way it doesn't coming from an impartial professional whose job it is. Literally, the most important thing for you to do is just be there. "It's okay. I'm here for you." That is honestly all it takes.

Be Supportive. So how do you support somebody who has depression? Let me show you something I wrote a few months ago when I was really low:
It's just so hard, because I look normal, so people forget that I have a disability. I wish just one person would not forget, and ask me how I am every now and then, or notice that I've not left my room for days. I really want somebody I can call to talk to when I feel low. Somebody who, once in a while, will just stay in wth me and watch movies. Put an arm around me and tell me it's okay.
It honestly doesn't take a lot. You don't have to put your own life to one side. Just call once a week to see how they are. Just that can make a world of difference, you have no idea. How happy you can make somebody just by taking the time to check in. If things are bad, and you live close enough, set aside one night a week to see them.

Procrastination. I just want to briefly mention this because I know it's been a problem for my friends and family. Letting things build up and not dealing with them until they get overwhelming is a classic symptom of depression. Especially in people who also experience anxiety (it's very common for depression and anxiety to go together). We're not lazy, we're just overwhelmed. Don't be too hard on us.

Look After You. You want to be supportive, and for that you are awesome. Seriously. It's not easy. I have had friends who were so depressed that they were completely exhausting to be around. You don't know how to help, nothing you say is right, and you don't even recognise them. They've become selfish, negative and constantly angry or upset. It's natural to feel overwhelmed, frustrated and confused. It's important that you look after yourself too. You are allowed to have boundries, and no matter how much your friend is hurting, s/he has to respect those boundries. If you feel overwhelmed or unable to deal with their problems, you get to say so. Find a helpline or a professional they can call instead. Your support is a gift and get to say how much you can handle, and when you've had too much.

To sum up: If you're concerned about somebody and you don't know what to do, don't panic. All it takes is "are you ok? Is there anything I can do?". If somebody says they are fine and they don't want to talk, then there's nothing you can do about it. You can't help somebody if they won't help themselves. If they tell you how they really feel, just listen, even if you can't relate, it still helps. Try to see the person underneath all the sadness. They may be acting totally differently, but the person you used to know IS still there underneath all of that. You might find if you just have a chat with them, make them laugh if you can, and make them feel comforted and loved, you can make a world of difference.

Monday, 19 October 2009

8 Tips For Students With Depression

Now that I am back at university, I have less time to blog. Sorry about that. But to make up for it I have compiled a list of things you really should do if you are a university student who suffers from depression. I hope you find it useful.

1. Register With a GP
Unless you're living at home while you're studying, you'll probably need to register with a local GP. It really is better to register with a practice as close to your university accommodation as possible, especially if you take medication and need regular prescriptions. Most universities provide students with contact information for near-by practices, but you can also search for a GP near you on the NHS website.

2. Get Referred to Local Psychiatric Services
Once you've registered with a local GP, it's a good idea to go see them as soon as possible and get them to refer you to local mental health services. You can also contact whoever was in charge of your care when you were at home, and ask them to write to your new GP and ask them to refer you. There are usually waiting lists, so do it sooner rather than later.

3. Meet Your Academic Contacts
All universities have a support service for students with disabilities, and it's a good idea to set up an appointment with them as soon as possible so you can ask them what they offer, and how you can access their services. Most academic departments also have their own tutors or advisors who you can go to if you have problems, so introduce yourself now and make sure they know about your condition (and bring medical evidence). It's good to have these contacts in place so that if you ever need an extension on a deadline or an exam concession, they can sort it out quickly without needing to ask questions.

4. Sign-Up For an Activity You Enjoy
Most universities have a 'Fresher's Fair' where you can find out all about the societies, sports and activities on offer. It's a really good idea to sign up for for one activity you know you will love, as an antidote to the stress of studying. Experimenting with new activities can help your self-esteem, and you might make your best friends there.

5. Buy Earplugs
If you live in a university halls of residence, trust me, you will need them at some point.

6. Avoid too much alcohol
Okay, I know it completely goes against the university stereotype and some people will think you're, like, totally uncool. However, large amounts of alcohol tend to have a chemically depressive effect on the brain. Which is a really, really bad idea when your brain is already chemically depressed. Having a couple of drinks is okay, but more than that and you could find yourself feeling extremely low, and since alcohol also makes you more impulsive, there's always the risk that you could act on suicidal thoughts. Cutting down on alcohol doesn't have to stop you socialising, just drink soft drinks, water or juice in between the alcoholic ones, so it doesn't add up to too much. If you're taking medication, always check with your doctor if it's okay to drink alcohol while you're on it.

7. Be Realistic
This is a tough one, but a very important one. Don't expect too much of yourself. There will always be some people who are more compatible with you than others, so you can't possibly get on really well with everybody. You can't read everything on your reading list. Read what you can, according to what you're going to write an essay about/talk about in a tutorial etc.

8. Apply for Disabled Student's Allowance
If you're a student and you have been diagnosed with clinical depression, or any other mental health problem, you could be eligible for Disabled Student's Allowance. DSA is a kind of government grant which helps fund extra support for disabled university students. It helps pay for any specific equipment or support you might need, like one-to-one support . You can download an application form by clicking on the link below. You'll also need a letter from a doctor or from your psychiatrist which explains that you have a diagnosed mental health condition, and how they think it might affect your studies. Click here to download an application form.