What is depression and how can you manage it?
[3 MINUTE READ] Approximately one in four people have a mental health problem, with depression in particular suffered by millions around the world. Jon Codd, trainee clinical psychologist, University of Oxford, talks about how you can manage it.
I have worked for several years now in a number of mental health services with adults, older adults, children, people with learning disabilities and people with autism. And as a trainee clinical psychologist, one of the more common reasons for referral to any of these services is people struggling to deal with low mood or depression.
And when people experience depression - in whatever form it appears, there will be a significant impact to their lives and the lives of those close to them.
What is Depression?
Officially, depression is low mood or a loss of interest or pleasure in daily activities that lasts for a long time, at least for two weeks, and affects your everyday life. And it is surprisingly common.
The American Psychiatric Association’s Diagnostic & Statistical Manual (2013) describes major depressive disorder as depressed mood and/or a loss of interest or enjoyment in activities and at least five of the following symptoms during a two-week period: changes in weight and appetite; changes to sleep patterns; being either agitated or slowed up; loss of energy; feeling worthless or guilty; poor concentration; and suicidal thoughts.
Depression is often considered on a continuum from mild to severe, and commonly affects people with other mental health problems, such as anxiety or drug and alcohol problems, as well as people with physical illnesses including cancer, heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, and Parkinson’s disease.
A recent survey in 2016 by the mental health charity MIND estimates 3.3 percent of the population in England have depression with another 7.8 percent having mixed anxiety and depression. The survey also measured the number of people who have self-harmed (7.3 percent), had suicidal thoughts (20.6 percent), or have made suicidal attempts (6.7 percent) over their lifetime.
Dealing with Depression -- Self-Care
MIND has produced some helpful tips and advice on their website around self-care for depression. I find a useful way of remembering all aspects of self-care is to encourage people to get their ‘DOSE’ right, and this is particularly important when dealing with depression.
D is for 'Diet': Eat well and get a balanced and nutritious diet which helps us to feel well, think clearly and increases energy levels. Avoid recreational drugs and alcohol, as although these may provide short-term relief to cope with difficult feelings, they make us feel worse in the long-term.
O is for 'Organisation': Use a diary/calendar to plan things into your week. Try and ensure you have activities planned that intend to provide you a sense of pleasure and/or achievement. Consider planning in activities that help maintain hygiene like having a bath or shower and getting a haircut. When feeling low, it may also be necessary to plan, organise and set reminders for other important things like paying bills, upcoming work/school deadlines, and special events like birthdays and anniversary.
Connecting with people is always important for our mental health, so organising realistic and manageable social contact with others is likely to help. This may involve meeting up with family and friends or it could be a telephone call or messaging a friend on social media. Try and set realistic and achievable goals when planning ahead, be kind to yourself and recognise that if you are feeling low you might not be able to do all the things you used to do right away. Start with the things that seem easier to do first and build from there.
S is for 'Sleep': Depression often interferes with sleep, and either sleeping too much or not enough can become a daily problem and makes depression worse. If you are struggling one way or the other with sleep, keep a sleep diary to work out on average how much sleep your body needs over a couple of weeks. Then try and create a regular sleep routine and stick to it without taking naps in the day, and aim to get up early, around 7am or 8am each day.
For example, if you work out you need about seven hours sleep each day and you’re aiming to get up at 7am, then set your bedtime to midnight and try and stick to it. As a rule of thumb, we tend to need more sleep when we are younger and less sleep as we get older. Routine is really important, especially when feeling low.
Consider your routine leading up to bedtime and what helps you to relax. Avoid eating or drinking too much soon before bed as this will affect the quality of your sleep and is likely to wake you up in the night. Especially avoid alcohol or caffeine as these are most likely to interfere with sleep. Consider your sleep environment, including things like your bed, noise, your sleeping partner, lighting and if there is anything that could help. Try and keep your bedroom for sleeping as far as possible so you can build an association with your bedroom being somewhere you can sleep peacefully, rather than it being a place where you watch television, do work, eat meals, or worry about things.
Sleep routine is especially hard for shift workers and so, particularly if you work a mixture of day and night shifts and you struggle with sleep which is affecting your mood, consider problem solving the pros and cons to working shifts. Think about whether anything could be changed, and whether working shifts is worth the impact it has on your sleep and mood.
E is for 'Exercise': Many people find keeping active a challenge and this can be especially hard when depression gets a hold of us. There is loads of evidence that exercise reduces the risk of depression. When we exercise, our body releases endorphins, feel good hormones, which can reduce stress and lift our mood. Exercise also provides something different to focus on and can break up racing negative thoughts and worries. It can also help increase self-esteem as we get fitter and lose weight. There are also the physical aspects of exercise reducing the risk of some diseases like heart disease and diabetes, keeping our organs healthier, strengthening bones and building muscle, boosting energy levels and improving sleep.
Dealing with Depression - Talking Therapies
So, aside the above, what other ways are there for trying to treat depression? Well, the National Institute of Clinical Excellence (NICE) recommends a stepped care model for treating depression in adults (see www.nice.org.uk/guidance).
This stepped model starts from assessment and recognition, usually by a GP or nurse, and can progress to low and high intensity psychological interventions, social support and treatments for recurrent or atypical depression. At the latter stages of treatment, electroconvulsive therapy (ECT) may be used for patients at most risk.
Cognitive behavioural therapy (CBT), or CBT-based treatments, is currently the psychological treatment of choice for people suffering from depression.
CBT includes a range of psychological therapies designed to treat depression, anxiety, anger, and stress. Variations of CBT are used to treat relationship problems, schizophrenia, addictions, and eating and personality disorders.
The underlying ideas of CBT are that it is our perception or thoughts about events, people and situations that determine our response or feelings towards them. In short, it is the concept that if we can manage our thoughts we can manage our responses towards those thoughts.
Through CBT (which you can learn more about here), our thought and behaviours can be measured and monitored, and change over time.
Other high intensity psychological treatments include behavioural activation, behavioural couple therapy, interpersonal therapy (IPT). A central idea in IPT is that psychological symptoms, such as depressed mood, can be understood as a response to current difficulties in our everyday interactions with others.
In turn, the depressed mood can also affect the quality of these interactions. When a person can interact more effectively with others, their psychological symptoms often improve.
IPT can typically focuses on conflict with another person; life changes that affect how you feel about yourself and others; grief and loss; and difficulty in starting or keeping relationships going. Counselling for depression and short-term psychodynamic psychotherapy is recommended for people with mild-moderate depression who decline CBT, IPT, behavioural activation, behavioural couples's therapy and anti-depressants.
Mental health is a postcode lottery
My experiences working in services leads me to believe there is a bit of a postcode lottery in terms of what psychological therapies some services do and do not offer and their waiting times.
The introduction of Improving Access to Psychological Therapies (IAPT) programme for adults with depression and anxiety in 2008 means more people than ever before in England have access to evidence-based psychological therapies. Over 900,000 people are reported to access IAPT each year and NHS England has committed to expanding services further, alongside improving quality, and particularly focusing on supporting people with long term conditions.
However, currently IAPT data reveals services are seeing only 15 percent of people with depression and anxiety. It is true that some people may be seen by other mental health services, hospitals, private therapists and charities but there are also a lot of people either not being offered or not engaging in the free NHS support. I think the stigma around metal health and depression is getting better, although it is often hard for people with depression, especially men, to access help and talking therapies.
I hope this article provides some useful information around dealing with depression and may help in encouraging people to seek help and support.
Jon Codd is a trainee clinical psychologist studying at the University of Oxford. You can find out more about his background here.