Last week I went to an evening of of talks on non medical approaches to treating depression. What stood out for me was the idea of a multi-focused approach to treatment, probably because it’s in line with my own thinking. Depression is not a one size fits all condition, there are many causes and different people respond to different treatments. So what are the factors that we need to consider?

Practical Problems

Practical problems can make depression more likely. Some of my clients have needed practical help as much as they have needed counselling. Inadequate housing, dead end jobs, debt, noisy neighbours, etc. According to Professor Chris Thompson evidence from a recent study points to a link between deprivation (especially unemployment) and depression. Sometimes sorting out the practical problems can be enough to lift depression, in other cases it can help as part of a package of measures.

Relationships

In a similar way unsatisfying or destructive relationships can lead to, or at least contribute towards depression. This can be a relationship with a partner, a parent, a child, a sibling or anyone else who is emotionally significant. Some of my clients have found their depression lifted when they decided to end a relationship, others improved when they made a definite decision to stay, but to create clearer boundaries and start living their own lives, rather than trying to change the other person. Often seeing a counsellor can help people to see things more clearly and work out what they want to do.

Beliefs and Thinking Patterns

Of course not everyone who lives in poor housing, is unemployed, or in a bad relationship becomes depressed. The impact that these events have on us will depend on other things. One of the factors is how we think about things, our beliefs and values. If we tend to think negatively about things that happen to us then we may be more likely to think ourselves into a negative spiral of depression.

Negative thinking often dates back to childhood and can be tackled through self help, positive thinking, CBT and other talking therapies. Other approaches such as meditation and spiritual exploration can also be helpful for some people.

Deeper Emotional Issues

Learning to think more positively is not always enough. Sometimes depression dates back to early childhood or a particularly traumatic event and may be linked to neglect, abuse or other deep rooted issues. Here a deeper shift is required. We may be able to see how destructive our negative thinking is and learn to substitute more positive thoughts, but the emotional trauma continues to seep though. In these cases longer term therapy is needed to work through our emotional issues.

Physical Health

There is increasing evidence to indicate that exercise can have a positive impact on depression. What we eat is also being seen as increasingly important. So a healthy eating plan and exercise programme should be seen as a basic part of any depression treatment package. This should include avoiding alcohol and cutting down on sugary foods and junk food. Supplements may also be useful, especially Omega 3 EPA. There is increasing evidence to show that fatty acids can be useful in treating conditions related to mood, not just depression, but ADHD, Schizophrenia and Dementia.

Stress

Stress has also been linked to depression, so reducing stress in our lives should be part of our package of treatments. This could include practical measures to de-stress our lives (e.g. changing jobs, time management skills, delegating tasks etc.) and techniques in stress reduction e.g. mediation, massage, yoga breathing, etc.

Maybe in the future we will see the NHS providing a package of care taking into account all of the above as well as providing any necessary medication. In the meantime you can use this checklist to make sure you are doing everything you can to aid your own recovery.

Checklist for Depression Care

1. Getting help with practical Problems. Ideally there would be a health care team linked in to social services and other professionals to provide the support that you need. In reality you may need to find help yourself. Some suggestions are – social services, friends, family, Citizen’s Advice, National Debt Line, Connexions (for young people).
2. Relationships – try counselling to help you resolve relationship problems. There are also some good books on the basics of relationship problems.
3. Beliefs and Thinking Patterns – There are numerous books on positive thinking and CBT that may be useful, as well as computerised CBT programs that may help (see the Depression Alliance website and the Resources page on this site). If you need more help then try a counsellor or psychotherapist .
4. Deeper Emotional Issues – try counselling to help you work through these issues.
5. Exercise – make sure you are getting exercise – at least 20-30 minutes three times a week. A class is ideal as you will also be meeting people and getting out of the house. If you find it difficult to motivate yourself then arrange to go with a friend, it’s harder to drop out at the last minute. Exercising outside is also great as sunlight is thought to help with depression too. Find a group to walk /run/cycle with. Yoga is also thought to be beneficial. If all that is too much then go for a short walk every day. Whatever you can manage is better than nothing. Read more in our Resources secton.
6. Diet – many people find changing their diet emotionally very difficult. We all have some sort of emotional relationship with our food. If you find changing your diet intimidating then just make one small change at a time. You may want to see a nutritionist for a more tailored diet plan, but here are some basic steps.
   • In general stick to unprocessed foods.
   • Eat plenty of fresh fruit and veg.
   • Cut down on sugary snacks.
   • Avoid caffeine and alcohol.

   Read more in our Resources secton.

7. Supplements – Consider taking an omega 3 supplement. This will usually be fish oils (vegetarians can take flax seed oil, but note that most research has been done on fish oil supplements, so the effects may not be the same). Make sure that you use a good quality source, as some of the high street store versions don’t seem to be as effective. You can be tested for deficiencies in omega 3 and also vitamins thought to be related to depression. Your nutritional therapist should be able to arrange this for you and give advice on supplements generally. (Unfortunately this is not yet available on the NHS).
8. Practical Stress Reduction – Remove any negative stress that you can from your life. Get help in doing this if you need to from friends, family, a counsellor, coach, time management classes, etc.
9. Stress Management – Find ways to deal with the stress that you can’t get rid of. Try meditation (start with a class, book, CD etc.), go for a regular massage, take up yoga, set aside ‘me time’, have fun, etc.

You can find more information on many of these steps on our Resources page.

Acknowledgements to the speakers at ‘The value of non-medical interventions in the treatment of depression’ organised by the Depression Alliance.

Dr Liz Miller MB BS MRCS LRCP – Mood and Food
Professor Chris Thompson MD FRCPsych – Work Opportunities for Depressed Patients
Dr David Purves Consultant AFBPsS CSci C.Psychol – CBT
Dr Diane Lefevre MB ChB FRCP FRCPsych – Psychotherapy and Nutrition

This week people from all over the UK will be helping to raise awareness about depression as part of the 13th Annual Depression Awareness Week (previously called National Depression Week). The Awareness Week was initiated by the Depression Alliance and has been very successful in previous years. This year there will be fundraising and awareness events taking place across the country hopefully resulting in lots of quality coverage in the media. This week’s post is my small contribution to the campaign.

How Widespread is Depression?

According to the Depression Alliance:

• * One in five people suffer from depression at some point in their life.
• * More than 2.9 million people are diagnosed as having depression at any one time.
• * As many as three in four cases are neither recognised nor treated.
• * The World Health Organisation says that by 2020 depression will be second only to chronic heart disease as an international health burden.
• * More than 80% of people with depression can be helped with the appropriate treatment.

Depression and Employment

This year the theme is employment. Many people suffering from depression find it difficult to keep working. Some are signed off on Disability Benefit, others struggle to keep going and keep their jobs. Some employers are supportive and understanding, but not everyone reacts in a sympathetic manner, so it can be difficult to broach the subject. Many fear the stigma that can still be attached to mental health problems and so try to keep their condition secret, making recovery even harder.

‘In almost any workplace – anywhere in the world – the number of employees suffering an undiagnosed mental health problem (probably depression) is 10 to 20 per cent of the total workforce. This is a conservative estimate.

The known prevalence of depression is growing and the average age at which it affects people is dropping, mostly striking people in their prime working years. In 40 per cent of the cases the average age of onset is 20 and the average age overall is 27.’ Depression Alliance

By raising awareness about depression we can help to make employers more knowledgeable about the condition and more sympathetic to employees who are affected.

ACAS, the employment relations organisation, has issued advice to employers and managers ahead of this year’s Depression Awareness Week. They point to research which suggests that almost 3 out of 10 employees will suffer from a mental health problem this year. The financial impact of lost hours and productivity on a company can be significant. They encourage employers to train their managers to spot potential mental health problems and take appropriate action to ensure that employees get help early on, before the problems become more severe. Read more here.

12 Steps to Tackle Depression at Work

The Depression Alliance has also provided guidance on improving mental health strategies at work. The 12 Steps in summary are:

1. Leadership. The business leader (MD, owner etc) needs to understand the importance of this issue in order to provide effective leadership.

2. Financial Incentives. Assess the impact of lost hours/reduced productivity on the business – e.g. cost of hiring temporary replacements, customer complaints, lost sales etc. Then set targets – such as reduced sick days, reduced spend on temporary staff etc. so that you can measure improvement. Achieving these targets will require an early detection strategy.

3. Referral System. The company will need to identify appropriate mental health workers to form their referral team (this could be through an Employee Assistance Programme, a team of local counsellors, etc.). A written policy is needed to ensure that employees are approached sensitively and that the correct support is provided in offering referrals. This should include training for managers and staff (see Step 4).

4. Training. Training is required for managers to help them deal appropriately with someone suffering from a mental health problem. This would include communication skills, spotting potential problems, confidentiality, who to refer to, remaining calm and dealing with situations appropriately etc.

5. Work Environment. Helping to prevent mental health problems developing by ensuring a healthy work environment – reducing stress, employee surveys, listening to staff, healthy work culture, addressing morale issues etc.

6. Tackling Information Overload. Emails can be a significant source of stress if staff feel they must be dealt with immediately and are therefore constantly interrupted. This can be tackled by reviewing the impact of emails/voicemail etc. on staff and consulting them on how to improve matters. Perhaps introducing technical filtering, restricting email delivery to urgent messages only at certain times, training on how to prioritise etc.

7. Understanding Depression. Raising awareness amongst managers and staff of depression as a physical illness, rather than a personal failing. Also of the impact of depression on the physical body e.g. increased risk of stroke and second heart attack, compromised immune system etc.

8. Inventory of Emotional Work Hazards. Understanding what motivates employees to come to work and what makes them want to stay away. Are there chronic customer service problems? Are there constant interruptions? Do managers waste staff time? Is office politics part of the problem?

9. Work-Life Balance Policies. ‘ A chronic imbalance between the work and home lives of individuals is believed to be the root source of one-third of all cases of depression recorded in the United States.’ Depression Alliance Policies to tackle overwork can include changes in work culture, options for part time and flexible working, onsite services (e.g. dry cleaning, pharmaceutical) etc.

10. Rule out Rule. When a person suffers from depression their performance at work may suffer. The Rule out Rule ensures that mental health is ruled out as a possible cause of deteriorating performance before disciplinary procedures are considered.

11. Productivity. Monitoring productivity as an indicator of the mental health of your work force. ‘It is estimated that the “downtime cost” of depression in the U.S. is 172 million person-years based on conservative six-month prevalence rates of the disease…’ Depression Alliance.

12. Eliminate Top 10 Sources of Stress at Work

1. Time and Space : stress caused by staff feeling they have to do everything now.
2. Make sure employees know what is expected of them.
3. Job Fulfilment.
4. Sharing Success at work: making sure all members of staff feel their contribution is valued.
5. Tackling email and voicemail overload.
6. Clarity from the top: where is the company going etc.
7. Distributing work wisely so no one is overloaded.
8. Listening to others at work: including face to face contact, not just email.
9. Feeling included: in consultation, decision making etc.
10. Trusting your employees: giving them some control.

You can read the full text here.

Of course the work place is not the only cause of depression, but it is a factor for many people. By raising awareness in the work place and improving working conditions we can help to reduce the occurrence of depression and help those who are affected to recover more quickly.

Special Offer

As a special offer for Depression Awareness Week I am giving away free copies of my Ebook. Just send me an email and I will email you a copy. This week I will also be doubling my usual donation to the Depression Alliance for each paperback copy sold.

Last week I read an article about how suicide rates are highest in late spring and early summer. The suggestion was that this was due to people having more energy at this time of year and needing an outlet. However, it doesn’t seem to fit with my own observation that my depressed clients often report feeling better in the good weather. Maybe both factors are present. Some people feel better and others have enough energy to actually take the step of committing suicide after thinking about it over the winter.

I decided to look up the actual statistics to check the facts and found the highest rates for the UK seem to be in January, March and April, with the lowest rate being for December. In fact variations overall are not enormous ranging from about 9 a day to 11 a day (allowing for reading off an online graph that only shows even numbers). So I’d probably interpret this graph rather differently. Overall we seem to see generally higher rates in the first half of the year and lower in the second half of the year, with the exception of February. So maybe the lower rates are the result of the summer weather kicking in and cheering us up and then the excitement of looking forward to Christmas seeing us through Autumn and the start of winter. (Graph courtesy of Chew, KSY and McCleary, R, 1995, “The Spring Peak in Suicide: A Cross- National Analysis”, Social Science Medicine, Vol 40 No 2, pp223-30).

Is such speculation meaningful or helpful? You can read pretty much anything you like into statistics like these. Many of my clients talk about committing suicide but none have actually done so. What is it that makes the difference between contemplating taking your own life and actually doing so? Could factors like the weather, birthdays, Christmas be the final straw for some people? Can such a personal decision be analysed in this general way.

Whilst we may not understand the seasonal variations the link between depression and suicide is pretty well established. Many people suffering from depression have suicidal thoughts, although only a minority actually attempt to kill themselves. If you find yourself thinking about suicide it’s important to get help. Here are some simple steps.

1. Find someone supportive to talk to; it could be a counsellor, the Samaritans, a friend or relative, your doctor, or a religious advisor. Just talking to someone about how you feel can make a big difference.
2. If you don’t know who to talk to then find more information on how to get help on these websites:

http://www.metanoia.org/suicide/

http://www.samaritans.org/

http://www.befrienders.org/

Remember that however bad you feel there are people out there who care and who want to help you.

You can now read the first two chapters of my book free before deciding whether to buy. Download the first two chapters as a pdf from this site. Also remember that the ebook will be available free from this site in Depression Awareness Week 21-26 April.

A recent study has indicated a link between depression with high levels of somatisation (i.e. physical symptoms such as fatigue, appetite changes etc.) and the ability of our cells to produce energy efficiently. Mitochondria in our cells take in nutrients and produce energy in the form of ATP for the cells to use. In some people the mitochondria works inefficiently and so not enough energy is produced. The suggestion is that some people may have a genetic pre-disposition towards depression (particularly the type of depression that has a lot of physical symptoms) due to low energy production in their cells.

This could be good news in terms of screening and treatment. If patients with somatic depression can be tested easily and cheaply for the relevant mitochondrial problems then a treatment which addresses the energy production can be tried. In fact there are already a number of nutritional supplements available without prescription that are thought to help with cell energy levels.

Coenzyme Q10
Thought to be vital for the process of ATP recycling in the mitochondria of the cells. It has been widely used in conditions where fatigue and insufficient energy production is a factor including Chronic Fatigue Syndrome. It is also an antioxidant helping to protect the body from free radicals which may cause cell damage.

D-ribose
ATP is usually created in the body from a related chemical called ADP. When this process does not work efficiently the body can make ATP from a form of sugar called D-ribose. D-ribose has also been used successfully treat chronic fatigue syndrome. Supplements of D-ribose allow the body to increase its levels of ATP and hence increase the energy available to cells.

L-Carnitine
This is an amino acid that is required to carry fats into the mitochondria where they can be used to produce ATP.

NADH
Another intermediate energy carrier in the mitochondria which has a similar job to coenzyme Q10. Available as a supplement and has been used to treat CFS.

Vitamin B2 (Riboflavin) and Vitamin B3 (Niacin)
Niacin is used to make NADH in the body. This is an intermediate energy carrier in the mitochondria, it performs a similar function to coenzyme Q10. Riboflavin is used in the same way to produce FADH, which has the same role as NADH in energy production.

There is already anecdotal evidence that these supplements have helped some people to overcome depression, however more research is needed to confirm their effectiveness.

The latest study shows interesting results, but do we know whether these individuals were born with low functioning mitochondria, or whether it developed later. Can we be sure that this is a purely genetic condition, or something that may have developed later? If it develops later what causes it? If it’s genetic what are the factors that cause some people with this genetic condition to develop depression whilst others don’t. As usual there are as many questions as answers, but if you are suffering from somatic depression then it might well be worth trying the supplement approach.

The full text of the report is available for a fee from Psychotherapy and Psychosomatics