Foundation Trust Members Event
DEPRESSION – ‘Myth and Meaning’
Dr Jenny Dale
Consultant in General Adult Psychiatry
Studdert Kennedy House
Worcester
Introduction
• Most people have some idea of what depression
is…but there are many myths
• Depression is a serious and very complex condition
• We are understanding more and more about the
causes and refining how we diagnose depression
• Management strategies are improving but require
skill, resource and expertise to implement
Myth 1: “Depression is the same as being sad”
Those who suffer from depression tell us that an episode of
depression is quite different to simply feeling sad…
“In its severe forms, depression paralyzes all of the
otherwise vital forces that make us human, leaving
instead a bleak, despairing, desperate, and deadened
state. . . Life is bloodless, pulseless, and yet present
enough to allow a suffocating horror and pain. All
bearings are lost; all things are dark and drained of
feeling. The slippage into futility is first gradual, then
utter. Thought, which is as pervasively affected by
depression as mood, is morbid, confused, and
stuporous. It is also vacillating, ruminative, indecisive,
and self-castigating. The body is bone-weary; there is
no will; nothing is that is not an effort, and nothing at all
seems worth it. Sleep is fragmented, elusive, or allconsuming. Like an unstable gas, an irritable exhaustion
seeps into every crevice of thought and action.”
Myth 1: “Depression the same as being sad”
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•
•
•
•
•
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D = Depressed mood
E = Energy lost (fatigue)
P = Pleasure (interest) lost
R = Retardation (thought and action slowed) or agitation
E = Eating changed (appetite/weight)
S = Sleep changed
S = Suicidal thoughts
I = Impaired concentration
O = Only me to blame (guilty/worthless)
N = Not able to function
Myth 1: “Depression is the same as being sad”
Depression isn’t just about reaction to bad
experiences…
• Although may be linked with a negative or stressful
event, depression can occur/recur spontaneously
• It lasts longer, is more pervasive and can have a more
profound effect on functioning than periods of
adjustment (which tend to be short-lived and resolve
when stressor is relieved)
• Reactive vs. biological depression – caution!
• 'Kindling'
Myth 2: “Depression isn’t that serious”
Statistics show depression is a serious condition…
• Depression is the leading cause of disability worldwide
• Depression is ranked as the third leading cause of burden
among all diseases worldwide
• Costs £8 bn in UK each year
• At least 1 in 20 people are clinically depressed at any one
moment
• In Worcestershire approx 15,000 people will suffer with an
episode of depression this year
• It affects any age, although women twice as often affected
as men
Myth 2: “Depression isn’t that serious”
The outcomes for people with depression can be extremely
serious…
• Suicide accounts for nearly 1% of all deaths and nearly twothirds of this figure is associated with depression
• Lifetime risk of suicide in depression is 15% (4 times more
than in general population rising to 20 times in most severely
ill)
• Depression is known to increase the risk developing a range
of physical health problems and increases the risk of poor
outcomes (including death)
• Chronic and recurrent depressive states can lead to brain
cell death
Myth 3: “Depression is a ‘syndrome of modern
life’”
Myth 3: “Depression is a ‘syndrome of modern
life’”
• Depression is observed in all cultures
• It is under-diagnosed rather than over-diagnosed:
80% of patients with depression will be treated by
their GP but 50-70% of patients with depression in
primary care remain undetected
Myth 4: “Depression is a single entity”
Depression is an ‘umbrella’ term…
• Mild, moderate and severe/‘melancholic’
• On a continuum but two ‘thresholds’
• Psychotic vs. non-psychotic
• Depression occurring with other physical and
psychiatric disorders
• Unipolar vs. bipolar depression
• Atypical, post-schizophrenic, post-natal etc etc...
Myth 5: “People who get depression are
‘weak’ and should ‘pull themselves
together’”
The causes of depression are complex and the
‘ingredients’ of an individual’s depression vary
considerably…
•Biased thinking and stigma
•We need to understand the causes of depression
in order to find the best treatment
Myth 5: “People who get depression are ‘weak’
and should ‘pull themselves together’”
•Coping style
•Perceptions
of control
•Biased ways
of thinking
BioPsycho-
Social
Depression
•Brain chemicals,
structure and
‘circuitry’
•Genes
•Physical illnesses
•Loss and stressful
events
•Early adversity
•Lack of support
Myth 5: “People who get depression are ‘weak’
and should ‘pull themselves together’”
Psychologist,
CPN
•Talking
therapies
•Psychological
support
BioPsycho-
Psychiatrist and GP
•Antidepressant
treatment
•Recognise and treat
underlying physical
causes/illnesses
Social
The individual
Their family, carers,
friends, supporters and
employers
Other
professionals/agencies
Recovery
Social worker,
Occupational Therapist,
Recovery Worker
•Employment, activities
•Finances
•Social support
Myth 6: “People with depression never really
recover”
People do get better and there are effective
treatments…
• Although recurrence rate is high after a first episode,
most people do recover with treatment and there are
effective strategies to maintain recovery
• Medication for depression is at least as effective as
most physical health treatments
• Antidepressants protect the brain against the toxic
effects of depression
Myth 6: “People with depression never
really recover”
Many highly respected, creative and successful
people have suffered with depression…
• JK Rowling, John Lennon, Winston Churchill,
Robert Schumann, Ludwig van Beethoven, Peter
Tchaikovsky, Edgar Allan Poe, Mark Twain,
Georgia O’Keefe, Vincent van Gogh, Ernest
Hemmingway, F. Scott Fitzgerald…
Depression: a CPN’s perspective
Keith Blueman
Community Psychiatric Nurse
Specialist Practitioner, Mental Health
Supplementary Prescriber
‘…like catching a glimpse of bright sunlight through a window from
the depths of a dark castle.’
What is a CPN?
- Community Psychiatric Nurses are experienced
qualified Nurses who work outside hospitals and visit
service users in their own homes, or in Resource
Centres, GP surgeries etc.
- CPNs are often Care Coordinators. A Care Coordinator
will make sure you have a clear Care Plan about how
you are going to be helped.
- Some service users may be put on the Care
Programme Approach, with meetings arranged for
everyone who is involved in their care plan.
• CPNs often perform mental health screening of people
referred with depression.
• Screening involves skilled observation of the service
user’s behaviour and taking a history which takes into
account biological social and psychological factors,
including defining the presenting problem, personal
and family history, risk assessment, mental state
examination, developmental factors, prescribed and
over-the-counter medication and herbal medication,
lifestyle factors, alcohol and substance misuse,
relationships and available support, financial factors,
housing,
employment and training, physical and
mental health history etc
A brief episode of care
• ‘Marcia’, Divorced female in 40s under care of CMHT.
• History of Bipolar Disorder with mainly depressive
episodes. Has attended bipolar education sessions in
the past and has a good awareness of early warning
signs (EWS) of relapse and CBT. Prescribed Mood
stabilisers.
• Contacts CPN by telephone after 5-day history of EWS
including lowering of mood and poor sleep with
difficulty getting up in the morning (some napping in
the day) and reduced energy and motivation. Marcia
denies any reason for feeling down and discloses no
self-harm ideas or plans. Discussed sleep management
etc and agreed to telephone review on the next day.
• Telephone review: Sleep still poor last night. Mood
unchanged.
• Arranged 7 day prescription of sleeping tablets.Agreed review in 2 days.
• Visit at home. Sleep improved but further evidence of
deteriorating mood: Only got out of bed because CPN
visiting; appetite reduced; lack of enjoyment; reports
low mood; avoidance of social contacts; less pride in
appearance; energy and concentration reduced.Discussed with partner who agreed to offer more
support and monitoring –Arranged blood test to check
level of mood stabiliser in blood.
• Blood test reveals level of mood-stabilising medication
too low even though dose unchanged for some time;
CPN discusses this with Marcia. She discloses that she
had stopped taking her medication many days ago
because she felt so low that she just could not see the
point of it. Appears severely depressed now but not
suicide risk.
• Review arranged with Home Treatment Team who
agree to provide input. They offer twice daily visits and
supervision of medication. Another mood stabiliser
added to medication.
• Mood lifts gradually over 2 week period.
• Marcia handed back to care of CMHT; CPN reviews at
home and her mood appears back to normal; Marcia
says that she is a little worried about having gained a
stone in weight in the past 6 months and would like to
consider extending her social networks. Agreed to do a
referral to Health Trainer and to Reablement Service.
Reablement Service Hub
• A countywide service aimed at reducing social
isolation by providing people with opportunities to
extend their social networks and form relationships not
only with other people with mental health problems
and staff, but also with people outside the mental
health system.
• Reablement is the restoration of optimal levels of
physical, psychological and social ability within the
needs and desires of the individual or family.
• The hub offers individually tailored information, advice
and support.
The Recovery Service is underpinned by the values of recovery.
The Recovery star is used to help in this.
The Recovery Star focuses on the ten core areas that
have been found to be critical to recovery:
• Managing mental health • Relationships
• Physical Health &Self-care • Addictive behaviour
• Living skills • Responsibilities
• Social networks • Identity and self-esteem
• Work • Trust and hope
The Recovery Star
•
The Recovery Star is a tool for supporting and
measuring change when working with adults of
working age who experience mental health difficulties.
• It is an outcomes tool, which means that it enables
organisations to measure and summarise change
across a range of service users and projects. It is also
a key work tool which means that it supports the
service user’s recovery by providing them with a map
of their journey to recovery and a way of plotting their
progress and planning the actions they need to take.
• The Recovery Star measures the relationship the service user has
with any difficulties they are experiencing in each of these areas
and where they are on their journey towards addressing them.
• The Recovery Star is based on a five-stage model of the process
by which people make changes in areas of their life that are not
working for them. The five stages of this model are Stuck,
Accepting Help, Believing, Learning and Self-reliance.
• The Recovery Star is underpinned by the assumption that positive
growth is a possible and realistic goal for all service users and is
designed to support as well as measure this growth by focusing
on people’s potential rather than their problems. In addition, the
Recovery Star is rooted in the Recovery Model, which is
underpinned by the idea that people with mental health issues can
live rich and fulfilling lives and that this is not necessarily reliant
upon the elimination of the illness but its effective management.
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•
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Reablement Service Providers include:
SHAW TRUST (Employment support etc)
ASHA WOMEN’S CENTRE (Women only support)
WORKERS EDUCATIONAL ASSOCIATION (Education
and training)
RETHINK INCLUSION (Holistic approach to social
inclusion, roles and activities)
ONSIDE INDEPENDENT ADVOCACY MOVING ON
PROJECT (Support and facilitation towards
volunteering)
EPIC (Support to access community learning)
A brief overview of Psychological application for the
treatment of depression
Lynne Reep
Consultant Counselling Psychologist
Registered Counselling Psychologist (HCPC)
Chartered Psychologist (BPS)
Adult Mental Health Service Delivery Unit – Secondary Services
The onset of depression:
It is suggested that no single factor can explain the onset of depression,
but that it is a consequence of an interaction between certain factors.
These factors include:
•Biological, e.g. disturbance in neurotransmitter functioning.
•Historical, e.g. early parental loss, neglect or abuse.
•Environmental, e.g. recent negative life events.
•Psychosocial, e.g. lack of adequate social support.
(Fennell 1989)
Psychological Interventions for depression
NICE (2007). Management of depression in primary and secondary care.
(Guideline 22 (amended)). The Stepped Care Model
Step 1 - Mild depression - GPs and practice based staff.
Identification, assessment, psychoeducation, active monitoring, referral for further
assessment and interventions if necessary.
Step 2 - Mild depression - Primary Care Mental Health Worker / Psychological
Wellbeing Practitioners, Counsellors.
Guided self-help, brief psychological interventions, counselling.
Step 3 – Moderate depression - Primary Care Mental Health Worker / Improving
Access to Psychological Therapies (IAPT)
Brief psychological interventions including, Cognitive Behavioural Therapy (CBT),
Behavioural activation, counselling.
Step 4 – Moderate to severe depression - Secondary Care / Highly Specialist
Psychologists
Specialist assessment and formulation of presentation. Complex psychological
interventions.
Step 5 – Severe depression - Secondary Care / Acute Inpatient and Crisis Teams /
Highly Specialist Psychologists
Specialist assessment and formulation of presentation. Complex psychological
interventions, such as behavioural activation. Also, assist the staff when working
with individuals who are at their most unwell, needing intensive care or needing
support whilst being seen in the home environment.
Evidence based Psychological Interventions for
depression
In 2001 the Department of Health gave directive with respect to the ‘Treatment
Choice in Psychological Therapies and Counselling : Evidence Based Clinical
Guidelines’.
They cited, “Depressive disorders may be treated with psychological therapy, with
best evidence for Cognitive Behavioural Therapy (CBT) and Interpersonal Therapy
(IPT), and some evidence for a number of structured therapies, including shortterm psychodynamic therapy” DOH 2001, page 37).
These evidence based therapies are incorporated into the Stepped Care Model
together with the more recent Payment by Results (PbR) Care Cluster Pathways
that are in the process of being developed locally.
An example of how Psychological theory and intervention
for depression might be applied in Secondary Services
Step 4 – Moderate to severe depression - Secondary Care /
Highly Specialist Psychologists
Specialist assessment and formulation of presentation.
Complex psychological interventions.
Specialist assessment and formulation of presentation:
•An individual presenting with depression attends for an indepth
psychological assessment of both their current difficulties and their
personal history. This includes all aspects of their parental / childhood
relationships, home life, school / educational life, relationships and working
life. From the assessment it can be established whether an individual
might gain from psychological intervention or not at this time.
•From the assessment a formulation is made with respect to why an
individual is presenting at this time with symptoms of depression. A
formulation is a hypotheses made from psychological knowledge and
therapeutic theory. This in turn informs the psychological treatment plan.
If an individual agrees to attend for psychological intervention the
formulation is shared with them and is continually tested out in therapy.
The Cognitive Behavioural (CBT) Model of Depression (Beck 1967,
1976)
The Cognitive Behavioural Model of Depression (Beck 1967, 1976)
suggests that experience leads individuals to form assumptions about
themselves, others and the world. These assumptions are subsequently
used to control perception and to direct and evaluate behaviour.
Some assumptions are dysfunctional when they are rigid, extreme and
resistant to change. For example, ‘I should always be loved’, ‘I should be
happy all the time’ and ‘I should never be wrong’.
Difficulties occur when ‘critical incidents’ happen that challenge
dysfunctional assumptions. For example, if an individual’s assumption is
‘he / or she should always be loved’ this could lead to depression following
a relationship breakdown or rejection.
Following a ‘critical incident’ a challenged dysfunctional assumption can
lead to a dramatic increase of ‘negative automatic thoughts’. They are
‘negative’ as they lead to unpleasant emotions. They are ‘automatic’ as
they just ‘pop’ into a persons head and are not as a result of rational
reasoning. At this stage they are usually evaluations of current
experiences, memories of past experiences and negative predictions
about future experiences.
These ‘negative automatic thoughts’ lead to symptoms of depression. For
example:
•‘Behavioural’ symptoms such as withdrawal from social contact and
lowered pleasure or achievement activity.
•‘Motivational’ symptoms, such as a loss of interest and inability to activate
self.
•‘Emotional’ symptoms, such as guilt and anxiety.
•‘Cognitive’ symptoms, such as indecisiveness, constant self blame,
constant thinking about loss and lack of concentration.
•‘Physical’ symptoms, such as sleep disturbance, appetite disturbance and
loss of libido.
Therefore:
“As depression develops, negative automatic thoughts become more and
more frequent and intense, and more rational thoughts are gradually
crowded out. This process is helped on its way by the development of
increasingly pervasive depressed mood. So a vicious circle is formed.
On the one hand, the more depressed a person becomes, the more
depressing thoughts they think, and the more they believe them.
On the other hand, the more depressing thoughts they think, and the more
they believe them, the more depressed they become”
(Fennell 1989, page 172)
Therefore:
The aim of Cognitive Behavioural Therapy for depression is to break
the vicious circle. This is achieved by teaching individuals to
question their ‘negative automatic thoughts’ and then challenge the
assumptions on which they are based.
A brief overview of Psychological application for the treatment of depression
As staff working with
Individuals with depression –
The values we need to
embrace working in a more
Recovery orientated
practice are:
Choice
Hope
Inclusion
Partnership
Empowerment
References
Anderson, I., Reid, I. (2004). Fundamentals of Clinical Psychopharmacology. Taylor and
Francis.
Beck, A.T. (1967). Depression, clinical, experimental and theoretical aspects. New York:
Harper and Row.
Beck, A.T. (1976). Cognitive Therapy and Emotional disorders. New York. International
Universities Press.
Beggley, S (2007). How the Brain Rewires Itself. Time Magazine.
Blenkiron, P (2010). Stories and Analogies in CBT. John Wiley and Sons.
Department of Health (2001). Treatment Choice in Psychological Therapies and Counselling.
Evidence Based Clinical Guidelines, London.
Fennell, M.J.V. (1998). Depression. In Hawton, K., Salkovskis, P.M., Kirk, J. & Clark, D.M.
(eds.) (1989). Cognitive Behavioural Therapy for Psychiatric Problems : A Practical Guide.
Oxford. Oxford University Press.
Redfield Jamison, K. (1997) An Unquiet Mind: A memoir of moods and madness. Vintage
Books.
NICE (2007). Management of depression in primary and secondary care. (Guideline 22
(amended)).
WHO (1992). ICD-10 Classification of Mental and Behavioural Disorders.