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From depression to freedom

J M G Williams J M G Williams is Professor of Clinical Psychology and Wellcome Principal Research Fellow at the University of Oxford. His books include Cry of Pain: Understanding Suicide and Self Harm and (with Zindel Segal and John Teasdale) Mindfulness-based Cognitive Therapy for Depression: a new approach to preventing relapse. From bitter experience I know that many who frequent internet discussions, whether because they are a chicken or an egg, have dalliances with depression, so I'm not reticent to publish this take from the Project Syndicate Health series, but in my own opinion our own Webdiarist Ross Chippendale had better advice.

by J M G Williams

Clinical depression affects roughly one in four people at some point in their lives. It is a severe and prolonged state of mind in which normal sadness grows into a painful state of hopelessness, listlessness, lack of motivation, and fatigue. But, however well defined, clinical depression is many things to many people, varying from mild to severe.

Mild depression can result in brooding on negative aspects of self or others, feeling resentful, irritable or angry much of the time, feeling sorry for oneself, and needing constant reassurance from someone. It can also result in various physical complaints that do not seem to be caused by any physical illness.

As depression worsens, feelings of extreme sadness and hopelessness combine with low self-esteem, guilt, memory loss, and concentration difficulties to bring about a severely painful state of mind. To make things worse, there may be a change in basic bodily functions. The usual daily rhythms seem to go wrong: can’t sleep, or sleep too much, can’t eat, or eat too much. Enthusiasm for what are usually enjoyable activities fades. Sometimes, there is even a feeling that life is not worth living and that one would be better off dead.

The most commonly used treatment for major depression is antidepressant medication. It is relatively cheap, and it is easy for family practitioners, who treat the majority of depressed people, to prescribe. However, when the episode has passed, and medication ceases, depression tends to return, and at least 50% of those who experienced an initial episode of depression find that depression comes back, despite appearing to have made a full recovery.

After a second or third episode, the risk of recurrence rises to 80-90%. Early onset depression (before 20 years of age) is particularly associated with a significantly higher risk of relapse and recurrence. For those who have been suicidal in the past, any depressed mood is likely to be accompanied by a return of suicidal thinking.

The problem with viewing antidepressants as the main method for preventing recurrence is that many people do not want to stay on medication for indefinite periods, and when the medication stops, the risk of becoming depressed again returns. Finding new ways of helping people stay well after depression demands an understanding of why depression keeps returning.

During a period of crisis in which someone becomes depressed and suicidal, an association is learned between the various symptoms (low mood, physical pain, suicidal tendencies, and so on). This means that when the negative mood returns, for any reason, it will tend to trigger all the other symptoms – a process called “cognitive reactivity”).

The discovery that the link between negative moods and negative thoughts remains ready to be reactivated even when people feel well is hugely important: it means that preventing future crises depends on learning how to keep mild upsets from spiraling out of control. Research has shown that combining the ancient practice of meditation with modern psychotherapies can accomplish this.

Based on Jon Kabat Zinn’s Stress Reduction program at the University of Massachusetts Medical Center, Mindfulness-based Cognitive Therapy (MBCT) combines modern cognitive behavioral therapy with meditation practices to help people become more aware of the present moment, including getting in touch with moment-to-moment changes in the mind and body (see www.mbct.co.uk).

In weekly classes (the atmosphere is that of a class, rather than a therapy group), and by listening to CD’s or tapes at home during the week, participants learn the practice of mindfulness meditation. The classes also include basic education about our moods, and several exercises from cognitive therapy that show the links between thinking and feeling and how participants can best look after themselves when a crisis threatens to overwhelm them.

The MBCT approach helps participants in the classes to see more clearly the patterns of the mind and to learn how to recognise when their mood is starting to sink. It helps break the normal link between negative mood and negative thinking. Participants develop the capacity to allow distressing moods, thoughts, and sensations to come and go, without having to battle with them.

They find that they can stay in touch with the present moment without having to ruminate about the past or worry about the future. Thus, they come to see with greater clarity and conviction how to approach moment-by-moment experience skillfully, taking more pleasure in the good things that often go unnoticed or unappreciated while dealing more effectively with the difficulties encountered, whether real or imagined.

Two controlled clinical trials have demonstrated that MBCT can reduce the likelihood of relapse by about 40-50% in people who have suffered three or more previous episodes of depression. As a result of such findings, MBCT has now been included in the British government’s national guidelines for treating recurrent major depression.

But this implies a redefinition of treatment itself. As our understanding of depression grows and we see that it is a recurring problem, the emphasis is shifting from cure to prevention. Mindfulness-based approaches have already proven that they will play an enormously important role in this.

Copyright: Project Syndicate, 2006.
www.project-syndicate.org

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It is in the genes?

I am one of those silly people who thought that my adult depression was all my fault... and if I couldn't cure myself then it was unfair to expect others to help me.

 However, this finding has given me some relief.

I am a 40-something intelligent and attractive person suffering depression and it makes my life very difficult. One of the greatest problems has been thinking I should “just get over it”. The article I've linked to makes me realise I may have had a predisposition to depression from a young age when a great multi-level trauma affected my family within a short time.

This is my first Webdiary post. Thanks for making a forum like this available.

Regards, Julie.

Craig R. Ed.: A most warm welcome to you Julie, and thank you for joining in the conversation with the contribution of a link that may help people.

look a bit deeper

I have to agree with others regarding cannabis: its effects are short term and those that appear to suffer from it, you will find, are using other drugs. Tobacco, alcohol, pharmaceuticals, even additives in foods, all contribute much more than cannabis to mental instability, I believe. My own experience sits well with what Phil and Ross say. Why the authorities are so obsessed with cannabis is because they can't control it, as you can just drop a seed in the ground and up she comes. Whilst other drugs – alcohol, alcohol, tobacco, and pharmaceuticals – are all in the control of politicians’ vested interests and make them lots of money.

Find me a survey or statistics that show the number of people who have been injured or died from consumption of cannabis, on its own and not combined with tobacco, alcohol and prescription drugs. To my knowledge, you won't find one case of death or serious illness. Sure, lots of people say when they are arrested for a crime, I was on dope. But that's because the system drops their sentence by saying they weren't in full control. I believe that if you have any drug in your system and commit a crime, then you should have the sentence doubled: it’s called being responsible for your actions. We may see fewer people before the courts and a lot less domestic and road trauma.

With what appears to be a growing collapse of our social fabric world wide and the growing amount of chemicals in food, and noise and air pollution, is it any wonder that mental health is suffering? After all, we are heading for enslavement to an economic dictatorship controlled by big business.

More research on all drugs

Gareth Eastwood, through personal observation I have known no one to suffer mental health problems solely from using marijuana. I have met literally thousands of people who use it or have tried it. Most people who try it don’t continue to use it, though a significant number who do try it continue to use it for a period of time. Most who use it usually give it away or grow out of the habit when work and family responsibilities take over. Only a small number of users will continue using it into old age: it tends to become rather boring.

So it would appear from my observations I would disagree with the surveys and reports you refer to, as Mike Lyvers does.

However, I fear that I could be jumping to conclusions here and wonder if there is some truth in your reports. I certainly would not dismiss them outright.

Although I have not had a close look at the reports nor the methodology, it does relate to young teenagers, whereas my experience with drugs did not occur until after I had left school.

It would interest me to see more research done on this topic, as I suspect that young developing brains may be disadvantaged by using any type of drug, especially alcohol. Are you aware of any similar surveys into teenagers, alcohol use and mental illness?

Although I am not trying to twist this post into an alcohol bashing thing I feel that we, as a community, should be investigating the effects of all drugs (used by juveniles) on human brain development and do that research in a very sincere manner.

I have also noted that over the years many western governments have spent literally billions of dollars researching the medical implications of marijuana use, yet not so with other legal and socially accepted drugs. Why is this?

The American government spent nearly 4 billion dollars in 2004 just on anti marijuana propaganda alone.

I sometimes wonder if we took the same approach with such things as alcohol, tobacco, amphetamines and Ritalin, then we would be better placed as a community to deal with the drug problem as a whole.

Somehow I feel that, if we spend billions of dollars researching any substance, then we will possibly find all sorts of interesting and disturbing relationships regarding things mental and things health.

Gareth...

Gareth, I have read a bit on the effects of cannabis and mental illness. Those that do start it early would surely suffer some effects mentally, as they would if they began any drug at an early age, even pharmaceuticals. Currently a lot of young people are taking some form of pharmaceutical concoction even as young as six to control their mental anguish and uncontrollable behaviour. Why this trend has grown needs to be looked at. To me it is simply our lifestyle, diet and heavily polluted environment. What studies have been made into the effects noise has upon us? We are bombarded by all kinds of noise well beyond our ability to cope, just walk out into a suburban street and you are hit with a constant scream of many high intensity noises. Most people become accustomed to this and don't notice it that much, but it still affects us and that effect must surely be cumulative.

I know a number of veterans that use cannabis and find it very helpful in controlling their depression and PTSD. I would expect they wouldn't have started to use it until their 20's. I've used it when younger (yep inhaled) and haven't met anyone that still uses it that suffers depression, quite the opposite. Mind you, they would all be well-adjusted in life and prefer it as a recreational drug compared to grog. I probably would as well if I needed a drug to relax and enjoy myself, but I can't stand smoking and rarely drink, being a two glass sleeper.

I can only speak from my observations and, being a veteran, understand what lengths we sometimes have to go to in calming the gremlins that constantly invade our minds. Sadly we are unable to enter another's head and experience what happens when the mind goes awry, so it is really a personal thing. Professionals still don't understand this and just open their book and categorise you, giving little relevance to individual circumstances.

I've seen lots of so-called knowledgeable qualified professionals over the years, until I cleaned myself out. I haven't found one that has a clue. All their knowledge comes out of books and classrooms, not from personal experience or as a witness to the events that spark manic depression. Now I treat myself and can finally handle what my mind puts in front of me as it's not distorted any more.

Causes of depression

Hey Alga and Gareth, there is certainly scientific "evidence" that marijuana may be related to developing mental illnesses. As there is with alcohol (rather than may: alcohol does cause depression) but we don't ban grog although it, like tobacco, is clearly identified as the causes of many deaths and illnesses, including depression. As a comparison think about the constant stream of advice telling us that such and such causes cancer. There are so many causes and substances identified that it is probably healthier to not eat or breathe. They just keep adding to the list.

Similarly there are many other substances we use, eat and drink which do contain chemicals that have not been studied as the causes of depression.

To identify marijuana as the cause is complete rubbish. It simply is a great line for anti-drugs people to use as it generates horrific images and fears. It is a cause for at least the young users.

Another part of the problem is the number of people who mix drugs. People get drunk then use some drug and whoops they are in trouble. It's like drinking different alcoholic substances in one session, usually it floors you.

Essentially there are two categories, being genetic and environmental (which includes all activities and consumed or injected substances).

One scientific comparison on the genetic issue tells us that about 30% are born with the illness. This came from a long term study in which identical twins were compared over many years. About 30% can be attributed to genetic causes. There are many such studies and the % attributed to genetics varies from about 10 - 30%.

Already that leaves only 70% looking for other causes. To state that marijuana contributes significantly as a cause of depression also does not gel with known facts.

From my own contact with many depression sufferers I can say with confidence that the family environment is by far the largest cause apart from genetic. Abuse when young, and the whole range of abusive situations, is frequently identified as the cause. In many such cases the person turns to alcohol and drugs and the cause and increase of depression becomes confused.

Alcohol is a huge creator of depression yet it is rarely raised as it's so bloody obvious and there are so many people using grog to hide (from themselves mainly) the illness. Of course it is also a huge money spinner for many so it stays legal.

I have to say the rate of people using all varieties of illegal drugs has risen consistently over the last 30 years. What has changed I think is that younger people are using these drugs and that, to me, is where the real issues lie.

I have seen plenty of links to depression and other mental illnesses arising from juvenile use of drugs, both legal and illegal.

The reason for that as I understand it is that marijuana reduces the young user's learning capacity. As such, despite my thinking legalising is the best option, it is necessary to draw an age distinction between people who do use the various drugs. From memory the report I read some time back was very strongly pointing to use up to about age 21. That is when science believes the human brain has finished its creation etc. Please correct me if this is not accurate.

There are too many reports over many years which show both results, being a problem and not being a problem. As usual.

I suspect a part of today's problem lies in the strength of the drugs bought on the street. This is one reason I would prefer such drugs to be controlled. Someone buying drugs that are illegal really has no idea what they are actually buying. Ecstasy is one prime example but marijuana too is stronger than years gone by. Controlled, this issue mainly vanishes.

Before any of us become too adamant about causes and cures perhaps we should recall Prof Williams’ words above:

"As our understanding of depression grows ".

This is consistent with what most medical people will tell you if they are experienced in treating and observing. They don't know that much yet. The point is they don't have irrefutable evidence for the causes of very much that is taking place in our brains.

Cannabis and depression

Alga, another potential catalyst for depression these days is the use of cannabis. Here is a link to a New Scientist article about three studies that concluded there is a link.

One of the key conclusions of the research is that people who start smoking cannabis as adolescents are at the greatest risk of later developing mental health problems. Another team calculates that eliminating cannabis use in the UK population could reduce cases of schizophrenia by 13 per cent.

Nonsense.

The rates of schizophrenia in western countries have not changed since the 1950s, despite the fact that cannabis use has skyrocketed since then. If cannabis caused schizophrenia the rate of the illness should have dramatically increased since the 1950s, but it remains unchanged. Ergo, cannabis use does not increase the rate of schizophrenia.

Link between cannabis and psychosis

Mike Lyvers, it is a shame that you ignore the endless stream of studies that conclude there is a link between cannabis use and mental health problems. Like tobacco and climate change before it, there are always folk who refuse to accept reality in the face of overwhelming scientific evidence.

Do you know of any recent work that contradicts the scientific establishment? Or do you rely entirely on the mistaken assumption that “If cannabis caused schizophrenia the rate of the illness should have dramatically increased since the 1950s”? A statement that would only hold any water if cannabis were the only factor involved in the rate of mental health problems.

Maybe a few more sources of evidence will persuade you.

BBC

SMH

British Medical Journal

Do you seriously believe the BMJ would make this statement: “The link between cannabis and psychosis is well established” if it did not believe it were true?

Depends how "psychosis" is defined.

Most mind-altering drugs can produce a temporary delirium or "drug-induced psychosis" and of course cannabis is no exception. This is not the same thing as schizophrenia, which is a lasting or recurring psychosis. Pot smokers may get temporarily anxious, paranoid or even delusional, but this state disappears once the drug is out of their system. Again it is a temporary state induced by drug overdose, not schizophrenia, which is a chronic condition.

chemical food

Depression is an interesting subject, but not a nice one. It's interesting that some are looking to prevention rather than suppression as with medication, however it is a growing problem that is getting worse in its effect upon us.

I believe there are many contributors to this problem, most seem to be either missed or rejected without investigation. As our brains act upon chemical and electrical changes within it, then any alteration to normal chemical and electrical balance brings about altered brain states. These can be expressed as forms of depression, and some types of mental instability.

When you consider urban environments are heavily polluted with massive amounts of chemicals and electromagnetic energies, is it any wonder many minds are becoming increasingly disrupted? This doesn't take into account the amount of depression within the rural community but it’s aligned. If we were to count the amount of chemical substances that are now within our diets, from herbicides, pesticides, enhancers, additives, preservatives, saturated fats and irradiated foods (microwaved), we find that our brains are subjected to constant bombardment with inorganic substances that alter the chemical and electrical balance of the brain. Naturally this leads to the wrong signals being produced and processed, leading to us becoming confused and depressed.

Because of a physical health problem, I was forced to change my diet and found that once I had eliminated processed foods, the debilitating depression I suffered from disappeared, only to return when I again consumed foods with additives. I compiled a list of what chemicals I consumed in foods during my day and was horrified at the number, incidence and quantity. Taken in isolation, they would probably kill me. I have yet to find any studies or tests done on these chemicals that saturate our lives, to see what effects they have upon our brains and biological processes.

If you want a subliminal conspiracy theory, pharmaceutical companies supply the additives that go into cropping, animal husbandry and processed foods which I believe are the basic cause of the rising incidence of depression and why after medication is stopped it returns. These same pharmaceutical companies also provide the drugs that mask the symptoms of depression. So if we were to remove the cause, chemicals from food production, we would have no need for symptom suppression and the pharmaceutical giants would go broke.

So they win both ways, they provide the cause and then the suppression, but not a cure. When you add the huge electromagnetic effects upon us by using AC currents which are deadly to the human system instead of DC which in the majority isn't harmful, we can construct a picture that may lead us to the causes: lifestyle, diet and environment pollution. One commercial jet, dumps tonnes of unburnt fuel on cities every flight, multiply that with the hundreds of flights a day. I read where studies done under flight paths in the US found a huge incidence of depression, brain tumours and cancers the closer they got to airports. Then consider the amount of chemicals that the farming community uses along with their reliance on buying processed foods, rather than growing them as they did in the past. So the growing incidence of rural depression may show that it's what we put into our bodies that may well be the cause of many clinical depressions.

Add all that to the number of chemicals people now use on their bodies to mask the smells that emanate from them, because of the chemicals absorbed into the body and you have bodies saturated with chemical cocktails from within and without.

Let's talk

Hey Hamish, I was rather embarrassed when I read your preamble to this article. I couldn't compare my knowledge to anything a specialist has to say as I have only my experience and my own problem(s) to lean on.

Depression is not an area I would have chosen as an area I know much about but fate has it...

Professor Williams has made a statement I think is critical for all to read and understand, particularly government. That statement is

"As our understanding of depression grows and we see that it is a recurring problem, the emphasis is shifting from cure to prevention."

This clearly spells out the truth: that medical science as yet knows very little about the brain and mental health issues. Our medical fraternity do the best they can with our current knowledge but, to me, it's really just the tip of a large iceberg.

Despite the recent HOG meeting where Premiers and Howard all slapped hands and swore to fix the mental health problems, those who heard John Howard the next day after that meeting would know they don't really have any idea.

He said words to the effect of, "In the old days everyone just used to get on with living. I think more people today should do the same."

That statement from Howard clearly demonstrated that he knows zip about how people suffer. People in the old days were frequently just locked up or quartered where others couldn't see or be affected by them. That's Johnny's world, I believe.

As well you see, anybody suffering depression has one basic aim. That is to beat depression and live normally, whatever that is. The last thing a mental health sufferer needs to hear is some moron saying, "Get on with it" as that's all they want to do. All mental health sufferers need is care rather than $, platitudes and documents a mile high which mean little. $'s of course help but I find that much of government spending on this issue is publicity rather than anything useful.

This statement from Professor Williams I don't agree with at all,

"The most commonly used treatment for major depression is anti-depressant medication. It is relatively cheap, and it is easy for family practitioners, who treat the majority of depressed people, to prescribe."

Why? Firstly, they are not cheap. Ask any USA user. The PBS subsidises most of these drugs in our country but not all. While this makes the drugs affordable for most Australians, it still costs the Australian community many times what the user pays. Government know that, but their approach is to cut the costs at the prescription stage rather than do what Prof Williams had said in the first statement above. That is, prevention is cheaper and more effective!

The other issue that I have as an individual is that I strongly believe that the ease with which many GP's prescribe anti-depressants is quite dodgy. Most of them know little about these drugs, but, unfortunately, they are stuck between the devil and the deep blue sea. By default they are the people most used to access treatment, and this too is almost mandated by the cost of specialist treatment. They try but there are many prescriptions which should be considered much more carefully.

The bottom line with any treatment is that they do not "cure" depression. You do. Any treatment that helps allows you to gather yourself, look at your life and make changes to solidify the relief of symptoms. Swallowing pills and waiting does not work in itself.

To Chris, I too would encourage anyone, everyone to join in, here or elsewhere to discuss depression. Either for themselves, family, friends and acquaintances who may have depression. Talking about it really helps and also assists in breaking down the stigma problem that many know just compounds the problems.

Ross's thoughts

Thanks Ross, after I posted I read your excellent contribution, which Hamish highlighted in the intro. Keep passing the open windows.

This technique

This technique sounds very much like (I hope the spelling is correct) Vissipana Yoga. I understand that there are free retreats run by this yoga group which involve complete silence but emphasise awareness of one's physical being in the moment.

It would be interesting to hear from a practitioner or teacher of this type of yoga.

On the topic of medication, I have to say that I use Avanza and I have no concerns about staying on it for good. Instead of waking up in the early hours and battling with the mind worms I now get a good night's sleep. Other symptoms which fellow sufferers would be all too aware of are also alleviated.

It would be good to hear from families of sufferers on this thread, since I know I put mine through hell for about three years - talk about walking on eggshells.

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