National Depression Awareness Week

20 April 2016

This week is National Depression Awareness Week. Here Dr David Bell, Consultant Psychiatrist in Psychotherapy, and Dr Julian Stern, Director of Adult and Forensic Services, describe their approach to a condition which is much more complex than its portrayal often lets on.

Depression is a term that covers a multitude of human problems. In extreme cases, someone with severe depression may suffer psychotic depression including delusions that they are wicked, responsible for suffering of others, deserve punishment and should not be alive.

For the majority of depression sufferers, the difficulties express themselves in a different way; but the degree of suffering should not be underestimated. Many make attempts to take their own lives and the condition can limit lives considerably.  Depression is often associated with feeling a deep sense of pointlessness, having difficulty in sustaining any feeling of pleasure or enjoyment and people with depression view themselves very negatively. They have great difficulty in forming relationships, or the relationships they have become easily contaminated with the feelings of pointlessness.
 
Whereas an infectious illness starts at a definable point and has a course limited to weeks and months, depression is different and increasingly we have come to recognise that depression is not best thought of in this kind of illness model.

Many people who are depressed recognise that they have been so for very many years – sometimes since childhood or adolescence. Although they may have managed to have relationships, work, etc., they are rarely without the feeling of the depressive shadow threatening to overwhelm them at any moment and when it does, they soon give up on things and retreat from normal life. Even when things are going well, they are very often continually anxious that the pleasure will soon dissipate and the shadow will overwhelm them again. 

It is thus more appropriate here, and in fact in the majority of cases, to understand the depression as part of what the person is, part of their personality. The depression, in this sense, is an authentic expression of their lives and its contents, and the negative thoughts and feelings need to be seen and respected as very important meaningful communications. For this reason, approaches that overemphasise the value of medication such as antidepressants and underemphasise the need for a person to understand this important part of their nature, may well increase the feelings of alienation and leave the individual feeling very short-changed.

Increasingly we are recognising that medication has only a limited role to play in treatment of depression. Although some individuals will benefit from relatively brief course of psychological treatment, we have found that many require considerably more help.

Central to our approach at the Tavistock is to understand depression as a meaningful communication about the person’s life history and current circumstances. All individuals referred here will have a number of in-depth consultations to understand the nature of their difficulties.  Where psychotherapy is a realistic option, individuals will often receive a course of treatment lasting 12 months, sometimes 18 months, sometimes even longer.

A recent study carried out by senior clinicians and researchers at the Tavistock was recently published in the World Psychiatry journal. The Tavistock Adult Depression Study, now a widely quoted study, found that many patients, all of whom had struggled with longstanding depression and had not been helped by other (often briefer) therapies, showed real benefit after more than a year of treatment. The study also demonstrated that the benefit of this therapy (unlike other forms of treatment) often continued increasing after the treatment had ended. Thus the therapy had helped the person onto a developmental trajectory which continued beyond the clinical sessions. The study also showed that many individuals have been depressed for much of their lives.

Some briefer therapies may sometimes help with certain symptoms, especially with patients with relatively mild, recently diagnosed depression. However a longer therapy, focussing on guilt, loss, attachments, relationships, and a propensity to lose the capacity to value good things in one’s life, is often the only route to a more longstanding understanding and recovery.  

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