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Depression 2010

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€œIf depression is creeping up and must be faced, learn something about the nature of the beast: You may escape without a mauling.€ Dr RW Shepherd
€œNo company€™s more hateful than your own
You dodge and give yourself the slip; you seek
In bed or in your cups from care to sneak
In vain: the black dog follows you and hangs
Close on your flying skirts with hungry fangs.€ Horace ( )

Are you dogged by the €œblack dog€? Feel like you€™re living a hell on earth or have died €˜an early death€™?
If everything around you looks bleak and the future impossible to see, you might be suffering from depression. At some point in their lives one in every four women and one in every six men will suffer from depression. The World Health Organization predicts that within 20 years more people will be affected by depression than any other health problem.( )
Even in these so-called enlightened times, with mental illness being shown on soap-operas such as Eastenders, depression still feels like being a social leper. That€™s partly due to the effects of the condition itself, partly to do with the lingering stigma that society still harbours for this invisible illness.
For those who have been afflicted, you may already be relating to what I€™m writing. For those who haven€™t, but have looked after someone with depression, you may also have a sense of familiarity. Anyone fortunate enough not to have crossed paths with the €˜black dog€™ (Churchill€™s description of his illness) may however simply not understand what all the fuss is about.
In writing this, I am hoping to tackle some of the issues and make it all a little less mystifying. There are many facets to depression, so I cannot hope to address all of them, but will try to cover the following topics:
1.    What is depression and what does it feel like?
2.    The link between depression and pain
3.    Why does it happen?
4.    What can we do about it?
What is depression?
Is it being €˜down€™ or €˜low€™? In some cases, maybe, but broadly speaking, depression is a persistent low mood lasting for 2 weeks or more. So the usual ups and downs of our moods don€™t really count.
There is of course a medical definition of depression which you can find in other articles. There are various types, but they all share a number of features:
€¢    Loss of pleasure in activities that previously were enjoyable: this can be extreme
€¢    Tearfulness/heightened emotional response e.g to music/news programmes
€¢    Feeling emotionally numb 
€¢    Loss of (or occasionally increased) appetite
€¢    Difficulty sleeping, particularly waking early in the morning
€¢    Loss of energy
€¢    Increased aches and pains
€¢    Either being slowed up or agitated
€¢    Feeling low self-esteem/guilt/worthlessness
€¢    Feeling unable to communicate effectively
€¢    Hopelessness/despair
€¢    Difficulty concentrating/making decisions

Does any of this ring a bell? You don€™t have to have all the symptoms for it to be depression. And you may want to avoid the idea that you are depressed. Shame is a part of it...and it can stop you from admitting to yourself or others that things are as bad as they really are.
One of the major features of depression is a sense of aloneness, that no-one else understands. This isolation often makes things a lot worse, and the sufferer tends to avoid people. With a mind either foggy or running around like an animal chasing its tail, telling others how you feel can seem impossible. And if your own thoughts are scary to you, perhaps you are afraid of letting someone else in on your mental landscape.
Depression and Pain
Former monk, psychotherapist and theologist Thomas Moore writes in his book €œDark Nights of the Soul€, €œIllness is a dark night of the soul...if you imagine illness is only a physical will reduce the entire experience to the material plane, splitting your mental and emotional needs from your physical requirements.€  He notes: €œA lengthy illness especially may take you into a long and deep tunnel, where you may feel frightened, cut off, and out of control.€
He goes on to explain that modern medicine is rooted in modernism, valuing speed, efficiency, evidence-based research: and as he remarks, these €˜hardware methods€™  are considered to offer the best way of responding to illness. But what of medicine as a €˜healing art€™?   
I€™m pleased to report that doctors are finally beginning to acknowledge the close link between depression and chronic pain. At the British Pain Society Annual Meeting last year, Professor Jain, an American Psychiatrist, gave a fascinating and very pertinent talk on pain, depression and anxiety. What€™s more, the Winter edition of the Pain Society journal, Pain News( ), carried an article by the editor, Dr Mike Basler, who clearly states €œthe link between depression and pain is incontrovertible.€  
Sir Liam Donaldson, Chief Medical Officer (CMO) issued a report in 2009 calling for improved services for people with chronic pain. Regarding its impact on peoples€™ lives, he commented:
€œChronic pain ruins lives: 65% of sufferers
report difficulty sleeping and nearly 50%
report problems conducting social activities,
walking, driving or having a normal sex life.
In 49% of those with chronic pain there is
depression, and this can result in suicide.€ (see extracts from the report )

So as you can see, awareness is growing and you are by no means alone!

What does a day with depression feel like?
Well, it starts early, often around 4-5 am. You wake with a jolt from a nightmare, heart pumping wildly. You feel agitated, want to get up and pace around, yet, have no energy and dread the idea of getting up because that means you have to start another pointless, impossible day.
You lie there, thoughts running around in your pounding  head, sometimes repetitive phrases that seem stuck in there. The day ahead fills you with a nameless dread. Pain fills you up and you have a sense of total despair.
Eventually, you force yourself out of bed and dress, painfully, slowly and soon feel exhausted. Your dry mouth doesn€™t make the idea of food attractive in the least. You skip breakfast, making do with a coffee and a fag.
And then the grey day begins. You drag your way through it. Even the smallest decisions are like wading through treacle. You question everything you do and feel you are achieving nothing, except mistakes. Past problems keep popping into your head, like unwelcome guests.
By the end of the day, when your loved ones ask how you are, you snap back, €œFine, what€™s it to you?€ and then feel another wave of guilt. Maybe a drink or two will help numb things, make the gnawing ache in your mind bearable.
When you lie back in your bed, you breathe a sigh of relief that another day is done, but then shudder when you think of the nightmares ahead of you; first you have to navigate your way through the end of day mental reruns of the bad parts of the day, the week, the year, maybe even your entire life. Misery fills you...

Why does this happen? Why you?
If you€™re depressed, you may think it€™s because you€™ve done something wrong. Depression itself is likely to make you think the very worst of yourself, so you reason that you somehow deserve this. Or perhaps you feel angry, that it€™s unjust?
As if you don€™t already have enough to be dealing with, what with the chronic pain, not having a job, no money, your partner doesn€™t understand what you€™re going through...the future looks bleak in every way. And through it may run the seemingly unanswerable question: €œWhy me?€
Well, I don€™t have all the answers, but one thing is clear: depression and chronic pain are unwelcome bedfellows. For logical and biological reasons. Logically, why wouldn€™t you feel depressed when you have chronic pain? But there€™s more to it than that. There is a bio-logical  reason! The chemical messengers that transmit pain are also involved with emotions and the parts of the brain that decode pain also have links with the emotion centres of the brain (the limbic system). Being depressed is NOT something for wimps!
Of course, it€™s not just chronic pain that can be linked with depression. Lots of life circumstances can trigger it, such as bereavement, divorce etc. Sometimes people are prone to depression without any obvious triggers, even from childhood. Sometimes it runs in the family. Some people get SAD (Seasonal Affective Disorder) in the dreary winter months. And some people...just get depressed, even when their life seems fine on the outside.
Speak to someone who has had depression and has had physical pain, and I will wager they€™ll say the physical is much easier to bear than the €˜psychic€™ (emotional) pain.  Of course, if you are unlucky enough to have both, that can seem cold comfort.
In fact, when you have depression, comfort is something in short supply.
So what can you do?
First, remember, you are not alone!!
Here are some quotes from other people who have had depression (some famous names..)
€œI start to feel like I can€™t maintain the facade any longer, that I may just start to show through. And I wish I knew what was wrong. Maybe something about how stupid my whole life is. I don€™t know. Why does the rest of the world put up with the hypocrisy, the need to put a happy face on sorrow, the need to keep on keeping on?... I don€™t know the answer, I know only that I can€™t. I don't want any more vicissitudes, I don't want any more of this try, try again stuff. I just want out. I€™ve had it. I am so tired. I am twenty and I am already exhausted.€ Elizabeth Wurtzel
I cry a lot. My emotions are very close to my surface. I don't want to hold anything in so it festers and turns into pus - a pustule of emotion that explodes into a festering cesspool of depression.€ Nicholas Cage (actor)
"I don't like standing near the edge of a platform when an express train is passing through. I like to stand right back and if possible get a pillar between me and the train. I don't like to stand by the side of a ship and look down into the water. A second's action would end everything. A few drops of desperation." - Winston Churchill (1874-1965)
€œ€¦if my black dog returns. He seems quite away from me now - it is such a relief. All the colours come back into the picture." Churchill
€œthis world brought me down...crashed me to the floor and stomped on me. let me down, turned its back and walked away to leave me lay on the cold hard ground to die alone.€
€œ€¦i'm here stuck in my deep dark pit..€ ( )
€œWhen you get just a complete sense of blackness or void ahead of you, that somehow the future looks an impossible place to be, and the direction you are going seems to have no purpose, there is this word despair which is a very awful thing to feel.€ Stephen Fry
Now, what else is there? Someone I know once said to me that being depressed is like getting lost in a dark wood and falling down a deep hole. You need one kind of help to get out the hole (and don€™t forget, the first rule of holes is: when you are in one..STOP DIGGING!): that might well mean taking medicines. Then you need another type of help to guide you back out of the wood to stop you falling either straight back in the hole you just climbed laboriously out of, or into another one. That might mean something like €˜talking therapy€™ or counselling. Which is really often just someone listening well to you telling your story. (see the Wounded Storyteller by A.Frank).
€œBut I don€™t need tablets€, you€™re now protesting. Maybe you think sheer willpower will keep the wolf from the door, and like Theoden in The Two Towers, you don€™t want to risk open war. As Aragorn responds, €œOpen war is upon you, whether you would risk it or not.€ Yes, you are under attack here by depression. You are going to need all the ammunition you can get to fight it off. You would never think of defending yourself against an armed robber with a water pistol or an empty gun: you need bullets!
€œI don€™t have the energy to fight...what€™s the point?€ That€™s a tough one...but even more, you need help: you may need a champion to fight your corner for you: not a novice, you need someone who knows the territory :an expert. Seek help! There€™s no shame in it.
€œBut I€™ve been on tablets, they don€™t work or they make me feel worse!€: you had the wrong ammunition! The right tools for the job are essential!
Recent figures show that prescriptions for antidepressants have almost doubled in a decade, from 18,424,473 in 1998 to 35,960,500 in 2008.( )

Types of antidepressant
€¢    Amitriptyline/nortriptyline: €˜tricyclics€™; older generation; 10-50mg for chronic pain (work within 10-14 days) ; 75mg+ for depression (take 3 weeks to work); side effects include dry mouth, difficulty passing water, hangover effect (try taking it at 8pm not at bedtime)
€¢    Doxepin: less side effects
€¢    Prozac (Fluoxetine)/ Seroxat/Citalopram : €˜SSRIs€™, take 2-3 weeks to work, can make you feel worse before you feel better
€¢    Venlafaxine/Duloxetine: €˜dual action€™ : thought to be helpful in chronic pain
€¢    Mirtazapine/ Trazodone: good for stimulating appetite and sedative so improve sleep
€¢    MAOIs (e.g. Phenelzine): not often used; need restricted diet
€¢    Trimipramine  : another old-fashioned drug, not often used
€¢    Moclobemide
€¢    Buspirone: more for anxiety
€¢    Combinations
But: doctors have at times spoken out against antidepressants in the media:
Dr Joanna Moncrieff, of the department of mental health sciences at University College London, says they actually put people into "drug-induced states".( )She argues that antidepressants are €˜psychoactive€™ drugs, akin to recreational drugs. I can€™t say I entirely agree with her on that. For a start, people with depression don€™t have normal brain chemical levels, unlike recreational drug users.
However, I do agree with the following comment:
It is a great pity that doctors tend to press the biomedical button, rather than one which enables patients to help themselves
Dr Mike Dixon
NHS Alliance

In 2005, a survey ( ) found:
71% of GPs believe anti-depressants are quite effective
57% say they are over-prescribed
55% prescribe antidepressants as their first treatment response for mild or moderate depression
But only 35% believe drugs are the most effective intervention for these conditions
42% feel most patients given antidepressants would be as likely to get better if they were unknowingly prescribed a placebo
60% would prescribe antidepressants less frequently if other treatment options were more available to them

That might, in some cases, mean that drugs ARE the most effective treatment, but they are not right for everyone.
Remember that most of what is talked about in the press relates to mild to moderate depression: not to moderate to severe which is more likely to need a €˜biomedical€™ approach.
How long to stay on the drugs?
A lot of patients, once they start to feel better, stop the drugs. That can be a big mistake, as Ruby Wax explained to Jo Brand ( fellow comedienne who used to be a Psychiatric nurse):
€œ Ruby Well when I get off then get depression again
Jo: How quickly?
Ruby It happens really slowly it creeps up on you, like there's triggers but I can't see the triggers€ ( )
It is usually best to stay on the tablets for 6 months, longer if you have recurrent depression (up to a year or sometimes longer).
Other treatments
€¢    ECT: not like in €œOne Flew Over the Cuckoo€™s Nest€! can be a lifesaver if depression is severe; course of several sessions, usually twice a week; usually as an inpatient
€¢    Psychotherapy: CBT, DBT, ACT: better when used in combination with other treatment.
€¢    Exercise: there is good evidence that exercise reduces depression; The National Institute for Clinical Excellence (NICE) recommends that patients with mild or moderate depression should follow a structured and supervised exercise programme of up to three sessions of exercise, each lasting 45-60 minutes, a week.(see below for more information)
€¢    Daylight : getting outside even for a short time; A light box for Seasonal Affective disorder 
€¢    Herbal remedies: e.g.St John€™s Wort: works like Prozac; be careful it doesn€™t interact with other medicines or complementary treatments
€¢    Diet: a recent study( ) suggested that fast food diets can trigger depression and there has been some evidence that a €˜Mediterranean style€™ diet can combat the symptoms: a recent Spanish study reported in the prestigious Journal of the American Medical Association that depression was more than 30% less likely to develop in people who followed a diet high in vegetables, fruit and cereals, and low in red meat ( )
In 2004, clinical guidelines recommended exercise as a treatment for mild or moderate depression.
In 2008: a further survey by the Mental Health Foundation of 200 family doctors in England found that 22% suggest exercise to help people with milder forms of the condition compared with 5% 3 years earlier. Exercise is thought to work by increasing self-esteem and also boosting the endorphin (feelgood brain chemicals) levels.
Psychological therapies
The arrival of IAPT €“ Improving Access to Psychological Therapies, should hopefully give patients better chances to use this type of treatment. The IAPT have produced a €œLong-term conditions positive practice guide€ which highlights chronic pain although doesn€™t specify which pain conditions. 
Do it yourself?
Sadly, most developing countries spend only about 2% of their national budget on mental healthcare.
What€™s more, it seems that GPs are not too good at diagnosing depression. But as one expert said ( )
If the diagnosis of depression cannot be agreed satisfactorily by the best minds in psychiatry, why should we expect the general practitioner to be a reliable assessor of the condition?
Professor Peter Tyrer, Imperial College London
Researchers from the University of Leicester reported last year in the Lancet that in a typical practice, where 78% of patients see their GP during a 12 month period, about 12% would have clinical depression, and about half would be picked up, whereas up to 12% would be at risk of being misdiagnosed as depressed if GPs relied upon a single clinical assessment. This is in part due to time constraints, especially as patients may be reluctant to voice their real concerns.  Even experts (Psychiatrists) may well not be able to improve on these detection rates if they were restricted to 10 minute consultations. Establishing that a patient has depression takes time, and not least, developing a sense of trust between the patient and the professional.
Speaking with my Psychiatrist head on, what I would like to stress is that the whole €˜trick cyclist€™ thing is still often a real barrier to patients: but it may only be when someone does a really full assessment (and that can take an hour or more) and perhaps over a number of sessions, builds up a rapport with you that they can really start to help you. Also, remember that usually Psychiatrists will want to speak to those closest to you who can have a more rounded perspective on how you are. 
So it  although it seems (yet again) that we, as the patients, may need to help ourselves, please don€™t discount professional help.  If doctors are off-putting, you might find a Community Psychiatric Nurse who could call on you at home, may be able to support you (and your family) through your depression. Your GP can refer you.
What to avoid
Alcohol: it may be a good anaesthetic short-term but it is a depressant itself so don€™t be tempted to use it as a treatment!
Isolation: you may want to hide yourself away, but try not to.
Inactivity: find something to do, however trivial.

When depression really deepens, life can start to feel too much of a struggle; sometimes people feel life isn€™t worth living. These may be fleeting thoughts, if so, that is not too worrying, but if they persist and start to take shape, such as in thinking of plans how to commit suicide, then this is serious and YOU SHOULD SEEK HELP IMMEDIATELY. Of course, you are not likely to want to reach out and admit these ideas, either because you feel guilty, or because by doing so you may then not be able to carry out the action.  YOU SHOULD STILL SEEK HELP!!
The other problem that can happen is that as the depression deepens is that the perspective you have becomes so negatively skewed that everything or everyone seems to be against you. You can start to have paranoid beliefs that no-one can convince you are wrong. You may even start to have experiences you can€™t explain, seeing or hearing things that  others can€™t see or here. This can be highly distressing and frightening. Again, you should seek help urgently.  
One thing that may worry you is that you can€™t think clearly and your memory is poor. You can€™t concentrate or make decisions. If you are over 60, you or your loved ones might worry that you are developing dementia. However, if you have depression, you may simply be suffering from the typical symptoms. Some doctors call this €˜psuedo-dementia€™. Again, it€™s important to ask for help with this, if nothing else, you can get reassurance from your doctor.
The important things to remember:

Here are some inspirational quotes:
€œIt will be sunny one day€ Stephen Fry ( )
"In moments of discouragement, defeat, or even despair, there are always certain things to cling to. Little things usually: remembered laughter, the face of a sleeping child, a tree in the wind-in fact, any reminder of something deeply felt or dearly loved.
No man is so poor as not to have many of these small candles. When they are lighted, darkness goes away-and a touch of wonder remains."
-- "These Small Candles" ...tombstone inscription in Britain
"In the midst of winter, I finally learned that there was in me an invincible summer."
-- Albert Camus   
"I like living. I have sometimes been wildly, despairingly, acutely miserable, racked with sorrow, but through it all I still know that just to be alive is a grand thing."
--Agatha Christie 
Any of the BBC references above will take you to websites with more details on the subjects I have touched on briefly.
Also: see
Taming The Black Dog How to Beat Depression - A Practical Manual for Sufferers, Their Relatives and Colleagues , Patrick Ellverton   ISBN-10: 1857039998

A brief word on assisted suicide
Following the recent news about the assisted suicide of woman who suffered from ME, there will no doubt be ethical debate once more on this thorny issue. Leaving aside the complex ethical and moral facets, I would just like to note that if someone is suffering from depression as part of their illness, this can and should be treated rigorously before any decision to end life is made.
Dr Sarah Fox
February 2010