to Augment Orthodox Treatment of Major Depressive Disorder
by Stephen Jackson
Email: depressionselfhelp@lycos.com
http://depressionselfhelp.tripod.com
Major Depressive Disorder (MDD) is a common, complex and serious psychological health problem that affects mood and thinking as well as behavioural and social aspects of a person’s life; it causes immense distress and suffering. According to the World Health Organisation depression affects 100 million people throughout the world (Gillet 1987), and in the United Kingdom it is estimated that at any one time 3% of the population are affected (Malhi 1998). The World Health Organisation estimates by the year 2020 depression will be the second most prevalent cause of disability worldwide (WHO, 2001). Everyone’s mood fluctuates much of the time, with short periods of feeling low which is normal, however when the symptoms are more severe and remain that way for longer than 2 weeks (except in the case of bereavement) this is Major Depressive Disorder. Untreated, depression can cause untold distress, relationship problems, alcohol misuse, etc. It is a complex health problem not caused by one factor but by a matrix of interacting factors such as genes, medical conditions, brain chemistry, substance misuse, low levels of social support, difficult childhood, psychological trauma to mention but a few (Mental Health 1999). Major Depressive Disorder can vary in severity from Mild to Moderate to Severe. Severe depression is a very serious condition needing referral to a medical practitioner; in this essay we are referring to mild to moderate depression
It has long been suspected that there is a link between stress and Major Depressive Disorder (Milligan, Clare 1994). Dr Ken Hambly (Hambly and Muir 1997) said that in one comprehensive review of the literature (Barlow 1988) it is suggested depression is simply a variable psychological expression of a common biological vulnerability activated by stress. Research (Lopez 2000) has found that one factor thought to be involved in depression is a problem with serotonin, a neurotransmitter in the brain that keeps our mood stable, and further research suggests that when Cortisol (one of the stress hormones) is secreted in excess, it can interfere with serotonin synthesis in the brain (Lovallo, 1997). It is however, important to point out here that biological factors are only one component in the aetiology of depression. Dr Kwame McKenzie, Clinical Lecturer in Psychiatry at The Institute of Psychiatry in London and author of the book Family Doctor Guide to Depression, has said “There has been an increase in rates of depression over the last 40 years which may be the result of the way we live our lives now. For many people the world is becoming increasingly stressful and stress can lead to depression.” (McKenzie 2000)
Fortunately the vast majority of cases of depression in the United Kingdom are in the mild to moderate forms, which can be helped with the holistic techniques often used in Stress Management (Tyler et al 1989). In my own experience, running a Depression Helpline for the past eight years using a Stress Management approach to help clients in their recovery from depression, the vast majority report they have found themselves sensitive to stress, finding it is a factor in their depression, they find the Stress Management techniques very practical, helping them to feel they can influence their condition, giving them a sense of control.
Stress Management Techniques
“Reducing the amount of stress in your life is one of the most positive steps you can take to lessen the symptoms and severity of your depression.” (McKenzie, 2000).
80% of people developing major depressive disorder will be treated by their local GP who has on average, 8 minutes consultation for each patient. The main treatments for depression are medication and psychotherapy but access to psychological resources, such as Cognitive Behavioural Psychotherapy, is limited to say the least; so the only, main practical treatment a GP has is the use of prescription antidepressant medication. This lack of a range of treatments can limit recovery and prevention. (Cornah, 2004) said, “A holistic approach to mental health recognises the complexity of factors that contribute to a person’s sense of well-being and acknowledges the real but partial answer offered by any one approach to treatment.” In my opinion Stress Management consultants have a wide range of tools to help their clients; strategies such as exercise, healthy eating, cognitive behavioural stress management, time management, relaxation, assertiveness, increasing social support, etc. are important techniques that can be used to augment orthodox treatment of major depressive disorder. The National Institutes of Mental Health has said, “Stress management techniques and meditation may help you calm yourself and enhance the effects of therapy.” (Hendrix&Dickey 2000)
In one study, Marion Tyler, a Registered Nurse and Health Visitor and colleagues at Ferndown Medical Centre, Dorset ran stress control courses for people with stress anxiety and depression, which involved teaching Stress Management techniques. The data from this study revealed reductions in anxiety and depression, of those who had a depression score consistent with clinical depression, 83% of the group in the stress control course ended with scores in the normal range. Another study looking at this group revealed that, after completing the course 20% stopped taking medication completely and 57% had reduced the amount of medication required. Dr Gerald Bennett, a Senior Clinical Psychologist with East Dorset Health Authority evaluated the group approach to living with stress and concluded, “People tend to think that Stress Management is for business people and for coping with work stress, but Stress Management training is also used in helping people cope with health problems.” (Tyler, 1989)
In another study (Johansson 1991) by a research team from the School of Nursing, Linfield College, Portland in Oregon looked at the effectiveness of a Stress Management programme to help reduce anxiety and depression in student nurses. There were two groups, one group was the active treatment group who were taught stress management skills and the second group acted as a control group and were not taught stress management skills. All the subjects in this study in both groups were given pre and post tests to assess their levels of anxiety and depression. The results of this study revealed that the active treatment group had significantly lower anxiety and depression levels than the control group.
We shall now go on to discuss in more detail the types of stress management techniques that can be used to help major depressive disorder.
Cognitive Behavioural Stress Management
“Cognitive Behavioural Therapy and interpersonal therapy in particular have been found efficacious in the treatment of depression with the best evidence for cognitive behavioural therapy.” (Treatment Choice in Psychological Therapies and Counselling, 2001)
There are many types of talking therapy that can be used to help Major Depressive Disorder, but Cognitive Behavioural Therapy (CBT) has been proven to be one of the most effective techniques. Aaron Beck discovered that depressed people think excessively negatively about themselves other people and the world in general. He developed Cognitive Therapy (Beck, 1976, 1991) maintaining that there are three elements to depression, which he called the cognitive triad - 1. Negative views of self as worthless and helpless, 2. Negative views of the world and 3. Negative views about the future. (Cardwell, 2000) Cognitive Behavioural Therapy helps us to identify and challenge this unrealistic, negative thinking that causes and fuels Major Depressive Disorder. In a major analysis of four randomised comparative studies Cognitive Behavioural Therapy was found to be as effective as a course of antidepressant medication for Major Depressive Disorder. (Depression 2003)
Stress Management Consultants often use a form of Cognitive Behavioural Therapy called Cognitive Behavioural Stress Management (CBSM). In one study (Laperriere et al 2005) examining the therapeutic value of CBSM a research team, from the Department of Psychiatry at the University of Miami School of Medicine, investigated the benefits of a 10-week group Cognitive Behavioural Stress Management course on disadvantaged minority women living with aids. They were taught stress management techniques like cognitive behavioural skills and relaxation techniques. The data from this study revealed significant decreased depression scores using the measurement of a Beck Depression Inventory; this study also revealed that the women still had reduced depression at one-year follow-up.
When Cognitive Behavioural Therapy is combined with medication (Bowers 1990) there is a better effect than the use of medication on its own. In a study (Keller, 2000) of 681 patients with Major Depressive Disorder, Cognitive Behavioural Therapy was compared with an antidepressant and a 3rd group were given a combination of both. Of the 519 patients who completed the study, 55% responded well in the antidepressant group, 52% in the Cognitive Behavioural Therapy group, whereas 85% had a positive response in the combination group. Cognitive Behavioural Therapy also helps reduce the risk of a depressive relapse (Paykel 2005), whilst in people treated with medications only, the risk of a future depressive relapse is high.
Part of the problem in treating depression is there are simply not enough trained Cognitive Behavioural Therapists available to treat the millions of people that are clinically depressed. (The Depression Report, 2006) so another option is the use of Computerised Cognitive Behavioural Therapy. There is a free online course in Computerised Cognitive Behavioural Therapy for depression www.livinglifetothefull, written by psychiatrist Professor Chris Williams at Glasgow University. It is important to point out however that more severe forms of depression may require referral to a psychotherapist.
Aerobic Exercise
“A recent discovery has been that exercise also increases serotonin levels, and so acts as a more natural potent than antidepressants because it has a dual action, by further increasing the sensitivity at nerve cell receptors to serotonin.” (Persaud, 2000)
Today, research shows that we are the most sedentary we have ever been (At Least Five a Week, 2000). The vast majority of us do not get enough exercise, which has left us more prone to developing a wide range of physical and psychological health problems. The Department of Health in their document “At Least Five a Week” have said, “Maintaining an inactive lifestyle over several years is associated with subsequent clinically defined depression (Camacho 1991, Farmer 1988, Paffenbarger 1994). These studies take account of a wide range of possible confounding factors such as disability, body mass index, smoking, alcohol, social status.”
There has been an increase in depression since the middle of the 20th Century (McKenzie 2000). There are a variety of factors for this one of these being a lack of physical exercise. Exercise is probably one of the most underused techniques for improving our mental health. Numerous scientific studies have shown that regular exercise helps to reduce stress and depression. For mild forms of major depression exercise has been shown in studies to be at least as effective for treating depression as medication (p5 At least five times a week) or psychotherapy (Lawlor 2001, Mutrie 2000) particularly in the longer term. Physical activity is also a potential alternative for the many people who do not wish to take medication for depression because of the side effects (Scott 1996). In fact recently the UK National Institute for Clinical Excellence has sent advice to the country’s General Practitioners advising them not to prescribe antidepressants for mild depression but to recommend regular exercise instead.
Physical activity has been shown to be effective in reducing clinical symptoms of severe, moderate or mild depression (Craft 1998, Lawlor 2001, Mutrie 2000). A number of studies have shown that physical activity can be as successful at treating depression as medication. For example one study showed that a 16 week exercise programme gave the same effect as a standard antidepressant drug (Blumenthal 1999). A follow up study showed that after 6 months those who continued to exercise were more likely to recover than those solely on medication (Babyak 2000). Depression effects motivation and energy so it can be difficult to maintain an exercise programme, however, in these studies, adherence to the exercise programme was at least similar to other forms of treatment. In one study adherence of the subjects to physical activity was comparable to that of the general population’s adherence to exercise regimes. (Matinsen 1993)
Exercise can also help prevent relapse of a person’s depression. A team led by Dr Micheal Babyak PhD, from the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center, Durham, North Carolina, carried out research on the role of exercise for major depression. This study revealed that ten months after the study was completed the research subjects in the exercise group had significantly lower relapse rates than the subjects in a medication group. (Babyak 2000)
Healthy Eating
“Nutritional deficiencies are common in people suffering from depression. Some of these have been identified via controlled research to be related to the intensity of mood disturbance, sometimes it is unclear whether dietary deficiencies are triggers or maintaining factors for the mood problem. People with poor or unusual diets are probably at greater risk of depression.” (Paterson 2002)
Some people may wonder what on earth does nutrition have to do with Major Depressive Disorder. As we have previously said depression has been increasing year upon year since the middle to the 20th century, there are many reasons for this and nutrition is thought to be one such factor. Recently the Mental Health Foundation, one of the UK’s largest charities specialising in mental health, published a report called Feeding Minds (Cornah 2004) in which it presents the case of poor nutrition as a factor in the development of psychological health problems such as Major Depressive Disorder. It should come as no surprise that nutrition can have an effect on our mental health because the neurotransmitter hormones in the brain needed for optimum psychological well-being are manufactured from the nutrients we supply it in our diet such as folic acid, Selenium (Benton 1990) and Omega 3 essential fatty acid vital for mental health (Geary 2000).
Our diet has undergone radical change in the last 50 years or so and a variety of nutritional factors have been implicated in depression such as low folic acid (Coppen 2005), low omega 3 essential fatty acids (Freeman 2006, Conklin 2007), excess refined sugars (Westover 2002), etc. Researchers (Tanskanen et al, 2001) looked at the value of Omega 3 essential fatty acids in depression; their study revealed that the likelihood of having depressive symptoms was significantly higher among people who didn’t consume much fish (a rich source of Omega 3 essential fatty acids) compared to people who frequently ate fish. Excess alcohol can be another factor in depression (WHO 2000). When people with alcohol problems stop drinking some symptoms of depression often lift within weeks. (Paterson RJ (2002). Some people are more sensitive to the effects of caffeine than others and there is suspicion that caffeine can be a factor in some people’s depression, removal of the caffeine improves mood (James, 1997)
We don’t have to make many severe, radical changes to the way we eat; small changes, over time, taking one component of the diet at a time, improving it and when that is successful moving on to the next, will help depression.
Clinical psychologist Dr Oliver James PhD, (James, 1998) said,
“People are often amazed at the improvement in mood that follows the adoption of a healthy diet and having seen the results, wonder out loud – what on earth is going into modern food that is so damaging.”
Relaxation Training
“Controlled scientific studies have established that relaxation can help relieve depression, fatigue and anxiety.” (Martin, 1999)
As previously mentioned Major Depressive Disorder is thought to be partly caused by chronic stress leading to an over-activation of part of the autonomic nervous system called the hypothalamic pituitary adrenocortical (HPA) axis causing chronically elevated levels of the stress hormone cortisol. Research has shown that chronically elevated levels of cortisol can be a factor in depression by interfering with the manufacture in the brain of the mood lifting neurotransmitter Serotonin (Lovallo 1997). Dr Helen Mayberg of the University of Toronto and Baycrest, Ontario, Canada said, “We know that depressed patients, even after they have become well have a tendency to remain highly sensitive to emotional stress. This phenomenon is seen in recovered patients, whether they are on maintenance medication or not. There remains a persistent vulnerability for further episodes.” (Mayberg 2006)
The opposite to the fight and flight response is the Relaxation Response which lowers blood pressure, heart rate, muscle tension and stress hormone levels (Benson 2000). The Relaxation Response is activated by the opposite branch of the autonomic nervous system, known as the parasympathetic nervous system. An excellent way to stimulate the relaxation response is through the use of relaxation techniques.
There are a wide variety of relaxation techniques a person can practice that research has shown can help people suffering Major Depressive Disorder and related stress; techniques such as Muscle Relaxation (Pawlo 2002), Relaxation Breathing (Kjellgren 2007), Yoga (Woolery 2004, Vedamurthachar 2006), T’ai Chi (Esch 2007) and Autogenic Therapy (Hidderley 2004, Kanji 2006).
Studies have shown that practicing relaxation techniques can be a useful tool in helping depression in fact its been shown to be as effective as a course of antidepressant medication. (Murphy et al 1995, Reynolds et al 1986). In one of these studies (Murphy 1995) a research team from Washington University in St Louis School of Medicine, St Louis, Missouri USA, compared the therapeutic value of Cognitive Behavioural Therapy, Relaxation Training and Tricyclic antidepressant medication following the subjects with depression for 16 weeks. The results revealed that Relaxation Training and Cognitive Behavioural Therapy were superior to Tricyclic antidepressant medication.
I have personally found that some people struggling with depression can find they have distracting thoughts that interfere with their relaxation sessions. One of the ways I have found round this is to recommend Guided Imagery which can help to focus the person’s thoughts on the relaxation; in guided imagery the person imagines a peaceful scene such as a tropical beach, floating on a cloud, a peaceful garden scene, etc.
As well as the useful audio relaxation techniques that accompany The Stress Consultancy course, another useful resource is from The University of Texas who allow people to download free mp3 relaxation files on guided imagery from www.utexas.edu/student/cmhc/RelaxationTape/
Resources
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