Depression's return journey

"Recovery from depression is a journey rather than a destination... Recovery does not mean the absence of feeling vulnerable

"Recovery from depression is a journey rather than a destination. . . Recovery does not mean the absence of feeling vulnerable. It means discovering a new strength in ourselves which accepts our vulnerabilities without being crushed by them. Someone who has truly recovered from depression is someone who carries with them a greater awareness of how weak they are, but also a realisation that their true self is not defined by their fragility."

- Extract from Depression: The Common Sense Approach by Tony Bates

Consumer surveys show that 20 to 30 per cent of the population suffer symptoms of depression in the course of a year. Most cases are a mild version of the "blues", but approximately one in 20 will have a moderate or severe episode of depression. Severe, recurrent depression affects men and women equally, while women are twice as likely as men to suffer from a mild version of the disease. Up to one-third of family doctor consultations relate to psychological issues.

When a person suffers an episode of moderate to severe depression, initial recovery will be driven primarily by anti-depressant medication. In the dark days of helplessness, lack of energy, sleeplessness and loss of appetite, it is the chemical refuelling of the brain that brings about change. Anti-depressants are usually required for a minimum of six months if a sudden relapse is to be avoided.

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However, as energy levels increase and thinking returns to a more objective state, then some kind of psychological therapy is usually recommended. There are various types available, but one of the best is a process called cognitive behavioural therapy (CBT).

CBT has evolved, as its name suggests, from two strands of psychology: cognitive therapy and behavioural therapy. Cognitive therapy is based on the principle that we are upset not by what happens but by the way we look at things. Behavioural therapy is based on the premise that our behaviour is "conditioned" by the response it generates in our immediate environment.

American psychologist Aaron Beck, one of the founders of cognitive therapy, noticed that the thoughts and images reported by depressed patients were characteristically self-blaming and defeatist. He reckoned that these negative patterns of thinking accounted for the behaviour of depressed patients in situations they found difficult. Beck found that people can learn to become aware of the negative thoughts which accompany their moods, and challenge them, rather than allow them to fester and make depression worse.

So the first step in CBT is to begin to fill in a mood log, under the guidance of a skilled therapist. Patients make a record of the situations in which they notice themselves feeling depressed. Next they identify the different feelings that contribute to their moods: these could cover a wide range, from anger to sadness or guilt.

The next step is to identify what are called Negative Automatic Thoughts (NATs). These are the thoughts that occur spontaneously in response to particular events. Typically, they are things depressed people might say to themselves, like: "Oh, God, this is terrible" or "I'm no good at dealing with this kind of situation". NATs may also take the form of fleeting images or memories which are triggered by certain situations and which are associated with specific kinds of feelings.

The key to helping people construct an alternative response to negative thoughts is to add a fourth column to the daily mood log, labelled "more helpful ways of thinking". The following questions help to put together a more positive response:

What would you say to a friend who was in the same predicament?

Can you see any way in which your thinking may be distorted?

What might be a fairer and more realistic way of thinking?

CBT may seem like hard work. Undoubtedly it is. A number of weeks of therapy and a commitment to "homework" in between visits are required before the effort bears fruit. Wouldn't it be easier to just "keep taking the tablets"?

The big plus of CBT is that it has been proven to be more effective at preventing further episodes of depression than just taking medication on its own.

Dr Tony Bates, senior clinical psychologist and course director of the MA course in CBT at St James's Hospital, Dublin, points to research showing that the relapse rate in depressed patients who take medication alone can be as high as 75 per cent. Those who are treated with a combination of CBT and anti-depressants have a relapse rate of only 30 per cent. "The relapse rate is high after people come off anti-depressant medication. Cognitive behavioural therapy gives people something to carry them through the inevitable challenge of the next bad patch," he says.

Patients are also taught to use their creative imaginations to "replay" events and to imagine themselves dealing well with stressful situations. A skilled therapist will also take the patient through a series of questions to elicit the assumptions underlying their negative automatic thoughts.

Eventually, the cognitive approach learnt in formal therapy sessions becomes an automatic part of patients' daily lives. And, if they do feel down for a number of days, then a return to the first principles of a mood log will usually prevent the negative thoughts coalescing and building into full-blown depression.

When someone has gone through an episode of depression, confidence levels are inevitably low. The behavioural aspects of CBT play an important part in restoring confidence. Techniques such as graded task assignments, in which simple tasks are gradually built up into more complex tasks by dividing them into achievable steps, are also helpful.

Self-reinforcement, in which patients remind or praise themselves for achievements, is important also. Some people find it helpful to think through how to respond to challenging situations before they happen - a process called cognitive rehearsal.

In fact, many of the principles of cognitive behavioural therapy can be applied equally to people with mild episodes of depression. Tony Bates calls this "the life skills therapy approach", which, he believes, allows people to face life problems and recover from them. In this way, CBT can offer a truly preventative approach to depressive illness.

Depression: The Common Sense Approach by Tony Bates is published by Newleaf, price £6.25.