1. Depression – some psychological thoughts… Martin Liebenberg Martin Liebenberg C.Psychol. Addenbrookes – 21 February 2013

2. The fog is like a cage without a key.’ ‘That’s the thing about depression: a human being can survive almost anything, as long as s/he sees the end in sight. But depression is so insidious and it compounds daily, that it’s impossible to ever see the end. The fog is like a cage without a key.’ Elizabeth Wurtzel, Prozac Nation

3. How can we tell? Motivation Motivation Apathy, loss of energy and interest: things seem pointless, hopeless Emotional EmotionalLow mood, emptiness, anger or resentment, anxiety, shame, guilt Cognitive Cognitive Poor concentration, negative ideas about the self, the world and the future. Behaviour Behaviour Lowered activity, social withdrawal, agitation or retardation. Biological Biological Sleep disturbance, loss of appetite, loss of weight, changes in circadian rhythms, hormones and brain chemicals.

4. Diagnosis of Depression Diagnosis requires presence of 5 of the following for at least 2 weeks: - Sad, depressed daily mood - Loss of interest in usual activities - Difficulties in sleeping - Poor appetite and weight loss - Loss of energy, great fatigue - Negative self-concept - Recurrent thoughts of suicide or death

5. Depression Issues Depression exists on a continuum Major depression is quite common - Lifetime prevalence rates range from 5.2% to 17.1% - Women are twice as likely to develop depression as are men - Higher rates in young adults and among individuals in lower socioeconomic groups. - Depression prevalence varies across cultures Prevalence of depression has been increasing over the last 50 years

6. Does depression have a purpose? The mystery of depression is not that it exists - the mind, like the flesh, is prone to malfunction. Instead, the paradox of depression has long been its prevalence. While most mental illnesses are extremely rare - schizophrenia, for example, is seen in less than 1% of the population - depression is everywhere, as inescapable as the common cold. Obsessed with our pain, we will retreat from everything. We will stop eating, unless we start eating too much. Sex will lose its appeal; sleep will become a frustrating pursuit. We will always be tired, even though we will do less and less. We will think a lot about death.

7. Darwin had some thoughts… If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction - it leads people to stop having sex and consider suicide - to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself. The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection - increased body temperature sends white blood cells into overdrive - depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer - we suffer terribly - but we don’t suffer in vain

8. Is it therefore possible? Depressed affect makes people think better – does rumination teach us something? “Do you not see how necessary a World of Pains and troubles is to school an intelligence and make it a soul?” – Keats Depression plays a protective role Sadness, like happiness, has many functions. Important note: Important note: To say that depression has a purpose or that sadness makes us smarter says nothing about its awfulness.

9. A comment on pharmacology? “I remember one patient who came in and said she needed to reduce her dosage,” he says. “I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great,’ she told me. ‘I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’ ” The point is the woman was depressed for a reason; her pain was about something. While the drugs made her feel better, no real progress was ever made. For some, medication is a life saver…

10. Is there a key?

11. Early relationships… Provide protection from external danger Provide needed resources – food, warmth Stimulate (positive) affect systems Emotional regulation Guide self-other evaluative systems Threats: Threats: low protection, low positive affect, neglect, trauma/abuse Depression highly linked to poor early attachments Reduced risk of depression in the context of high care even if there is a genetic vulnerability

12. Feeling safe in the minds of others… Creating positive feelings and thoughts in the minds of others, about oneself, makes the world safe safe and will not be rejected or attacked likely to be available in time of need co-create advantageous relationships (e.g., sexual, co-operative) physiologically regulating (e.g. oxytocin, cortisol) stimulates positive feelings for self and other lay down emotional memories of warmth Creating negative feelings (contempt, anger, ridicule) in the minds of others leading to attack, rejection or ‘un-included’ makes the world unsafe major threat --- generating defensive behaviours such as fight/flight/submit Paul Gilbert

13. Do I feel shame? (Gilbert & Allen) Social comparison Compared to others I generally feel: Inferior 1 2 3 4 5 6 7 8 9 10 Superior Submissive behaviour I agree that I am wrong even though I know I’m not I do what is expected of me even when I don’t want to External shame I think that other people look down on me Other people see me as small and insignificant

14. Self correction vs Self attacking (Paul Gilbert) Compassionate Self-Correction is focused on: The desire to improve Growth and enhancement Forward-looking Given with encouragement, support and kindness Building on positives (e.g. seeing what one did well and then considering learning points) Focuses on attributes and specific qualities of self Focus and hope for success Increases the chances of engagement Shame Based Self Attacking is focused on: The desire to condemn and punish Punishing, past errors Backward-looking Given with anger, frustration, contempt and disappointment Focuses on deficits and fear of exposure Focuses on a global sense of self Focuses on a high fear of failure Increases chances of avoidance and withdrawal

15. SHAME KEY Is SHAME a cage and compassion a KEY?

16. Some helpful dos… (not said much about treatment) Sunbathing in the Rain (Gwyneth Lewis) Remember that depression can’t harm you It’s not people who get depressed who go mad, it’s those who don’t Listen to what depression is telling you, and change your life accordingly Get what depression is stopping you doing…

17. However much you blame others, depression will you back to yourself Learn to distinguish between your rubbish and what is true Depression teaches you that the only permanent way out is by finding and accepting the truths you have been avoiding, even if you thought you’d already faced them.