Hallucinations can be described as profound distortions of reality where sensory perceptions are believed to be real even though there is an absence of external stimuli.
They are a common feature of Schizophrenia but are also sometimes experienced by people with Bi-polar disorder (manic depression) as well as other mental or psychotic or medical disorders and also with the use of certain drugs.

By far the most common type of hallucination in people suffering from Schizophrenia is what is known as auditory hallucinations. This is where an individual hears something and believes it to exist outside of himself but which is inaudible to anyone else.

Auditory hallucinations will often take the form of voices which may be critical, aggressive or compelling the individual to carry out certain tasks or in some cases they may be supportive and offering advice and guidance. Usually though they are not pleasant.

Although it is less common, others may experience musical hallucinations where they hear a piece of music, quite often the same piece, over and over again.

Another type of hallucination that can be experienced by people with schizophrenia involves seeing things that aren’t there. These visual distortions can include seeing people, pets, demons, ghostly apparitions, religious figures, colours, objects or anything for that matter, which is not actually there but again, is perceived to be very real by the person who ‘sees’ them.

Hallucinations can affect any one of the other senses too such as taste, touch and smell.
For example, a person with schizophrenia experiencing gustatory hallucinations might find their food tastes strange. As people with schizophrenia often suffer from delusions and paranoia they may believe their food has been tampered with or that they are being poisoned.

Tactile hallucinations involve sensations of touch which may take the form of feeling something crawling under the skin or surges of electricity through the body. Sometimes the hallucinations can be of a sexual nature too.

If the hallucination involves something happening inside the body it is known as somatic hallucinations. Some people with somatic hallucinations might believe they have things living inside them, for example snakes or worms.

Hallucinations involving the sense of smell are called olfactory hallucinations and include examples such as smelling gas or smoke. A person suffering from schizophrenia may believe another individual is trying to kill them.

The important point is that these hallucinatory experiences are very real to the person who experiences them and naturally, can be extremely distressing, particularly when two or more different types of hallucinations are experienced at the same time.

Treatment for people with schizophrenia who experience hallucinations or other forms of psychosis consists of anti-psychotic medication which is generally quite effective at keeping the symptoms under control.

However, some people are beset by severe, crippling chronic anxiety that does more than just give their mortal life its spice. This kind of anxiety takes over their lives.  Psychologists have given a name to this form of kind of pathological anxiety: generalised anxiety disorder.

People who suffer from generalised anxiety disorder live their lives in the service of their fears. They can’t stop worrying about whatever is at hand: their children’s safety, whether or not their upcoming dinner party will succeed. the state of the world’s economy, whether or not the car they just bought is safe to drive, whether the cat will make a mess by throwing its litter around all over the bathroom (and whether or not the resultant bits of stray cat litter will result in a disgusting, wet mess when they come into contact with water spilled from the shower onto the bathroom floor), and whether or not there might be a roach infestation in their apartment. People with chronic anxiety disorder will always find a subject to worry about.

It is difficult for mental health professionals to talk about generalised anxiety disorder as a mental illness. The problem is that everyone experiences symptoms of generalised anxiety disorder at some point in their lives. Everyone worries about their children, the state of the world’s economy, and whether or not their flat has roaches.

The difference between generalised anxiety disorder and ordinary anxiety is just a matter of degree. People with generalised anxiety disorder just can’t stop worrying. They just worry and worry and worry, and can’t stop. Worst of all, they worry about the fact that they’re worrying. They torture themselves, to the point of showing physical signs. Ulcers, headaches, difficulty, pain, suffering–this is all a part of life for those who have chronic anxiety disorder. Most people can put their worries aside, and think about something else. This is simply not the case among sufferers of generalised anxiety disorder.

A magnified suspicion and irrational, extreme distrustfulness of others that has no basis on fact, paranoia is sometimes a bipolar disorder psychotic feature, which can reveal itself as hallucinations, systematised delusions and unfounded delusions of persecution.  Often a personal will develop a completely unfounded, irrational belief that someone will harass or harm them.  People with bipolar paranoia may believe people are talking about them, putting poison in their food or they even think they hear voices plotting against them or trying to kill them.  It can be a psychotic condition in manic or depressed bipolar episodes although it usually indicates bipolar type 1 disorder.

Treatment for bipolar disorder is usually comprised of medications and therapies although there are other less common treatments often used only in extreme cases.  In the case of bipolar paranoia and other severe symptoms, patients sometimes require psychiatric hospitalization to stabilize their condition safely.  Doctors use drug treatments to keep the patients extreme mood swings from depression and mania stable.  There are many mood-stabilizing drugs to reduce symptoms and help stop future depressive and manic episodes when used responsibly.  Some of these medications include:

? Mood Stabilizers – Prescribed to help relieve mood swing symptoms primarily in the mania phase mood stabilizers may also help during a severe depression.
? Anti-Anxiety and Sedatives – These drugs that include hypnotics and tranquilizers help bipolar disorder patients with severe manic episodes, reduce anxiousness and get them back on a regular sleep pattern.
? Antipsychotic Drugs – Doctors prescribe antipsychotic drugs to treat symptoms such as bipolar paranoia, help relieve psychotic conditions often occurring during severe mood swings and aid in controlling mania.  Psychiatrists sometimes hospitalize their patients in order to get their bipolar paranoia under control.

Once a doctor diagnoses his or her patient with bipolar disorder, including bipolar paranoia, it often takes a while to find the correct drugs and dosage because everyone is unique and so is the treatment.  No psychological treatment or one specific medication works for all bipolar patients so, although it may be frustrating, there is definitely a treatment right for everyone.  Make yourself as knowledgeable about bipolar disorder as possible and always follow your doctor’s instructions.

I take the view that mild depression can for many people be entirely an natural response to some life events. Clearly, there are some circumstances, like the death of a loved one for example, where we would almost expect the bereaved person to become very sad, to withdraw and to reflect on their loss.

I believe that the world we live in often puts enormous pressure on us to ‘fit in’, to be ‘normal’, to ‘bounce back’. I sometimes watch TV (especially American TV) and see the hero fall in love in one episode, only to lose her at the hands of a villain. He’s sad at the end of the episode but by the following week it’s another case, another city another girl! We all know this isn’t real life, but to what extent do we truly allow ourselves the time to adjust to the major changes that life can throw at us? The truth is, we need time to process things in our mind — and modern life often doesn’t recognise this.

Mild depression

In days gone by we might have talked our feelings over in confidence with perhaps an older or trusted member of what might of course have been quite a large extended family. Or we may have sought counsel from a priest, rabbi or other form of religious or spiritual leader. Many people are still fortunate to be able to do this, however, many of us do not have this facility, or would feel uncomfortable with it. In such circumstances, an alternative is to speak to a counsellor. Many people prefer this, valuing the confidentiality and finding it easier or preferable to speak to an ‘impartial’ third party.

In such cases the counsellor’s role is to offer you a safe and non-judgmental space, to listen and to reflect with you on what they are hearing. They will listen out for and support you to be aware of, your feelings. They will support you to acknowledge all of your feelings, including any that you feel may be ‘inconvenient’ or which you perhaps do not wish to have or acknowledge. It is a gradual process that takes place at your pace. The emphasis isn’t on ‘problem solving’ but on allowing you to ‘take stock’ of things.

If life adjustments are necessary, it is for you to come to this in your own way, in your own time. The counsellor won’t get tired of listening because clients sometimes have to back over things many times in order to ‘straighten things out’ in their heads. Sometimes, nothing can be done about what has happened, or will happen, yet talking about things allows you to move towards acceptance, or to gently adjust your perspectives or expectations and therefore to live more comfortably with your situation.

Depression affects twice as many women as men. Midlife is often considered a period of increased risk for depression in women. It is not known why, but it may be related to having a personal or family history of depression, life stressors, and role changes. Menopause is often believed to be a time when women are more likely to become depressed. Studies actually show that menopause depression is more likely to occur in the years during transition to. This period is associated with gradual declines in estrogen levels. Some studies suggest that changes in estrogen levels are associated with onset of menopuase depression.
Menopause depression

What are the symptoms of depression during midlife?

The symptoms of depression in pregnancy are: two or more weeks of depressed mood, decreased interest or pleasure in activities, change in appetite, change in sleep patterns, fatigue or loss of energy, difficulty concentrating, excessive feeling of guilt or worthlessness, thoughts of suicide, extreme restlessness and irritability. Many symptoms of menopause overlap with symptoms of depression including problems with sleep, physical symptoms such as hot flashes, fatigue, irritability, anxiety and difficulty concentrating. Some women suffer needlessly because they think these discomforts and problems are a natural part of aging. Depression should not be dismissed as a normal consequence of later life for women.

Depression that goes untreated can lead to more severe episodes of depression and even physical complications. For example, depression is associated with increased risk for heart attacks. A recent study suggests that depression leads to loss of bone mineral density, therefore increasing a women’s risk for broken bones.

What is menopause?

Menopause is the time in life when a woman stops having menstrual periods. All women who live long enough will eventually experience menopause. The average age for menopause is 51. As a woman approaches menopause, her body gradually makes less estrogen and progesterone hormone. As a result, most women have symptoms such as hot flashes, vaginal dryness, lower sex drive, urinary incontinence, and depression. Less common symptoms include sleep disorders, dry skin, mood swings, and fatigue.

ertain health problems, such as osteoporosis (brittle bones) and increased heart disease, are associated with menopause. To help prevent such problems, many women choose to take an estrogen replacement therapy (ERT) or hormone replacement therapy (HRT) to replace what their body is no longer producing. Along with over the counter products, this is the primary treatment for the symptoms of menopause.

Lifestyle changes can also help relieve or prevent menopausal symptoms. Avoiding alcohol, caffeine, and spicy foods can help prevent hot flashes. Keeping cool and dressing in loose layers of natural fabrics such as cotton can help reduce the discomfort of a hot flash. Kegel exercises can strengthen pelvic muscles, preventing urine leaks and improving bladder control. Regular exercise can help prevent osteoporosis and heart disease. It can also lessen symptoms of menopause depression.

The downside is only now emerging. Although studies show that it is effective for mild to moderate depression and two million British people are taking it, you do have to be careful.

The chief drawback is that the remedy, derived from the yellow flowering hedgerow plant, interacts with other drugs causing them to metabolise through the body too quickly. This is obviously very significant for people on the contraceptive pill or the blood-thinning drug warfarin, who are at risk of a stroke.

Herbal remedies for depression. Warnings issued

The Medicines Control Agency issued a warning on March 1st 2000 that patients who are on a long list of drugs should stop taking St John’s wort until they have consulted their GP or pharmacist. Medications for asthma, epilepsy, depression, migraine and heart problems are all implicated.

The authorities in the Irish Republic have gone further by banning the over-the-counter sale of the ancient herbal remedy since January 1st 2000. It is now available only on prescription.

In the United States, the Food and Drugs Administration (FDA) issued a warning in February 2000 that the herb could interfere with drugs used to treat HIV-infected patients. It also raised the possibility of complications for other patients taking similar medication, including those undergoing heart transplants. The FDA cited research showing that for patients taking St John’s wort, the effectiveness of the antiviral drug Indinavir was ‘dulled’.

There have also been some reports from America that St John’s wort can cause nerve damage or cataracts when combined with bright sunlight. This is believable because herbalists have always known that when St John’s wort is used externally, you have to keep out of the sun. Combined with oil, it is used on the skin for paralysis or to treat pain from nerves or shingles.

Researchers have found that hypericin, the active ingredient in St John’s wort, does react with sunlight. This is particularly significant for people who suffer from the ‘winter blues’ or seasonal affective disorder, who might be tempted to combine a course of St John’s wort with light-box therapy – sitting for long periods bathed in bright light.

Herbal remedies for depression

A better alternative to St Johns Wort as an herbal remedy for depression would be high grade EPA fish oil.

EPA fish oil has been scientifically proven to be very effective for depression, bipolar – manic depression and related disorders, and unlike St Johns Wort the side effects are all positive, thick long healthy hair growth, good nails and fantastic skin. High grade omega 3 EPA fish oil taken in the correct dose and strength give count less benefits.

If you are going to use High Grade Omega 3 fish oil EPA as a natural remedy for depression it is imperative that you take the strongest concentrate of EPA fish oil (90%) and in the correct dose daily to give your self the best chance for the EPA to work and give the maximum therapeutic effect.

It has recently been reported that the Epa works best without the DHA , this notion came about from studies that have been performed on people suffering from depression, researchers found that the higher the EPA to DHA ratio the better the results have been.

Welcome to the 21st-century lab, where hormones, brain pacemakers and magnetic coils can be a depression treatment

We’ve come a long way. Some psychiatrists used to think you could cure depression by removing a patient’s colon or teeth. In the late 1800s, there was a doctor who observed his anxious patient become calm on a bumpy train; thereafter treatment consisted of shaking the poor man for greater and greater lengths of time.

In an attempt to cure the ancient malady of melancholia, we have resorted to scads of strategies, some of them plainly stupid or cruel, others, like Prozac, that work. But an estimated 30 percent of depressed patients are what’s called treatment resistant; they don’t respond to pills or talkor even shock. The good news is that there are new treatments making their way into the 21st-century world—treatments that offer hope for the newly diagnosed or for someone who has been suffering without, so far, a cure in sight.

Miracle Meds – depression treatment

It used to be that psychiatrists would try a patient on one antidepressant medication, wait eight weeks and, if it didn’t work, switch to another one. While this is still a viable (if frustratingly slow) tactic, psychiatrists are relying more and more on secondary, and even tertiary, drugs to boost the primary player. One of those booster drugs is Cytomel, a thyroid stimulator. Even women with normal thyroid levels can, under a psychiatrist’s supervision, take Cytomel in addition to an antidepressant. About 50 percent of the time, it helps the primary drug work more effectively. Other popular booster medications are lithium and Ritalin.

Hormone Therapy – depression treatment

Scientists have spent years and years investigating chemicals like serotonin and their effects on mood, while neglecting to study brain chemicals still more common, and abundant, like estrogen and progesterone. Andrew Herzog, M.D., a neuroendocrinologist at the Beth Israel Deaconess Medical Center in Boston, treats many women who don’t respond to Prozac and its chemical cousins with sex steroids. “The future of psychiatry lies largely in the realm of using hormones to regulate brain states,” Herzog says.

He believes many women become depressed either because they have a measurable imbalance of estrogen and progesterone or because their brains are too sensitively tuned to normal fluctuations. “Hormones are psychoactive,” Herzog says, “and there’s no doubt that they can have huge effects on our feelings.” Progesterone, claims Herzog, is seven times stronger than your average barbiturate, and it exerts a strong calming, even sleepy, effect. Estrogen, the opposite, provides pep just as well, if not better, than that Prozac pill you’re taking. For women with agitated depressions that make them nervous and jumpy, Herzog might prescribe progesterone to calm with a bit of estrogen to brighten, in the form of a cream the woman rubs into her skin. For lethargic depressions, Herzog emphasizes the estrogen instead, and he’s had remarkable success treating women who were deemed “untreatable.” “These hormones gave me my life back,” says one of his patients, who became depressed in her 40s and was incapacitated by her 50s.

Hormone treatment for depression requires that you see a knowledgeable neuroendocrinologist and that you undergo a hormone profile, having your levels of progesterone and estrogen measured at the beginning and end of the month. The procedure is new but so far highly promising.

“Get Happy” Pacemakers- depression treatment

The vagal nerve connects your brain stem with your upper body, specifically your lungs, heart and stomach. The nerve is a critical conduit for relaying information to and from your central nervous system, carrying electrochemical signals up its tubing and depositing them directly into your cortex.

Some years ago researchers began implanting a small pacemaker into the vagal nerves of epileptics to see if tiny pulses might help stop the seizures. The pacemakers did indeed reduce or eliminate seizures in some epileptics, but they did something else, as well, something surprising and critical. Epileptics with vagal-nerve pacemakers got happy. Their moods improved. That’s when researchers decided to try using them in people with treatment-resistant depression.

No one quite knows how or why they work. Some doctors hypothesize that vagal-nerve stimulation (VNS) instigates changes in norepinephrine and serotonin, two neurotransmitters closely associated with mood. John Rush, M.D., at the University of Texas Southwestern Medical Center at Dallas, and colleagues did a study of 30 people with treatment-resistant depression. They implanted the pacemakers into those people and, over a two-week period, gradually increased the amount of stimulation current to levels the patients could tolerate comfortably.

Forty percent of these patients showed a substantial decrease in depression as measured by a verbal test asking them about their thoughts and feelings; 17 percent had a complete remission.

After one year of VNS, more than 90 percent of the patients who benefited from the initial treatment continued to show a decrease in depression.

Magnetic Healing

Transcranial magnetic stimulation (TMS) may someday replace electroconvulsive therapy (ECT) altogether. In TMS, an electrical current passes through a handheld wire coil that a doctor then moves over your scalp. The electrical current makes a powerful magnetic pulse, which passes straight through your scalp and stimulates nerve cells in the brain.

TMS is in part remarkable because of its specificity. Researchers now believe they can target brain structures that they know are involved in the creation and maintenance of depression and anxiety.

Many studies indicate that magnetic brain stimulation once daily for two or more weeks may relieve depression (a typical patient’s symptoms are reduced by almost 30 percent). Although TMS is still considered an experimental form of treatment, various hospitals and clinics offer it. Within five to ten years, TMS may become a common form of treatment for people with depression.

And this is just the beginning. Twenty years ago we had only the crudest psychiatric drugs; in the space of two short decades, we’ve developed an arsenal, and more important than that, we’ve shown we’re capable of ever more complex and innovative treatment strategies. The next few decades will bring as-yet-unheard-of kinds of cures, for us, for our children and so on down the line.

What is depression?

Most people, children as well as adults, feel low or `blue’ occasionally. Feeling sad is a normal reaction to experiences that are stressful or

upsetting.

When these feelings go on and on, or dominate and interfere with your whole life, it can become an illness. This illness is called `depression’. Depression probably affects one in every 200 children under 12 years old and two to three in every 100 teenagers.

What are the signs of depression in children

• Being moody and irritable – easily upset, `ratty’ or tearful

• Becoming withdrawn – avoiding friends, family and regular activities

• Feeling guilty or bad, being self-critical and self-blaming – hating yourself

• Feeling unhappy, miserable and lonely a lot of the time

• Feeling hopeless and wanting to die

• Finding it difficult to concentrate

• Not looking after your personal appearance

• Changes in sleep pattern: sleeping too little or too much

• Tiredness and lack of energy

• Changes in appetite

• Frequent minor health problems, such as headaches or stomach-aches

• Some people believe they are ugly, guilty and have done terrible things.

If you have all or most of these signs and have had them over a long period of time, it may mean

that you are depressed. You may find it very

difficult to talk about how you are feeling.

What causes depression in children

Depression in children is usually caused by a mixture of things, rather than any one thing alone.

Events or personal experiences

can be a trigger. These include family breakdown, the death or loss of a loved one, neglect, abuse, bullying and physical illness. Depression can also be triggered if too many changes happen in your life too quickly.

Risk factors

People are more at risk of becoming depressed if they are under a lot of stress, have no one to share their worries with, and lack practical support.

Biological factors

Depression may run in families due to genetic factors. It is also more common in girls and women compared to boys.

Depression seems to be linked with chemical changes in the part of brain that controls mood. These changes prevent normal functioning of the brain and cause many of the symptoms of

depression.

Where can I get help?

There are a lot of things that can be done to help people who suffer from depression.

Helping yourself

Simply talking to someone you trust, and who you feel understands, can lighten the burden. It can also make it easier to work out practical solutions to problems. For example, if you are stressed out by exams, you should talk to your teacher or school counsellor.

If you are worried about being pregnant, you should go and see your general practitioner or family planning clinic. Here are some things to remember:

• talk to someone who can help

• keep as active and occupied as possible, but don’t overstress yourself

• you are not alone – depression is a common problem and can be overcome.

How parents and teachers can help

It can be very hard for young people to put their feelings into words. You can help by asking sympathetically how they are feeling, and listening to them.

When specialist help is needed

If the depression is dragging on and causing serious difficulties, it’s important to seek treatment. Your general practitioner will be able to advise you about what help is available and to arrange a referral to the local child and adolescent mental health service.

Many young people will get better on their own with support and understanding. For those whose symptoms are severe and persistent, the most effective forms of treatment include cognitive behavioural therapy (CBT) and sometimes antidepressant medication. CBT is a type of talking treatment that helps someone understand their thoughts, feelings and behaviour (see Royal College of Psychiatrists Factsheet on CBT).

Antidepressant medication may help and usually has to be taken for several months. They are not addictive, but there may be some withdrawal symptoms for a short time when you stop taking them. All medicines have side-effects, but if you are concerned about these, you should talk to your general practitioner or psychiatrist (see Royal College of Psychiatrists’ Factsheet on antidepressants; www.rcpsych.ac.uk).

References

• Carr, A. (ed.) (2000) ‘What Works with Children and Adolescents?’ – A Critical Review of Psychological Interventions with Children, Adolescents and their Families. London: Brunner-Routledge.

• Rutter, M. & Taylor, E. (eds) (2002) ‘Child and Adolescent Psychiatry’ (4th edn). London: Blackwell.

• Scott, A., Shaw, M. & Joughin, C. (eds) (2001) ‘Finding the Evidence’ – A Gateway to the Literature in Child and Adolescent Mental Health (2nd edn). London: Gaskell

No one should be ashamed of being depressed. But we are. As Kathy Cronkite (1994) points out, people who openly discuss going to Betty Ford’s Clinic for alcohol abuse will carefully conceal their depression. About 1 in every 10 of us will be seriously depressed sometime in our lives. Baby boomers are having even more episodes of depression, perhaps because the high hopes of the 1960′s were crushed by the economic troubles of the 1970′s and beyond. Remember, there is serious depression which is beyond ordinary sadness; in this condition you may have no appetite, no pleasure, no energy, no hope. And, there is being “down” or in a bad mood for a few days; it may involve crying, social withdrawal, being irritable, having no ambition, being pessimistic, etc. These two conditions are probably two different things. Both should be treated but the really severe major depression must be taken very seriously; 15% kill themselves, many more attempt it. Depression is not your fault; you are not a terrible or hopeless person. Unfortunately, 70% of people suffering depression never seek treatment. Please be among the 30% who go for help and stay with it. Depression is one of the most treatable emotional problems–psychotherapy can help you, drugs can, and you can.

Note If your depression is serious (disabling or suicidal), seek professional help immediately. If you are in therapy or a group, be sure to tell the therapist how much you are hurting. If not in therapy, call a therapist or your mental health center. Do not delay by trying to treat yourself or by hoping you’ll get better. Serious depression and manic-depression seem to have genetic, hormonal, and/or chemical aspects that are activated by stress and upsetting life events and thoughts. Thus, when the depression is serious, you always need to be evaluated by an MD, who will decide if you need medication.

If your depression is primarily chemical, psychological coping techniques are useful but not sufficient. Likewise, if your depression has psychological causes, drugs may be useful but not sufficient. There is usually no way to tell if your depression is chemical or psychological, so consider both.

If you’ve read parts of the chapter relevant to you, you probably already have some ideas about how and why you have responded with sadness. Therefore, certain self-help methods in this section will seem more appropriate for you to use. Fine, try two or three and see if they work. If not, try something else. In general, gaining some optimism about getting better, having an easy going disposition, and utilizing family support, along with selected self-help methods, will lead to a better recovery from depression.

The methods for coping with depression are arranged by levels in this section. Quickly read or skim the entire list of methods before you select a few to use. This is a preview:

1. Behavior–increase pleasant activities, avoid upsetting situations, get more rest and exercise, use thought stopping and reduce your worries, atone for wrong-doings, seek support, and use other behavioral changes,
2. Emotions–desensitize your sadness to specific situations and memories, vent your anger and sadness, try elation or relaxation training, etc.,
3. Skills–learn social skills, decision-making, and self-control to reduce helplessness,
4. Cognition–acquire more optimistic perceptions and attributions, challenge your depressing irrational ideas, seek a positive self-concept, become more accepting and tolerant, select good values and live them, and
5. Unconscious factors–read about depression, learn to recognize repressed feelings and urges that may cause guilt, explore your sources of shame (perhaps even going back to childhood).

The Use of Anti-depressants

Anti-depressants have been a major part of the pharmacological era in psychiatry. In the last twenty years, psychiatric practice has changed in major ways, namely, the shift from talking to giving pills. Many factors have contributed to this treatment revolution: (1) the development of safer drugs with fewer side effects, especially the SSRI anti-depressants. These medications may not reduce depression better than older drugs but they are less likely to kill you when an over-dose is taken. (2) The pharmaceutical companies have advertised intensely, turning consumers into drug advocates and permitting drug sales representatives to target primary care physicians rather than the much more rare psychiatrists. Moreover, (3) HMOs have realized their profit-margins can be greatly increased when the drugs are dispensed by a family physician requiring only brief and occasional follow-up visits rather than by expensive psychiatrists. The distribution of drugs got much easier: just tell your regular doctor that you have been feeling down or tired and have had some crying spells, and you immediately get a prescription for anti-depressants paid for without question by your health insurance. Millions have started taking anti-depressants and while they may have shifted from one brand to another, many have been satisfied. Nevertheless, it is generally recognized that anti-depressants take about 30 days to work and about 30% of depressed patients get little benefit from anti-depressants.

During the last two decades, the stigma against taking psychiatric drugs seems to have been considerably overcome but the stigma against “seeing a shrink” (psychological or psychiatrist) is still strong. Moreover, while Cognitive-Behavioral therapy has developed during this period, it hasn’t had a breakthrough in terms of highly publicized effective techniques or in terms of cheap or easy treatment. In other words, anti-depressant drugs haven’t had a lot of competition. Also, most people do not realize how little training and experience primary care doctors, in general, have in dealing with serious psychological disorders, including depression. Yet, as you know, if you have read the rest of this chapter, depression is a very complex and potentially dangerous disorder. It isn’t something to be diagnosed in a few minutes. Since anti-depressants take 30 days before having full impact, a significantly depressed person needs frequent and careful monitoring immediately and during the first several weeks. The treating physician needs to get a detailed mental health history (mental problems or illness often accompany depression) and he or she should strongly encourage the patient to also get psychotherapy as well as drugs. Depression is not an easily treated disorder. The doctor/therapist should be expected to maintain long-term contacts with their depressed patients, at least every week for a few months and maybe much longer. Depression frequently comes back.

Ideally, a health care service for depression would have enough coordinated psychiatric and psychological specialists to carefully diagnose each case of depression, assessing the possible psychological, personal, circumstantial, interpersonal and physiological or genetic causes of the disorder. As a part of this evaluation there should be a careful assessment of the risk of self-injury (see earlier sections of this chapter). This initial evaluation is not a trivial frill; it is crucial. This process should usually involve psychological testing and a detailed history as well as medical tests. The general practitioner is not this kind of specialist. (Light cases of depression could, I suppose, be handled more casually—but how can anyone identify a light case just by talking to a person for a few minutes?)

Another serious problem is that the general public has NOT understood or paid close attention to the research about the frequency of suicide and the obvious connection between depression and suicide. For instance, we often don’t like to think about suicide as being an integral part of depression. Suicide is the eighth leading cause of death in the US. It is the third leading cause in 15 to 24-year-olds and the fourth most common cause of death between ages 10 and 14. This is serious—60% of high school students have had thoughts about killing themselves, 9% have tried. At every age, especially in old age, depression must not be dismissed and taken lightly. The “just take these pills and call me in three months” is not acceptable treatment.

Not only has the risk of suicide underlying depression been taken too lightly, the generally positive public opinion about the effectiveness and safety of anti-depressants seems to have a major disconnect with the scientific evidence. There have been many, many studies. Of course, some of the studies have shown anti-depressants to be effective, sometimes. These drugs, however, are big sellers–among the best-selling medicines in the world, with such names as Prozac, Serzone, Wellbutrin, Zoloft, Remeron, Celexa, Effexor, Lovox, Paxil, and others—all similar in chemical composition. The total sales world-wide are about 20 billion dollars per year. In 2002 alone about 11 million prescriptions were written just for children and teens in the US. Let’s think about why is it difficult to honestly know the effectiveness of anti-depressants (or any other treatment).

People come to see doctors and therapists because they are feeling badly, often their discomfort has gotten gradually worse, and they are seeking help at the height of their depression. If so, the chances are (for a variety of reasons) that the problem will later get better rather than staying awful or getting worse. This amelioration process is observed so often when scientists re-assess unusually high or extreme conditions; this going back towards normal (for you) is called “regression to the mean.” So, you see a doctor with a bad cold, an aching back, a tension headache, etc., and soon in the natural course of things you begin to feel better (closer to average for you).

There is another process that also makes it hard to evaluate the effectiveness of a treatment method—the suggestion or placebo effect. It is well known that a sugar pill can help many people feel better (if the doctor suggests it is very effective medicine and will take care of the problem in a couple of days or weeks). If such a suggestion is made or just implied when actual medication is given, then the placebo effect and the drug effects combine together and both may be working. To prove the effectiveness of a drug (or any treatment) the amount of improvement shown to be due to the drug alone has to be significantly greater than the placebo effect by itself. Note: according to testimony given in the fall of 2004 to the Congressional Energy and Commerce Committee, about half of all studies of anti-depressants have not shown in adults that the SSRI drugs are significantly more effective than a placebo alone. Even worse, insignificant results were found in two thirds of the studies in which children were given anti-depressants and compared to children given a placebo. This is not well understood by the general public. Please note that these research findings certainly do not prove that anti-depressants are entirely ineffective (in fact, half the studies may suggest anti-depressants yield some benefits), but these results cast considerable doubt on the effectiveness of the drugs. Psychiatrists know the effectiveness of anti-depressants is limited; they commonly point out that anti-depressants do not help about 1/3 of their depressed patients.

In addition to these difficulties interpreting the results of research, more recently there is a new and very disturbing possible problem with using anti-depressants, especially with children and teens. Over several years, there have been occasional clinical reports of suicide and violence associated with taking anti-depressants. For instance, it was reported that Eric Harris, one of the suicidal shooters in Columbine High School, had been taking an anti-depressant (Luvox). Parents have described the sudden, out-of control suicide of a college student after taking a regular dose of anti-depressants (http://www.nypost.com/news/nationalnews/30505.htm). Britain prohibited prescribing anti-depressants to children and teenagers in late 2003 (a year before the US considered such action). Even more alarming, Shankar Vedantam of the Washington Post reported on September 10, 2004, that testimony was given at a congressional meeting that two internal FDA analyses showed that anti-depressants, given to children and teens, were associated with increased suicidal thoughts, actual self-harm, and hostile behavior. How much of an increase? FDA recently estimated that these drugs might double the risk of suicide in children. This sounds very risky but if the risk of suicide without drugs is 1% and with drugs 2%, there the anti-depressant doubles the risk. But if the 1% higher risk of suicide is associated with taking an anti-depressant that reduces depression in 60% of patients (compared to 35% who improve taking only a placebo), then you would probably take the drug if you are miserable. Bigger and better controlled recent research has yielded results about like that example (The Journal of the American Medical Association study of Prozac also confirmed an increased tendency towards suicidal thoughts and action). So, taking a drug that slightly increases the very low suicide rate, which sounds terrible, could be a very reasonable thing to do. We need a lot more information.

The suicide prediction problem is an increasingly important part of the decision to use anti-depressants or not. Also, the patient and his/her parents, if a child or teen, should be involved in the tough decision-making about the use of drugs, the kind of psychotherapy needed, the precautions to take, how to measure progress, etc. It isn’t just a question of what approach offers the most hope for improvement but also what methods have helped and not helped in the past, how desperate the situation is, the patient’s level of motivation, etc. If I am feeling terribly miserable, I’d be willing to take more chances with a risky drug…just the same as when risky surgery is an option.

Please remember I am not a physician. I have no expertise concerning drugs. My review is just a summary of the relevant available about anti-depressant research which suddenly seems very important. The data and my comments should in no way be interpreted as opposing the use of anti-depressants. There surely are circumstances in which it is a very good judgment to give anti-depressants to children and teens. This new information about anti-depressants with children just makes it critical that case studies and treatment plans are done at the highest level of professional competence.

I strongly recommend each depressed patient (and his/her parents, if the patient is a minor), with the help of his/her physician (the prescription writer), explore the pros and cons of taking anti-depressants. It is not a simple decision. If the prescribing physician is not a psychiatrist or a psychotherapist, then a therapist (Psychologist or Social Worker) should permanently join the team. At this time (fall of 2004), only about 15% to 20% of children and teens being treated for depression are prescribed anti-depressants. If research continues to find suicide risks are associated with anti-depressants, surely a number of changes are likely to be made in the treatment of depression. Probably many family doctors will avoid prescribing drugs having a strong warning label. Certainly, since therapists know more about the potential for suicide, they will increase the safe-guards used against the risk of suicide.

We will need to know the rate of suicide in certain types of patients in specific circumstances depending on whether they are taking anti-depressants or not. Science needs to map the high risk points for depressed patients on and off medication. Certain dangerous times have been known for many years, like when released from a hospital, but we need to know more. For instance, Wessely, Kerwin & Kaye (2004) found that the most dangerous times for adults and children taking anti-depressants were in the first nine days of treatment (a four-fold increase in non-fatal suicide behavior). The risk is also three-fold higher during days 10 to 29. What if they were not taking anti-depressants? We don’t know. Other high risk times for children and adults are when anti-depressants are started at a high level or when suddenly stopped. Start anti-depressants at a low dose and gradually increase. Reduce doses gradually. It is important that the doctor, the patient, and others around him/her know the high risk times so everyone can be especially vigilant, looking for extreme restlessness or agitation (can’t sleep), violent outbursts, psychotic behavior, talk about suicide and so on. Close supervision is really important–usually there are warning signs that people dismiss. If you think you see a warning sign, consult with others, including school counselor, close friends, and others who might know more. The patient and family members or others who are with the depressed patient should have the therapist’s cell phone #.

A recent study at the University of Colorado by Valuck, Libby, Giese & Sills (2004) illustrates the crucial need for more research into the risks of self-harm for adolescents taking antidepressants. These researchers followed 24,000 depressed adolescents for six years. The risk of a suicide attempt, in their sample, was not greater for young people given antidepressants than for those not getting antidepressants. Of possible additional significance, the adolescents given antidepressants for at least 180 days made fewer suicide attempts than adolescents taking the drug for less than 55 days. Standing alone, these results are difficult to integrate with the above studies: Do different outcome measures (suicide attempts, near-lethal acts, and suicide rates) yield different results? What factors correlate with being prescribed antidepressants? Why did some subjects take medication much longer than others? The authors suggest that the quality of health insurance may influence what medication one gets, who administers the antidepressant, who gets antidepressants alone, who gets only psychotherapy, and who gets both? Many, many studies are needed to answer these vital questions.

In summary, moderate or serious depression carries with it a threat of self-injury. This risk requires special precautions. Taking anti-depressants must be considered carefully because the drugs may slightly increase the risk of agitation and suicide in some young people while the drug may effectively relieve depression in other people. The prescribing doctor, the collaborating psychotherapist, the patient, and the parents of a child or teen should be involved in making the treatment plans. The prescriber and/or the psychotherapist must see the patient frequently, probably weekly or more for an hour, especially during high risk or high stress or high agitation times. The FDA’s concern is now high enough that all anti-depressants must display a warning label about the increase risk of suicide if used with children or teens. For unexplained reasons, the news reports describe the manufacturers as being more eager to have a blunt, rather scary label placed on their medications than was the FDA.

COPING WITH DEPRESSION

A review by levels of the useful Psychological Methods

Self-observation

Although depression frequently seems (to the depressed person) to come from nowhere, i.e. isn’t related to daily events, that isn’t true in most cases. The Lewinsohn research has clearly shown that positive events or activities lead to positive moods; negative events to depression (Grosscup & Lewinsohn, 1980). The depressed person must become aware that this is true in his/her life too. So rate your mood on a 1 to 10 scale (see chapter 2) and keep a log or a diary every day of positive events and activities. It is likely that your mood will reflect what is happening in your life.

As we have seen, depressed people tend to focus on negative events and overlook positive ones. They don’t know they are doing this. So, it is important that they “give careful recording a try and see what happens.” Look for and record all pleasant events and activities, even small, trivial, seemingly unimportant pleasant events. It is vital that you learn, again, to see the beauty, feel the warmth, and smell the roses. Don’t forget ordinary things: a cup of coffee, a walk, seeing a bird, reading a book, helping someone, watching kids go to school, watching the news, reading an advice column, going shopping, listening to music, making yourself attractive, visiting a neighbor, completing a chore, calling a friend, daydreaming, playing with children, expressing an opinion, getting a long kiss, getting or giving a compliment, etc., etc. Record in your diary (3 or 4 times each day, otherwise you’ll forget them) a brief description of these pleasant events.

After about a week, plot your daily mood rating and number of pleasant events for that same day on the same graph (see chapter 2). See if your mood doesn’t go up and down according to how many pleasant events occurred that day. If so, this is a powerful argument to increase the number of pleasant events in your life and to appreciate the nice things that happen.

This is a simplified version of a “behavioral analysis” (method #9 in chapter 11) in which one would look for the antecedents and consequences of good and bad moods. The objective is to find cause and effect relationships that can be used to increase happiness and reduce sadness. I would recommend a behavioral analysis because it explores the causes of the depression as well as the sources of satisfaction.

Look to the future

Like procrastinators, when we become depressed we tend to focus on the past or to see primarily the immediate consequences, not the long-term results of what we are doing now. We hurt, so we focus on immediate relief, disregarding activities that might be stressful but very important to our future, like getting training for a new career. To increase your awareness of the effects of your activities, do one “outcome analysis ” each day of some activity, i.e. estimate the short and long-term, both positive and negative, outcomes. Examples:

The objectives are (a) to encourage realistic, long-range planning, (b) to see the lasting consequences–or the wastefulness–of certain daily activities, and (c) to make some important but uncomfortable activities more tolerable today because they pay off tomorrow. This is important for all of us to do, but it is even more important and difficult for a pessimistic person with low self-esteem to do.

One small step at a time

Earlier we learned that global thinking (or end goal wishing), e.g. “I need to get better grades,” overlooks the necessary details of how to get there. Also, unrealistic, perfectionistic expectations, e.g. “I’ll get all A’s,” may lead to disappointment and self-criticism. Thus, it is important to learn to have a plan, to set realistic goals and sub-goals, and to have some success experiences. It is important to be satisfied with small gains. So, decide on some practical, possible, important self-help project–dieting, increased socializing, more detailed and prompt record keeping at work, learning to play tennis, spending more time alone with spouse, or whatever. Then, for each project goal, set several clear, explicit, attainable sub-goals (small steps), perhaps things you could do every day or every few hours (see goal setting in chapter 2). Schedule the time, give it priority, and be sure you are successful. Record your progress in a diary, along with the positive outcomes.

Self-evaluation

When discouraged, we feel at fault when things go wrong and “just lucky” when things go well. Rehm has an exercise to help you realize your contribution to success and reduce your responsibility for failure:

• Think of an important recent event and describe it.
• In what ways were other people, chance, luck (good or bad), or fate responsible for this event?
• In what ways were you (your efforts, skills, abilities, experience, appearance, etc. or lack thereof) responsible for this event?
• What percentage of the responsibility for this event was attributable to you? _____%

Do this for several events, including both positive and negative ones. You have almost always worked for positive events and against depressing events. So, if you do not think you are truly responsible for more than 50% of the pleasant events, reconsider your explanation of those events and see if you aren’t causing more positive things than you thought. Factually based confidence in your self-control is a powerful antidote to pessimism and helplessness (remember depressed people underestimate their problem-solving ability).

Usually others or circumstances or just bad luck cause unpleasant events (the exception to this general rule is when our passive-dependency is the cause). So, if you see yourself as responsible for negative events–over 50% of the time–go back and see if others and chance aren’t more responsible. If your passivity is the problem, see chapter 8. Ideally, you will come to believe (accurately) that your general, stable abilities and traits, e.g. intelligence, personality, organizational, and communication skills, etc., cause good things to happen and uncontrollable, temporary external factors that you are not responsible for produce the downers. (You are correct if you are thinking this fits better in level IV. See #29 below.)

Self-reinforcement

Self-depreciating people feel that giving themselves overt self-rewards–going out for dinner–is being selfish, and they think giving themselves covert self-rewards–”I really handled that well”–is shameful bragging. These attitudes become barriers to using some of the most powerful self-control tools, such as self-reinforcement and self-praise (see method #16 in chapter 11). Rehm recommended making a list of assets–true positive traits. Read it frequently and add accomplishments to it. Make another list of possible rewards, as in method #16 in chapter 11, and use them in self-help projects. Depressed people need more good things in their lives.

Get active. Actually, research has shown that we do fewer fun things when we feel low, but simply doing more pleasant activities is no guaranteed cure-all (Biglan & Dow, 1981). Yet, actions do change feelings. Increase your activity level, get out of bed (or your chair or house), find interesting, fun things to do but, more importantly, undertake profitable, beneficial activities that solve problems, improve your situation or future, and replace sad thoughts. Start with easier tasks, work up to harder ones. Reward your progress.

Several therapists recommend that every major activity on your daily schedule be rated for “mastery” (how well you did it) and for “pleasure.” From these rating we can learn a lot, e.g. that we are getting more pleasure than we thought out of life, that we can do many things pretty well, that many activities are satisfying even though we aren’t very good at them, and so on. You may have to push yourself to be active. A book by McGrath (1994), stressing converting depression’s dissatisfactions into motivation to self-improve, could also prod you into constructive action. Examples: feeling like a victim may lead to correcting the situation, anguish about aging may encourage exercising, a poor evaluation may inspire us to learn more, etc. Deep depression makes it very hard to get active (in those cases medication may be needed).

Exercise promises long-lasting results. In just the last couple of years, there have been a couple of interesting studies showing that an aerobic exercise program–stationary cycling or treadmill–for 30 minutes 3 times a week reduced major depression as much or more than medication (Zoloft). After 16 weeks, the remission rate was 60% for both groups, but at follow up after another 6 months the exercise group had a higher recovery rate (than the drug group) and they were less likely to relapse (8% vs. 38% in the Zoloft group). The subjects in this study were middle-aged or older (Babyak, et al, 2000). Be sure to check with your doctor first, but exercise would be good for you in many ways, not just with depression. Seriously consider this. Even more recently, other studies report that daily exercise reduces depression by 1/3 or 1/2 within 10 days, that is faster than most people respond to anti-depressive medications.

The data keeps coming in. Please pay attention to this. Another well done study (Trivedi, M. , January, 2005, American Journal of Preventive Medicine) shows that exercise alone three or five times a week for 30 minutes reduces depression by about 50%. That is as good as taking antidepressants or as good as getting Cognitive-Behavioral psychotherapy. The study observed mild to moderately depressed 20 to 45-year-olds.

Avoid unpleasant, depressing situations. Take a vacation, get complete rest and lots of sleep (just for a week or two–not for months). Our interpersonal situation powerfully influences our happiness and depression. Barnett and Gotlib (1988) found that introversion, loneliness, dependency, and marital problems often precede the onset of depression. Avoid losses and these conditions if you can (of course, it can be a joy to lose a lousy marriage).

Change your environment. Try to change your depressing environments –working conditions, family interactions, stressful relationships and so on. Our mood reflects our surroundings.

Reduce negative thoughts. Reduce the negative thoughts that characterize depressed people: self-criticism (“I’m really messing up”), pessimistic expectations (“It won’t get any better”), low self-esteem (“I’m a failure”), and hopelessness (“There’s nothing I can do”). How do you stop or limit these depressing thoughts, memories, or fantasies? Try using thought-stopping, paradoxical intention (massed practice) or punishment (chapter 4). Or restrict unwanted sad thoughts to specific times or places, e.g. a “depression” chair; then reduce the time spent in the chair (see McLean, 1976). Or reward stopping negative thoughts; replace them with pleasant fantasies (Tharp, Watson & Kaya, 1974).

Have more positive thoughts. Make an effort to have a lot more positive thoughts: satisfaction with life (“Living is a wonderful experience”), self praise (“I am thoughtful–my friends like that”), optimism (“Things will get better”), self-confidence (“I can handle this situation”), and respect from others (“They think I should be the boss”). Even if you don’t feel like saying these things every hour, say them anyway. They will become part of your thinking.
Ask others to model for you how they control depressing thoughts and guilt producing ideas. What self-instructions do they use to “get out of a bad mood?” Practice talking to yourself out loud, then silently. See method #2 in chapters 4 and 11.

Become aware of any payoffs for depression or self-putdowns. Reduce these reinforcements: don’t complain or display sadness, ask others to ignore your sadness (but interact with you more during good times). Remember excessive talking about your depression may sometimes make you more depressed (don’t use this as an excuse for not seeking help).

Act happier. Practice smiling more, speaking in a less whiny voice, standing up straight with chest out, dressing up more and expressing compliments, feeling self-satisfaction, and acting as though the future will be better. Acting happier can change our mood.

Become a better self-helper. Become a better self-helper as you work on a variety of personal problems (Rehm, 1981). Learning to master a life–your life–is not easy. Read self-help books. Use the steps in my chapter 2 to make some self-improvements. Prove to yourself that you can change your environment, your behavior, your mood, and so on. Recognize your increased ability…but know your limitations. Both knowledge of useful psychology and self-confidence are important. Feeling in control of life is an important part of enjoying life.

Atonement. Figure out a way to make up to others or to society for the things you have done wrong (see discussion of guilt above).

Develop marital contracts. Develop marital contracts that provide each partner with a reward for changing in ways requested by the mate. See method #16 in chapter 11.

Seek support. Self-Help or Support Groups, Marriage Enrichment Programs, Parents Without Partners, Integrity Groups, Singles Groups, Emotions Anonymous, The Compassionate Friends (for bereaved parents), Neurotics Anonymous, Recovery, Inc., Theos Foundation (for widows), Widowed Persons, encounter groups, group therapy, church groups, or local groups of people in similar circumstances. Use the phone book and/or Mental Health Center to find the appropriate group for you (see discussion in chapter 5).

Clinical depression usually strikes people between the ages of 25 and 44, although it can affect any person at any age. For most people, episodes of major depression last from six to nine months. Sometimes, even if major depression goes untreated, it will run its course and leave by itself. Doctors are not sure why this happens, but it is often attributed to the body’s tendency to correct abnormal situations.

What Causes Clinical Depression

The dramatic success of antidepressant drug therapy for severe major depression has made many scientists question if depression has a strong biological, rather than psychological, basis. Thus many are questioning whether genetics or stress plays the major role in causing major depression. Recent research has shown that both play a major role in major depression.

Surprisingly, stress has been shown to play a major role in the patient’s first two episodes of major depression, but not in later episodes. Genetics and temperament appear to play the most important role for later episodes of a patient’s depression.
It appears that major depression often requires stress to “get the ball rolling”, but after a few episodes, the illness develops its own momentum and no longer needs stress to “keep rolling”. This is a familiar pattern seen in many medical illnesses. Thus, the treatment of major depression must address the major contribution that stress, genetics and temperament play in this disorder. Unfortunately, most current therapies lack this well-rounded approach.

Symptoms of Clinical Depression

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either: (1) depressed mood or (2) loss of interest or pleasure. (Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.)

• depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
• markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
• significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
• insomnia or hypersomnia nearly every day
• psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• fatigue or loss of energy nearly every day
• feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
• recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).

The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.