UnLtd Blogs - depression

Dr. Crippen's Perspective on Children with Depression

Thu, 09 Nov 2006 18:42:52 +0000

The excellent Dr. Crippen has posted a remarkable discussion of children with depression. He goes through the NICE guidelines for managing depression in children and young people.

The discussion makes for grim reading. Earlier this year, the Great and the Good of the BMJ's Science Committee published a very dispiriting report about the state of children's mental health in the UK. What makes Dr. Crippen's analysis particularly disappointing is the news that GPs seem to be so overlooked despite their front-line position.

Crippo has left a comment on Dr. Crippen's post. He articulates much of the pain and difficulty experienced by families who care for a family member who is depressed.

I don't know what the solution is to the estimated mental health treatment needs of 1 in 10 children. I strongly suspect that the only probable large-scale delivery mechanism that is practical will be based in schools. I am confident that any multi-agency solution must involve the family doctor.

Oliver James Rubbishes CBT and Happiness

Tue, 24 Oct 2006 16:37:44 +0000

I like the work of Oliver James: he is an interesting speaker and an engaging writer. I've been aware for some time that he is not in favour of Layard's enthusiasm for cognitive-behavioural therapy (CBT) and he usually makes his viewpoint in a cogent manner.

Not today. Today, Oliver James has contributed a piece to the Daily Mail: Therapy on the NHS? What a crazy waste of �600 million! He starts off with the headline figure that depression and anxiety cost the �17 billion per year and then moves on to deride Layard's proposed �600 million investment in expanding the provision of CBT on the NHS.

It's an infuriating piece. James makes several sideswipes about the efficacy of CBT.

CBT is a form of mental hygiene. However filthy the kitchen floor of your mind, CBT soon covers it with a thin veneer of positive polish. But shiny surfaces tend not to last.

According to James

The CBT patient is taught a story to tell themselves, a relentlessly positive one. If the therapist is skilled, the patient becomes able to ignore many of their true feelings.

When tested at the end of the treatment, like a well-coached pupil taking an exam, they often regurgitate the positive story.

I thought that one aspect of CBT might be the examination of whether negative thoughts and feelings are grounded in unrealistic beliefs. Is it possible that these negative thoughts and feelings are false rather than true?

Is It Depression or Bleak Life Circumstances?

Fri, 13 Oct 2006 12:40:25 +0000

Have you come across the Patient Health Questionnaire (PHQ-9)? Pfizer is terribly proud of the PHQ-9 and claims that it is an

easy to use patient questionnaire [which] is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders.

I'm met a number of carers who have been put through the PHQ-9. By anecdotal report, the lowest score to date is 20 (severe depression). Oddly enough, lots of carers have trouble falling/staying asleep, particularly if they are listening out for sounds of illness or an indication that someone is up and wandering (e.g., someone with Alzheimer's Disease). Some carers lose their appetite with anxiety and others overeat for comfort. A number are in such distressed financial straits if they've given up work to care for someone that it's not unusual for them to feel like they're failures and face a future that is so bleak that they don't want it. These questions would catch a lot of carers and their everyday circumstances.

Is it hopelessly naive to say that the PHQ-9 is describing a state of mind that would disappear in many of the affected carers if they had appropriate resources and their future didn't look quite so bleak? The GPs who administer the PHQ-9 are familiar with the circumstances of carers: do they administer anti-depressants or offer talking therapy (good luck with that waiting list), or do they look at the score and decide that it is not really indicative of depression?

The Toll of Being a Caregiver

Thu, 28 Sep 2006 12:46:06 +0000

AADT has a good discussion of a recent story about the stress of caring and its impact on physical and mental health.

[C]aregivers, a group whose health is typically much poorer than contemporaries not caring for a loved one, endure stress and health deterioration in relation to the amount and intensity of the care they give. This burden, usually above and beyond work duties and nuclear family obligations, leads to high levels of depression, anxiety and stress. In describing her own experiences, one caregiver highlights how health can decline so rapidly:
Sometimes you didn't have time to take a shower. You didn't eat properly because you're so busy preparing their food and tending to them. You miss doctor's appointments because you can't get somebody to stay with him or you can't (bring) him," [Barbara Redmond, 68, said of caring for her husband for 2 1/2 years before his death.]

They give a very good summary of the statistics.

Carers need practical support for what they do and they need support for themselves. Yet again, this problem is only going to increase as our population ages. Fewer people will have the physical resources to allow them to carry out heavy-duty caring. There will be a time when we realise the cost of doing nothing.

Happiness and The Moral Consequences of Economic Growth

Wed, 30 Aug 2006 08:40:54 +0000

Polly Toynbee has written a piece asking "why have we never had it so good". She argues that:

There has never been a better time to be alive in Britain than today, no generation more blessed, never such opportunity for so many. And things are getting better all the time, horizons widening, education spreading, everyone living longer, healthier, safer lives.

However, it doesn’t seem as if all of these "[u]nimaginable luxuries and choices" have increased our happiness levels: it is also not clear that the opportunities and benefits that she describes with such approbation are available to all. Many people are involuntary participants in the postcode lottery that governs whether or not you are eligible for a variety of procedures on the NHS (e.g., cardiac catheter ablations). And the increase in foreign travel and holidays is limited: the number of British people who did not take a holiday over the course of a year has remained stable at 41 per cent over the last three decades.

Brad DeLong has posted an extensive and interesting review of Ben Friedman's thought-provoking The Moral Consequences of Economic Growth.

Stress Therapy Offer To Ill Jobless: Really?

Thu, 06 Jul 2006 07:29:17 +0000

According to The Guardian, the government is about to offer stress therapy to people who have had to quit work because of stress or depression.

So, would this be a separate plan to the Layard proposal for enhanced access to cognitive-behavioural therapy? Or is this a separate proposal? If so, is this a well-researched and validated programme? Or is it a nice, worthy sounding initiative that is not expected to go anywhere?

Why focus on stress therapy? Has anyone looked at the possibility of focusing on people's character strengths and virtues and using those to help someone to help themselves? Has there been any investigation of resilience work that would not only relieve stress in the short-term but sustain it? Is accepting the health benefits of positive emotion still too much of a leap of faith?

Moods and Emotions Are Contagious

Thu, 01 Jun 2006 19:08:40 +0000

Not many 12 year-olds are so desperate that they consider killing their own father. Several years ago I heard an author talking about his childhood. The memory that stays with me is when he described his father entering a room and acting as a black hole for all positive emotion or blitheness of spirit. The family responded by self-censoring their emotions even when the father wasn't present. The author recounted an incident when he was 12 years old when desperation made him offer a cup of tea to his father that he had laced with rat poison. He never made tea for his father. The boy's father took the tea, looked at it, looked at him and laughed. The father enjoyed a bleak victory in driving his family to such extremes.

I've always considered that childhood account to be a crushing and bleak example of emotional contagion. I think that many of us know people who are so sensitive to the moods of others that they sense anger, or can themselves become depressed. Fear and sadness can be transmitted from one person to another without the parties being aware of it.

Interviewed by Stacey Colino in a recent article for the Washington Post, Professor John Cacioppo attributes this transmission to the human instinct to mimic others during communication.

[T]he more expressive and sincere someone is, the more likely you are to see that expression and mimic it...The muscle fibers [in your face and body] can be activated unbeknownst to you, at much lower levels than if you were to express those movements yourself initially.

For those familiar with the ideomotor response it seems as if our muscles can react and respond without our conscious knowledge. Several theories of communication suggest that this process initiates a feedback loop where we see someone smile, our smiling muscles mimic the action, this behavioural action is linked to our state and raises our positive state which may make us smile. Unfortunately, there is a similar mimicry for negative emotions that may result in the transmission of fear, alarm, depression or sadness.

The Role Of Supportive Communities

Sat, 20 May 2006 10:46:34 +0000

Dr Crippen has written several entries in his diary for this week that elicit both sadness and anger. Sadness for the predicament of the patients who consult him and anger that the resources are not available to help them. In the Thursday 18th entry for the diary, Dr Crippen poses the question:

What happens to children with learning difficulties? They become adults with learning difficulties. Because they are grown up, people do not realise and are less tolerant.

We learn about Patrick who is 42 and has learning difficulties. Patrick is currently not working and when he is cross he hits people. Patrick does not meet the criteria for help from the local mental health departments. His local 'regular' psychiatrists do not work with people with learning difficulties: his local learning difficulties psychiatrist had diagnosed a Borderline Personality Disorder which Dr. Crippen translates as, "I can't help you and I don't like you."

The Relief of Like Minds

Thu, 18 May 2006 17:28:23 +0000

The notion that happiness can be taught sometimes leave people feeling baffled by the language (like the translations in the accompanying photograph) or even outraged. I participated in a fascinating Like Minds event last night. I had the opportunity to present some of the work that I do with positive psychology to an audience of battle-hardened GPs, Community Mental Health workers, psychiatrists and even a Mental Heath Commissioner (I think; he was up until last Friday, but from bits and pieces last night it seems as if he was so successful and innovative there that he has been appointed to a different post).

The GPs were concerned with the medicalisation of unhappiness and patients' requests for anti-depressant medication. There was some discussion of claims that GPs don't know how to make appropriate referrals for depression. The GPs felt that they had limited resources rather than limited knowledge: in terms that were reminiscent of Dr. Crippen they felt that they were being treated like the dinosaurs of medicine and asked to become more and more remote from their patients rather than giving them the one-on-one time that so many of them need.

Dr Serani's 6 Myths About Stress

Tue, 25 Apr 2006 13:33:22 +0000

Psychologist Dr Deborah Serani dispels six myths about stress in the hope of promoting greater understanding. It sounds a lot like being aware of the allostatic load of your life. I've borrowed this following explanation of allostasis from Dr. Salt's summary of a classic paper:

[stress has] many mechanisms, but among the most prominent are the manifestations of physiological stress responses as a result of living and working conditions, inter-personal conflict, as well as the sense of control of one’s environment and optimism/pessimism toward the future. "Allostatic load" refers to the cost of adaptation to a stressful environment, which elicits repeated and sometimes prolonged adaptive responses ("allostasis") that preserve homeostasis in the short run but can cause wear- and-tear on the body and brain. Functional symptoms and syndromes, decreased cognitive function during aging, abdominal obesity, increased risk for hypertension and cardiovascular disease, insulin-dependent diabetes and decreased immune responses are all manifestations of allostatic load.
We have powerful ways of modulating the harmful output of the stress response systems that include belief systems and behaviors. An important quote attributed to Dr. McEwen is, "We must also remember that the biggest problems for the human race in the future are those associated with our own behavior and misbehavior and the impact of the social and physical environment on our bodies and brains."

Stress, Anxiety and Depression: diverse findings from mice and stressed people

Wed, 19 Apr 2006 14:18:19 +0000

There is a lot of disagreement about anxiety and depression among professionals. Some argue that they are discrete categories. Others say that they tend to co-exist. There is disagreement about whether the anxiety that often accompanies chronic depression is a cause or effect of the illness.

Research in mice suggests that chronic stress as a precursor of anxiety may be a trigger for -- rather than a symptom of -- depression. People with depression typically have measurably higher levels of cortisol (stress-fighting, anti-inflammatory hormone), but researchers disagree whether this is a cause or effect of depression. The findings of the mouse research indicate that chronic exposure to cortisol may contribute to the development of depression.

The mice were acutely (24 hours) and chronically (17 to 18 days) dosed with their stress hormone. They mice were then given a common behavioural test for anxiety in animals: researchers measured how much time it took to leave a small dark enclosure for a brightly lit, open field. The research reports that the mice exposed to chronically raised levels of stress hormones were more hesitant less to explore their new environment and more fearful.

The research also indicates that the mice with chronic exposure responded with dulled reactions to being startled: an indication that their nervous system might be overwhelmed.

Happiness As Flexibility Of Mind and Openness?

Wed, 15 Feb 2006 16:56:17 +0000

There are several classic experiments that are summarised and commented on in Prof. Seligman’s Authentic Happiness. The consistent result is that positive emotion allows us to be more flexible, creative and open to new ideas.

I was thinking about this today when I read the explosion of comments on the topic of ME on the excellent NHS Blog Doc. The original article discusses the dilemma that faces Dr. Crippen when asked to provide a sick note for a patient with ME, a condition that he does not “believe in”. Take a look at the comments and the references that are provided in them. They are truly fascinating, and they seem genuinely to be contributing to a desire to learn by the GP in question. Dr. Crippen seems to be taking a real-time journey of listening and discovery that leads to him discussing a new assessment of his patients who currently have the label, ME.

I was recently lamenting that depression and anxiety statistics should not be used to comment on the prevalence of happiness. And I was exposing my thinking on various matters (such as the diagnosis or treatment of depression). I’m actually quite comfortable with holding “on the one hand this, on the other hand...” opinions. I just find it difficult when talking with people who want a definitive viewpoint.

Is Unhappiness A Symptom Or A Passing Phase?

Sun, 12 Feb 2006 20:26:06 +0000

I am troubled by a recurrent practice in the popular literature on the theme of happiness and the economics of happiness. It’s an intellectual sloppiness that I try to guard against but it happens from time to time. The practice is this. There are many articles that comment on happiness by dragging in statistics about anxiety and depression to bolster the perception/argument that unhappiness is endemic. One proof that is frequently aired is the sheer volume of prescriptions for anti-depressants and anti-anxiety medications that is dispensed in the UK, US, name the country under discussion.

Horwitz and Wakefield have offered an excellent overview of what my wife would refer to as the semantic shift of the word depression and what used to be understood by it. Apparently, 300 years ago silly used to mean innocent or blessed rather than its current connotations. In a much faster variation of this process, depression seems to have shifted from a medically defined term to one that is readily used (almost as a metaphor in its own right) to describe any negative emotional state: no matter how appropriate that reaction might be under the circumstances.

It is not unusual to come across reports that claim more than half of the population will develop a mental disorder at some time over the course of life. This immediately raises the issue of what constitutes mental health and mental illness. Although there are internationally standardised criteria for the latter, their application varies enormously. And even psychiatrists can not provide a united front as to where the boundary lies.

BACP On Disagreeing With Layard's Proposals

Sun, 12 Feb 2006 18:03:21 +0000

A while ago the British Association for Counselling and Psychotherapy issued a press release that criticised some of the Layard proposals: specifically those calling for the training of more therapists (BACP argues that a sufficient number already exist), and those that emphasis the importance of the cognitive behavioural therapy approach above other strategies.

Economists argue that anxiety and depression are a burden on the economy. Mental Health specialists (among others) counter that they are an unaffordable burden on society. Layard says that happiness should be seen as more than a health issue. The BACP unhelpfully offers the counter-claim that

Unhappiness is the consequence of more than a diagnosed condition and always arises from a life situation.

And they offer counselling etc. as part of the solution. Which still looks like medicalisation of a psychosocial issue to me. I will put more about this in another post.

Happiness and The Moral Consequences of Economic Growth

Tue, 03 Jan 2006 18:26:20 +0000

Polly Toynbee has written a piece asking "why have we never had it so good". She argues that:

There has never been a better time to be alive in Britain than today, no generation more blessed, never such opportunity for so many. And things are getting better all the time, horizons widening, education spreading, everyone living longer, healthier, safer lives.

Brad DeLong has posted an extensive and interesting review of Ben Friedman's thought-provoking The Moral Consequences of Economic Growth.