It is important to distinguish between normal depression, usually designated as unipolar depression, and bipolar mood disorder, a completely different illness, but which features some of the same characteristics.

Simple Unipolar Depression

Periods of feeling down, sad or low are, like anxiety, innate to the human condition. All of us experience such periods following, for example, bereavement, the end of a relationship, the death of a beloved pet, major disappointment or loss, illness to ourselves or a loved one, or stressful periods in our lives. Such periods are usually of short duration and we quickly bounce back to our normal selves. But for hundreds of thousands of people in Ireland every year, this natural feeling of being low gives way to a much more serious mood state, namely major depressive disorder, which we will refer to as ‘MDD’ for the remainder of this discussion. MDD is the red flag.

Confusion surrounds the use of the word depression, regarded by therapists as a normal emotion, and the use of MDD, a biological illness with a classic combination of physical and psychological symptoms which, if undiagnosed and untreated, can lead to serious consequences. This difference is crucial because many people in the worlds of media and therapy blur this distinction. This has led to widespread uncertainty amongst those most affected. MDD can present at different stages and phases of our lives for completely different sets of reasons. Irrespective of the person’s stage in life, it can cause untold chaos and suffering in the lives of those involved. The following list of symptoms provides a glimpse of what it is like to live in the world of serious depression:

LOW MOOD: ‘I feel weighed down by hopelessness and sadness. It is a physical pain in my heart and no one understands how terrible it feels.’

John is a nineteen-year-old undergraduate student who has developed depression after moving away from his family for the first time to live in a flat in Dublin. He is successfully hiding it from his family and friends. Alcohol relieves the pain for short periods but its embrace is fleeting and illusory.

FATIGUE: ‘The simplest of tasks drains me of all my energy. I just want to sleep all the time.’

Mary is a twenty-seven-year-old mother with two small children who has developed symptoms of depression following a series of stressful events, in particular the loss of a close friend to cancer.

ANXIETY: ‘I am constantly on a high state of alert and always feel under pressure. I cannot cope when something goes wrong. I sometimes feel panicky for no obvious reason.’

Peter is twenty-two and has successfully hidden how he feels for the previous three years.

WEIGHT LOSS/GAIN: ‘I’m just not hungry any more. Food does not look appetising and it’s too much energy to eat. Hopefully I will waste away into nothing.’

Catherine is a single parent aged twenty-four. The stress of coping with a small child on social welfare, of living in a small, poorly equipped flat, with a partner who abuses alcohol, has triggered a bout of depression. She has lost more than a stone in weight. Her diet, which was already poor due to lack of money and lack of knowledge about nutrition, has now been reduced to coffee and cigarettes.

LOSS OF SELF-ESTEEM: ‘I am ashamed of the weak, useless, boring, incompetent failure that I am. People hate spending time with me.’

Carl is a twenty-four-year-old mechanic whose quiet disposition and painful shyness has disguised his inner torment from those close to him. Depression affected him first at the age of seventeen and has been an unwelcome but frequent visitor since.

LOSS OF DRIVE: ‘I don’t enjoy any of the activities that I used to. It all seems like so much effort now, and I don’t see the point.’
Maura is a twenty-four-year-old working mother who has developed depression three months after the birth of her first child.

POOR MEMORY: ‘I have become increasingly forgetful and have difficulty remembering the simplest of things, like what I did yesterday.’

Noreen is a single, busy twenty-seven-year-old manager who is struggling to cope with her day-to-day duties due to depression triggered by a prolonged period of sustained stress.

REDUCED CONCENTRATION: ‘I don’t read any more. It’s too much effort to make sense out of the words and it is becoming difficult to pay attention to anything.’

George is a seventeen-year-old Leaving Cert student who is struggling to study as he battles with a bout of unrecognised depression.

LACK OF PLEASURE (ANHEDONIA): ‘I can barely manage a smile any more. I’m sick of people telling me to cheer up or saying “It can’t be that bad”. It is – and much worse than they can imagine.’

Paula is twenty-eight and has had bouts of depression for the previous five years. She was sexually abused at the age of nine.

SUICIDAL THOUGHTS: ‘The world will be a much better place without me. I am a burden on everyone and they won’t miss me at all.’

Jack is twenty-nine and has already quietly planned in great detail how he will end the pain. If his depression is not recognised and remains untreated, he may soon put these thoughts into action. This is made more likely by his dramatic increase in alcohol consumption to numb the pain of a recent break-up with his girlfriend.

To diagnose MDD, one must have a significantly depressed mood for over two weeks, combined with at least four of the above symptoms, particularly difficulties with sleep, appetite and fatigue, feelings of worthlessness, and anhedonia.

For those who have doubts about the physical and other consequences of this illness, the following risks should clarify the issue:

The above explains why we call it major depression or the red flag. Before exploring the pathways and therapies involved, it is worth stating what MDD is not. It is not, as many people assume:

The Depression Pathways

Depression, or MDD, is a complex disorder that gives rise to a constellation of physical and psychological symptoms. It can occur at different stages of our lives for vastly different reasons and has puzzled researchers as to its underlying mechanisms. Once again, some may not be interested in the neurobiology which follows and wish to move on. For the rest, there are a number of important questions we must answer:

In Flagging the Problem, I detailed how difficulties in the mood system in the brain lead to all the symptoms of depression. The main neurobiological findings can be summarised as follows:

While this analysis is of assistance in understanding how this illness affects us, it does not answer the question of ‘why’. Up to a decade ago, it was felt that the underlying problem was a chemical one: we were lacking key neurotransmitters such as serotonin. Modern scientific research has, however, made this view outdated.

The modern twenty-first-century approach to MDD recognises that the condition has more to do with the following:

  1. A malfunction within the internal workings of the neurons (and glial support cells) themselves and their connections (synapses) with each other.
  2. As a result, there is a breakdown in some key brain systems and circuits.
  3. In turn, this leads to mood, behaviour and thought difficulties. The physical consequences at the heart of this illness have already been outlined.

At present, a revolution in our understanding of the nature of this illness is occurring. This revolution is crucial in assisting us to examine the causes of MDD, answer some of the questions asked above, assess available therapies and, most importantly, develop new ones. Let’s now examine two key components of this new understanding:

The role of the SECOND MESSENGER SYSTEM is an exciting development in our understanding of MDD. I will deal with it in detail in the technical section but I include here a broad outline of how it works.

Each neuron in the brain connects up with at least two thousand of its colleagues, busily sending neurotransmitters over and back across the small gaps, or synapses, between them. These little messengers lock in to receptors on the cell membrane. They have two main functions: to encourage the neuron to fire or not, and also to pass on information into the heart of the cell, where our genes reside. This second function is facilitated by the most extraordinary system within the body, the ‘second messenger system’ (the ‘first messenger’ being the little neurotransmitter itself). Figure 33 represents a cross section of the neuron. We can see the outer layer, where the neurotransmitter receptors are based; the middle layer, situated between the cell membrane and the third layer; and the third layer itself, the nucleus of the cell, where our chromosomes and genes/DNA reside.

The second messenger system transfers information between the cell membrane and our genes. It is composed of a series of chemical messengers which activate a choreographed sequence of reactions where each one ‘talks’ to the next. The second messenger system is extraordinarily complex. Within every neuron, this cascade of internal chemical messages activates our genes to produce vital neurotrophic (neuron-nourishing) proteins which have essential functions, central to our whole understanding of depression:

There are two major neurotrophic proteins produced as a result of the second messenger system. The first is BDNF, whose functions are very much connected with the first two functions. The second is called Bcl 2, whose functions also relate to the third. It is not important to know the actual mechanisms involved. (These will be explored in the technical section.) All that matters is that anything which interferes with our second messenger system will interfere with these vital nourishing proteins. Any decrease in functioning of the latter interferes with the structure, function and survival of the neuron.

The second messenger system is strongly influenced by:

There is a large amount of research going on into this complex system (both the second messenger system and neurotrophic proteins) and the genes underlying it. When we have built up a total genetic and functional picture, we may see how individual malfunctions within this system can be triggered and perpetuated by environmental influences.

The malfunctions within this internal cascade of second messengers can lead to either deterioration in the function of, or the death of, individual neurons. This offers profound implications for our understanding of depression, partly because this system is influenced by such a wide variety of factors (which fits with what we know about depression) and partly because it provides an explanation for the second main finding: the widespread disruption of the brain’s mood departments and circuits.

The role of the mood system in depression was described earlier; here, I would like to examine how malfunctions within the second messenger system affecting individual neurons can in turn lead to a breakdown within the brain circuits of which they are an integral part.

One of the most important findings in this area in the past ten years has been the discovery (through research into people suffering with recurrent bouts of significant depression) of a subtle loss of neurons, dendrite connections and even support glial cells scattered throughout key parts of the mood system. Of particular interest has been the finding of such brain-tissue loss in the logical brain (the logic, social behaviour and attention boxes: all key players in our ability to control negative emotions and thoughts). Researchers have discovered a similar loss of grey matter in parts of our emotional brain, particularly our memory and stress boxes. It now seems as if these losses of crucial neural connections, and indeed neurons themselves, most likely arise secondary to malfunctions occurring within the second messenger system, leading to a loss of the vital neurotrophic proteins already mentioned.

The result of all these changes is an inability of the logical brain to switch off the negative barrage coming from the emotional brain, particularly the stress box. This leads to the breakdown in the functioning of the two big mood circuits, the appearance of the dysfunctions in our mood system detailed earlier, and the arrival of the symptoms of major depression in our lives.

Let’s examine the effects of all these changes and how they in turn affect our brain and mind pathways in depression.

The stress box lies like a spider at the centre of the web of depression pathways. It become overactive, producing (with the assistance of the island) most of the negative emotions of depression which cause so much distress. In particular, it pours out the feelings of overwhelming sadness which flow down our sadness pathway (Figure 12). This path winds its way through Area 25 and communicates with the emotional and social behaviour boxes, the key control areas of our logical brain. The final result is the creation of an extreme low mood, the key symptom of depression.

Normally, Areas 32 and 24, together with the left logic box, are able to calm things down by focusing attention on the emotional state and helping to reappraise and modulate such feelings of low mood. In depression, for the reasons already outlined, this normal control is gone. We know, for example, that Area 24 may be reduced in size, may malfunction and may struggle to exert any control.

The logic box on the left side of the brain suffers from ‘power failure’ in depression. This is the most-reproduced finding in this illness. It is a key player in helping us focus on positive emotions and thoughts, and works with Areas 24 and 32. It is therefore no surprise that this logic-box power failure is felt by many to be partly responsible for our inability to ‘switch off’ the torrent of negative emotional sadness and low mood emanating from the stress box, and the very distressing cascades of automatic negative thoughts in MDD.

The social and emotional behavioural boxes normally try to exert a modulating effect on our negative emotions, but they too are malfunctioning in depression. In a desperate effort to calm things down, they become overactive, but they are unsuccessful.

This breakdown in normal control of the stress box by the various departments of our logical brain leads to most of the symptoms of depression. Feelings of anxiety, negative thinking or reinterpretation of social interactions, behavioural responses to the latter, poor self-esteem and suicidal thoughts are all created by it.

Another major symptom is the disappearance of joy from our lives. This occurs because we experience a dampening of our pleasure pathways, due to underactivity of our dopamine mood cable and pleasure box.

The memory pathways also become disrupted. Reduced activity of the left logic box leads to difficulties with short-term memory, so we struggle to retain information recently gained. Our memory box itself becomes very disrupted by high glucocortisol levels, and as a result struggles to consolidate and retrieve longer-term memories.

The three mood boxes and cables, due partly to a high glucocortisol barrage, become underactive, leading to physical symptoms such as sleep, appetite, concentration, libido, drive and, most of all, energy difficulties – all of which make MDD such a debilitating illness.

High glucocortisol levels lead to other physical consequences, like heart disease, diabetes and osteoporosis, as already discussed. I refer those who would like to examine the above mechanisms in more detail to Flagging the Problem.

It is useful to examine also the three phases of brain development and their role in MDD.

THE DEVELOPING BRAIN is the phase of brain development from the womb to age thirty. There are three stages to consider.

Within the womb itself, genetic and epigenetic factors shape brain pathways. This is the phase where the hard-wiring of the brain occurs, influenced by male and female sex hormones (testosterone and oestrogen). Many researchers feel that the developing brain at this stage can be affected by alcohol, drugs, infections and perhaps severe stress in the life of the mother.

There is a great deal of interest in the first three years of the life of the child in terms of the future development of potential depression and anxiety pathways. When a child is born, the key players in its life are the stress box in the emotional brain and the social control box in the logical brain. Our memory box is completely immature, so we do not remember these vital years. But our stress box does retain its own ‘version of events’. The small infant and toddler is strongly influenced by what happens during this phase.

If, for example, the mother develops postnatal depression, the child may become withdrawn and less communicative, and may even reduce feeding. This occurs because the infant’s mirror neuron system tunes in instantly to those in its immediate environment, sensing where they are at emotionally, without, of course, any conscious ability to understand why (see page 24). Thankfully, the infant’s demeanour and behaviour quickly improves if the mother receives some assistance with her own mood.

If the small infant undergoes major stress, either directly or through the experiences of those closest to it, high levels of stress hormones like glucocortisol will be produced, giving rise to the development of early potential anxiety or depression pathways that remain buried in the unconscious mind of the child. In such cases, there may be genetic predispositions present, but environmental and epigenetic influences generate these pathways.

The result may be a predisposition in that child’s future, whereby stress at a later stage, possibly in the teens, can unmask depression. Numerous psychotherapy approaches, from Freud onwards, have zoned in on this period, with the assumption that the source of a person’s present problems may lie here. One interesting possibility as to how this might occur lies in the potential for high glucocortisol levels to damage our spindle cells and support cells, particularly in the attention box. Since these are such key players in how our sadness, anxiety and socialising pathways develop, any such damage could predispose us to depression. The most likely vehicle for such changes is the second messenger system.

As the child moves past three, there is a period of around nine years where there is significant activity in the developing brain, but it is a relatively peaceful time: the calm before the storm. For the first twelve years, brain development is partially under the influence of our serotonin and dopamine systems. So they are not only important neurotransmitters in themselves but key players in brain development. Again, this is probably mediated through our second messenger/neurotrophic system.

The thirteen-to-thirty stage is one of the most important periods in our life, in terms of both brain development and future depression. Just prior to this phase, the brain increases its neuron numbers, but from thirteen onwards it is all about pruning the connections between cells, increasing efficiency for future adult use, and starting with the emotional brain limbic mood department. This is driven by our sex hormones, which, as we have seen, communicate with our genes through the second messenger system. This is a period of massive change and adaptation in the life of both the young adolescent and the brain itself. During this phase, the person’s emotional world is turned upside down as they and their immature brain struggle to deal with approaching adulthood.

After age twenty, attention switches to our logical brain, in the form of our frontal mood department. Here, further pruning and increased connections between the logical and emotional brains leads to the gradual development of maturity. Our logical brain is practically mature by twenty-five but a final spurt takes place around thirty. Depression frequently appears in the fifteen-to-twenty-five age groups, and it is easy to see why. It is often an incredibly stressful period for the emerging young person, who has to cope with their newfound sexuality, peer-group pressures, learning to mingle and socialise when often feeling awkward and vulnerable, and exposure to alcohol and illegal drugs before the brain is able to cope with them.

There seems little doubt that high levels of glucocortisol produced in response to the above, exposes those who are vulnerable to depression. The big swings in female hormones in particular may also play a role. We now know that oestrogen, through its effects on the second messenger system, has a positive effect on our mood, and progesterone a more negative one.

It is difficult to over-emphasise the role of alcohol and illegal drugs on the developing brain, particularly before the age of fifteen. They have a powerfully negative effect on the second messenger system, significantly increasing the risks of depression. We have been in the throes of an alcohol epidemic nationally for the past decade in particular and have been exposed to increasing usage of cocaine in the past five years. It is therefore almost inevitable that the incidence of mental distress and depression in this group will increase. Other important environmental factors are lack of exercise, poor nutrition and family breakups at vulnerable times in the life of the emerging young adult. Consumerism, materialism, sexual-identity issues and bullying all play their part too. In the case of young men in particular, uncertainty about their place in the brave new world of sexual equality, and the possible absence of spiritual meaning in their lives, may all contribute to the ascent of depression.

Equally, if we over-protect our children, teenagers and young adults, paradoxically we set up a risk situation. This is because we shelter them from ‘real life’, and when they are finally exposed to the rough and tumble of life’s vagaries, the young person has difficulty coping. Stress-hormone levels rise for a completely different reason, but with similar results. The best advice for parents is consciously to decide from an early age to allow the child to experience stress in a carefully modulated manner. Let them experience pain and discomfort in a controlled environment every step of the way from early childhood to their twenties. If we teach young people skills like problem-solving, emotional coping, sharing, and learning to take responsibility for – and deal with the consequences of – their own decisions, we will have gone a long way towards improving their mental health.

Another fascinating aspect of this situation is that we in the West have actually created ‘teenage culture’. As a result, we have separated the growing adolescent from what they need most: to work side by side with their adult parents, absorbing their wisdom and life skills first-hand. In the developing world, for example, young people learn vital life skills and knowledge in this way. We, on the other hand, separate them from us beginning in early childhood, allowing our educational system to shape them. We should try as much as possible to spend time with them doing normal household chores, sports and other activities, subtly passing on our experience and wisdom to them.

THE MATURE BRAIN relates to the phase between thirty and sixty-five, when our brain has finished its reorganisation. From a mood-system viewpoint, there is a healthy relationship between our emotional and logical brain and the right and left hemispheres, and the development of increasing ‘wisdom’, where we learn more quickly to get to the ‘essence’ of situations in emotional and everyday lives.

This is the phase where we develop careers, meet partners and make long-term commitments, have and rear children and engage in the many problems that life throws at us. The stresses in this phase are complex and change from decade to decade as we grow and develop as human beings. For women in particular, this can be an enormously stressful period, as they have to cope with rearing children and holding down a job, while all the time being exposed to pre-menstrual hormonal shifts, during and after pregnancy and again in the menopause (where the protective effects of oestrogen are removed). It is no surprise that so many women develop depression during this phase. Both men and women may have suffered bouts of MDD in their teens or early twenties but may develop them anew as the pressures of life expose them to high glucocortisol levels, triggering latent depression pathways. It is likely that the later one develops a first episode of depression, the greater the stress necessary to trigger it. This is probably because the genetic/epigenetic predispositions are weaker than in situations where it developed in the under-twenty-five age groups.

The most likely environmental triggers in the case of the over-twenty-five groups are loss and bereavement, relationship breakdowns, addiction problems, financial disasters, and mental or physical illness involving children, to name but a few. Once again, alcohol and drugs like cocaine can also act as a catalyst, either on their own or in conjunction with the above, to trigger bouts of depression.

THE AGEING BRAIN is the third and final stage in our journey. With modern neuroimaging and other research findings, we are building up a picture of what happens in our brain as we reach sixty-five and onwards.

Firstly, as we age, our neurons gradually start to shrink in number – in particular those in our three big mood cables (serotonin, dopamine and noradrenalin). This makes us less able to adapt to what life throws at us. Thankfully, most people will retain enough to get through this phase safely. But apart from the neurons themselves, many elderly people begin to develop atherosclerosis (hardening of the arteries) of both large and small blood vessels supplying key parts of the brain. We now know that blockages to small vessels leading to the left frontal mood department of the brain in particular can trigger depression, even in those who have never experienced a previous bout, and also that large blockages (as happens when we have a stroke) in the same area can have a similar effect.

These vascular changes are believed to damage the second messenger/neurotrophic systems within the neurons of our logical brain. This leads to a loss of normal control over negative thoughts and emotions emanating from the emotional brain. Vital pathways have been disrupted and damaged. Environmental factors can also play a role in overcoming our more vulnerable mood system during this phase. The absence or otherwise of loved ones, physical health, independence and self-esteem plays an important part in the expression of this illness.

Other illnesses affecting the brain strongly disrupt key pathways, often triggering depression. The best example here is Parkinson’s disease, which disrupts the dopamine cable supply to the emotional and logical brains, producing depression in up to 50 percent of cases. Alzheimer’s disease is also very destructive to key pathways, in particular to the memory box, and is also associated with the development of depression. There will obviously be a cohort within this age group who will have suffered bouts of depression throughout their lives. All the accumulated damage, plus the natural ageing process, increases the risks of further problems. Special mention has to be made of the capacity of alcohol to play havoc in the ageing brain. As with the developing brain, it can interfere with the normal functioning of key pathways and increase the likelihood of depression occurring.

We have examined the depression pathways and how they are triggered, as our brain develops, matures, and ages. Let’s now examine how our holistic therapy pathway can treat and prevent this distressing illness.

The Role of Our Holistic Therapy Pathway in Depression

There are a number of important statements we must make before we examine this in detail:

To treat this illness, the person must present for help.

Depression is almost unique in this regard, as one of the cardinal symptoms is negative thinking (‘I am of no value, untreatable, nobody else could possibly be of help, and anyway I don’t deserve such help’), which often prevents people coming for help.

Almost 50 percent with MDD do not present to any health professional for advice or assistance.

The other 50 percent are self-treating and are often drawn into the world of alternative medicine without any real diagnosis being made, and often without knowledge as to whether a particular therapy has been scientifically researched or proven.

Even when those in mental distress present to health professionals, there is often confusion in terms of diagnosis between chronic stress, general anxiety disorders, a short-term life crisis and genuine depression.

This distinction is vital for the correct therapy pathway to be activated.

Many of those who do not present for help will usually recover from individual bouts of depression, usually within (an extremely difficult) twelve months. Relapse is, however, very common.

Treating MDD is vital when it comes to reducing the long-term physical consequences already outlined, to prevent ‘as much as possible’ the potential for relapses, to reduce the risk of suicide and to help the person and their family to have a normal, healthy life.

Finally, there are two big goals that must be achieved at this stage: to treat the particular presenting acute bouts of depression and to put in place as much as possible measures to reduce the risk of relapse.

When examining the role of our holistic therapy pathway in the treatment of MDD, this last statement is of great importance. It is not enough just to help somebody recover from a bout; we must also try to reduce the risks of recurrence.

Foundations

With the emphasis on drug, talk and alternative therapies, foundations are often forgotten. But we must remember that, without good foundations, houses will quickly get into difficulties. This concept is equally applicable to depression.

Empathy is one of the most important foundations, and finding an understanding family doctor or other health professional is crucial. Empathy pathways have to be set up between the GP or therapist and sufferer, otherwise any intervention is likely to fail. Earlier, we explained how these pathways are activated and why they are so important in encouraging self-healing.

Exercise is another cornerstone of both treating acute episodes and preventing relapses. The simplest regime involves thirty minutes of reasonably brisk exercise for at least five days a week – I myself look for a daily commitment. The benefits of exercise in depression are so great that some rate it alongside drug therapy in terms of its importance. Since, as already discussed, there is a link between MDD and coronary heart disease, there are also cardiac benefits to the above regime. The major problem in practice is that sufferers with depression have extreme physical and mental fatigue and so find it extremely difficult to become motivated to engage with this crucial therapy Useful tips include:

Nutrition is another important foundation. Many people with MDD eat poorly or not at all. This occurs because our depleted dopamine system prevents us from the normal enjoyment of food. Our brain requires key nutrients to survive and function, so a vicious cycle may occur: we become depressed, lose interest in food, stop eating or else eat rubbish; our brain becomes starved of nutrients and becomes more dysfunctional, our depression worsens, and the cycle begins again.

As with exercise, the person with depression may struggle to motivate themselves to eat the three meals a day required, may take high-stimulant snacks like chocolate and caffeinated soft drinks instead, and may use coffee as a stimulant or, if a smoker, increase usage. Once again, I strongly encourage a healthy diet as part of my holistic package. The following tips are useful:

MODERATION THERAPY is another lifestyle foundation. In depression, this involves examining many often unhelpful areas of our lives. We have to mention the importance of alcohol in this illness. Many (particularly young men) use alcohol as a crutch in MDD. It gives them a temporary lift but their mood drops quickly, further increasing suicidal thoughts or actions. When taken in large amounts, it is very destructive to the developing brain, greatly increasing the risks of future depression arising. I am also becoming increasingly concerned about the numbers misusing hash, cocaine and alcohol, which increases destruction of the developing brain and indeed, as a cocktail, can cause fatal cardiac arrest.

THE PLACEBO EFFECT; We dealt with this in great detail in earlier chapters, but it is important to look at its place in MDD. Depression is an extraordinary illness in that the emotional brain convinces us that negative thoughts (such as ‘I will never get better’) are true, while knowing deep down that they are not. In reverse, there are few other illnesses where suggestions that a particular therapy (whatever its scientific truthfulness) can help us get better leads, in many cases, to an immediate, if temporary, improvement in symptoms. This is because the same areas of the brain involved in depression are stimulated by the actual thought that something positive is going to happen. We dealt with the pathways involved earlier.

Difficulties arise when we choose to compare some forms of therapy versus placebo treatments, but accept others as effective without any proper trials. In my opinion, this leads thousands of people to head down roads that will turn out to be expensive dead ends. The person in trouble will experience some form of placebo positive effect, almost no matter what the particular therapy concerned (this will usually have occurred in part due to the empathetic relationship developed with the alternative therapist in question), but this will usually wear off after one or two months. But this may be enough to convince the sufferer that it has been effective. The main issue here is that this may prevent the person from receiving the holistic package they really need, making relapse and further difficulties almost inevitable. So from the beginning, let us accept that:

The Main Structure

Moving on, let’s examine the role of the next two main planks of our holistic pathway, drug and talk therapies.

TALK THERAPIES

When dealing with depression, the opinion that drug therapy, on top of a solid foundation, helps us to feel better so that we can engage with the various forms of talk therapy to help us get better is indeed true.

There are many forms of talk therapy. We have examined most of them earlier, but some stand out as being of help in MDD. These include counselling, psychoanalytic psychotherapy, cognitive behaviour therapy (CBT), behaviour therapy, interpersonal therapy (ITP), supportive psychotherapy, brief dynamic psychotherapy and mindfulness-based cognitive therapy (MBCT), all of which would be classified as traditional mainstream therapies.

Counselling, CBT, ITP and MBCT would be regarded as the most helpful talk therapies in depression, and most research has been into CBT and IPT. We have already reviewed these therapies in detail but let us now briefly examine their role in depression.

Let’s examine the role of CBT and MBCT in depression in a little more detail. CBT is extremely useful in both the treatment and prevention of depression. The Five Areas model teaches the person to link together their thoughts, feelings, physical responses, behaviour and environment and shows how altering any one of these things in a positive sense can help improve the others. If, for example, I make a behavioural change, such as starting to exercise daily, this may in turn lead to my mood lifting, my fatigue reducing and my thinking becoming more positive.

The Ellis (symbolised by the Raggy Doll Club) approach helps us challenge the core negative belief that ‘I am awful’. If I learn to accept myself without conditions, I have travelled a long way down the journey back to mental health. This too will challenge unhealthy safety and avoidant behaviour. I find this approach more helpful when dealing with depression.

MINDFULNESS-BASED COGNITIVE THERAPY (MBCT) may become increasingly important in the prevention of major depression. We examined earlier the place of meditation in depression. Eastern medicine has recognised the importance of this therapy in the area of mental health for millennia. In the past ten years, Western medicine has begun adapting these concepts into the CBT model and applied them to depression in particular. This has led to the development of MBCT.

If we have suffered from depression in the past, streams of distressing emotion, negative thoughts and resulting behaviour have usually become firmly embedded in our memory banks. These memory pathways can be easily triggered when internal or external events generate a similar mood, setting off a chain of emotions, thoughts and behaviour, and tipping us back into depression. This ability of the emotional brain to descend quickly into a flow of negative assessments about ourselves and the world is called ‘rumination’ and is felt by many psychologists to be a common reason for sliding back into the world of depression.

This makes sense because, as already discussed, each bout of depression seems to weaken the ability of our logical brain biologically to dampen down the negative barrage from the emotional one. In this sense, our mind and brain pathways are as one. The real battle in preventing depression must involve using therapies which target this tendency to ‘ruminate’. We have already seen the power of normal CBT to help identify and actively challenge such thoughts and behaviour. In many senses, this is an active, ‘hands-on’ approach.

A second approach to the ‘prevention’ of depression is to use the skill of mindfulness to teach us to become increasingly aware of our thoughts, emotions and bodily sensations in the present moment. Through this awareness, we can learn to identify unhelpful thinking patterns, subtly breaking this negative chain of thoughts and emotions. A common ruminating pathway involves the criticism of ourselves that we are beginning to think and feel this way again (‘Here we go again, what is wrong with me that I am unable to stop this happening, I am so weak and useless’). This harsh judgement of ourselves leaves us more prone to re-enter depression pathways.

This pattern develops because we spend most of our lives living in the world of ‘doing versus being’. Unfortunately, the more we feel we have to do something to change the rumination barrage in our mind, the more we strengthen its hold. This is because our emotional brain is so strong. Mindfulness encourages us to be with our emotions and thoughts in the present moment, shutting down the negative ruminating pattern by focusing in on them, without actively trying to alter or change them.

This is why it is so essential that you are not in the middle of an active bout of depression while learning this technique or you might be overwhelmed by an awareness of the huge amount of negative thoughts flowing from your emotional brain. Rather, it is important to wait until you are well, and only then to learn the necessary skills to shut off at source these streams of negative thoughts.

MBCT is all about gradually learning, through graded mindfulness exercises (like the Three Minute Breathing Space detailed earlier), the capacity to identify unhealthy thoughts, emotions, physical feelings and behaviour patterns as they are at this particular moment of time (not in the past or the future), and to learn to accept and embrace them without harshly judging ourselves.

One of the most important benefits of this approach is the learned ability to accept individual thoughts (and emotions) as being just temporary, as experiences or events occurring in our mind rather than actual realities. This might be the most important single concept in the whole area of mental health, particularly in anxiety and depression. One of the most beautiful and visual ways of conceptualising this is to consider such thoughts and emotions as temporary phenomena like clouds floating across the sky, disappearing after a while, leaving behind a clear blue sky.

Techniques involved in MBCT are a cross between modern CBT and ancient yoga and meditation exercises. A number of such programmes have been developed. Ideally, they are best taught by experts and in groups. They usually involve focusing on mindfulness awareness of our breath, body, sound, touch, emotions and thoughts. A full explanation of all the techniques involved is beyond the scope of this book. Should you wish to learn more, I would highly recommend The Mindful Way through Depression (see bibliography), which is a superb book on this subject.

I would like to refer briefly to a meeting between Western scientists and Eastern experts in 2007. Participating in a day-long symposium entitled ‘Mindful, Compassion and the Treatment of Depression’ was the Dalai Lama and some Eastern colleagues, internationally acclaimed researchers Charles B. Nemeroff, MD, PhD, Professor Reunette W. Harris and Professor Helen S. Mayberg, MD, (department of psychiatry at Emory University), Zindel V. Segal, PhD, (one of the authors of The Mindful Way through Depression) and other distinguished guests.

The conference focused on the role of meditation in promoting cognitive, emotional and physiological states that protect against depression. This was within the broader context of whether developing mindfulness and greater compassion through meditation training in adulthood might help individuals compensate for the depression promoting effects of adversity, trauma and lack of nurturing early in life – all primary environmental contributors to major depression. Researchers presented data suggesting that mindfulness practices may help prevent the recurrence of major depression and that meditation practices, specifically designed to promote compassionate cognitions and emotions towards others, may have effects on the brain and body that are directly relevant to depression.

There is much to learn from this wonderful meeting of minds, with East and West both teaching and learning from each other. The conference emphasised the importance of empathy, the links between mind, body and spirit (whatever we perceive that to be), the role of stress, the importance of our social connections and, most interestingly, how both recognised the place of effective biological (drug) therapy in helping a person with this illness reach a place where talk therapies and mindfulness can be effective.

ANTIDEPRESSANTS: We discussed earlier the importance of the second messenger systems in MDD, and this allows us to reassess the importance of antidepressants. We know that they have an immediate effect (which starts to kick in after two to three weeks), improving many of the physical symptoms of depression (such as sleep, appetite, drive and concentration), and psychological ones such as low mood and anxiety. But we now know that there are delayed positive effects on the second messenger system /neurotrophic system, particularly in relation to BDNF which seem to take up to six months or so to consolidate. This prevents the further shrinkage of neurons and their dendrites – a crucial piece of information which is often overlooked.

There are some practical observations to make here:

If we start a course of antidepressants, we must accept that the course is for six to eight months if we want to achieve maximum effect.

It is important to decide with your doctor just how long the course will last.

The SSRIs are the treatment of choice in the majority of cases. They do have side effects like initial nausea (due to initial activation of serotonin receptors in the gut), sweating, tremors of the hands, and heavier periods in the case of females (through their effects on blood platelets). These often disappear after a while as the body adapts to the medication.

Many people taking SSRIs for depression suffer from a loss of sexual libido, impotence and delayed or abnormal orgasm. For some, who may have had no sex drive due to their depression, this may not be a great problem. However, after several months of treatment, people will start to feel better and will regain their interest in sex. It is then that any sexual side effects caused by these drugs become an issue.

If side effects do occur, they will disappear within a few days of finishing the course.

If we stop taking these drugs suddenly, we will experience dizziness and a sense of spinning, which is relieved immediately once the course is started again. This is why it is so important to follow directions from your family doctor to the letter.

When a course is over, your doctor will lay out how to come off the drugs.

They are not addictive and generally do not cause drowsiness.

They should generally, apart from Mirtazapine, be taken in the morning with food.

Escitalopram (Lexapro) is the most commonly prescribed SSRI. It is extremely effective in most cases and generally well tolerated. I would regard it as a first-line option.

The biggest problem in my experience is that many people are treated with doses that are too low and are not increased swiftly as required.

If the SSRIs are not effective on their own, adding in small amounts of Mirtazapine can, in my experience, be of great help. If the person is still having problems, SRNI drugs that affect both serotonin and noradrenalin mood cables, like Cymbalta or Efexor, are the next options. Extra side effects like severe sweating and headaches can be a problem, and I find that Efexor has more sexual side effects than the SSRIs.

I am more uneasy about using SRNIs, particularly Efexor, in the elderly due to potential cardiac and cerebrovascular side effects, although some may find them helpful.

These drugs will only be effective in up to 70 to 80 percent of cases. Where they are not effective, a review of the diagnosis is essential, and applying other parts of the holistic pathway, such as lifestyle changes, mood stabilisers and talk therapies, will usually solve the problem.

If you are misusing or abusing alcohol, hash or cocaine and do not inform your doctor of this, you will struggle to get your mood back up and are only fooling yourself.

If you are under eighteen, drug therapy should ideally be started by a psychiatrist, and Prozac is the one most favoured in this group.

In the elderly, drug therapy should be part of a total package, and should be started in doses half the normal level.

In the case of recurrent significant depression, I feel that, due to the underlying neurobiological data already discussed, we should be considering using a mood stabiliser with an SSRI to reduce such risks.

MOOD STABILISERS are a second line of defence in more severe recurrent depression, often combined with antidepressants. Apart from stimulating the second messenger system to produce BDNF, which helps nourish the neuron and make new dendrites, they also increase Bcl, which prevents the neuron from self-destructing. The most common mood stabilisers are Lamictal and Lithium. Once again, we dealt with these drugs and their side effects in earlier chapters, and they are also covered in the appendix. We will be also dealing with them further in the section on bipolar depression.

ALTERNATIVE DRUG THERAPIES relate to drugs other than mainstream ones that purport to be effective in the treatment of MDD. The two main groups here are homeopathy and herbal remedies. In relation to the latter, the main herb of choice is St John’s wort, which we have discussed in detail already. Although it has shown to be effective in research trials, concerns about its interactions with other drugs, its side effects and the quality of the product limits its usefulness, with most experts feeling that modern SSRIs are safer. We have also dealt in detail with homeopathy, and the lack of any real scientific basis for this therapy. The main ‘remedies’ used here are Arsenicum album, Ignacia psorinum, Pulsatilla, Natrium muraticum and Aurum metallicum.

While many will continue to use alternative drug therapies, I counsel caution. My biggest concern is that a person with significant depression may not receive the vital help they need and may as a result waste time, energy and money on often dubious remedies, ending up in real difficulty. I recommend that you attend your family doctor before going down such roads.

Ancillary Therapies

This relates to those therapies, mainstream and alternative, that are also used to treat depression.

SLEEP DEPRIVATION has been recognised for decades to improve mood in those suffering from a bout of MDD. Sleep is essential for normal brain function: it is when our brain (1) heals and repairs itself (through NREM, or deep sleep), and (2) reorganises and strengthens our memories (through REM, or dream sleep). In the first, the brain is quiet. In the latter, it bursts into activity, particularly in the second half of our sleep cycle.

These bursts of REM sleep, lasting about twenty minutes, are when we dream. REM stands for ‘rapid eye movement’; during this phase, our eyes oscillate back and forth, and the movement ceases when the burst of activity is over. Dreams are created by our memory box passing information over and back to parts of the brain where previous memories are stored, and this explains their jumbled nature.

The average sleep cycle is eight hours. Both phases interchange throughout the night, and most REM sleep occurs in the second half. During sleep, our brain secretes melatonin (making us drowsy), generally switching off serotonin and noradrenalin systems. On waking, melatonin levels fall and serotonin/noradrenalin systems (making us alert) switch on. Sleep difficulties (particularly difficulty getting to sleep, broken sleep and early-morning waking) are the cardinal symptoms of depression. Many with depression note that their mood is low in the morning, and improves as the day goes on.

In depression, the serotonin system is already under active, with a greater tendency to REM sleep when serotonin activity is switched off. Some feel that, in depression, the brain actually strengthens negative emotional memories while asleep. This occurs during REM sleep, which focuses in particular on emotional experiences.

Normal REM/NREM sleep patterns are disturbed, with more REM sleep occurring in the first half of the sleep cycle. There is a shortage of nocturnal melatonin (which is produced from serotonin), explaining difficulties in falling asleep or staying asleep. Because of the serotonin system’s general nocturnal underactivity and the disruption of normal NREM/REM brain activities and reduced melatonin, many people with depression wake feeling very down and exhausted. If a person with depression takes a daytime nap, their serotonin system switches off, so they wake up even more depressed. This is problematic, as their behavioural pattern (due to mental exhaustion) encourages them to retire to bed, yet this worsens their symptoms.

An immediate way to improve low mood in MDD is a single night of total (all night) or partial (second half of night) sleep deprivation. This improves mood within hours. Although the effects of such therapy are helpful, it is not practical for use on its own. The brain needs sleep to repair itself and reorganise its memories, so chronic sleep deprivation would be toxic in the long run. Some have also combined it with light therapy as a possible approach when drug therapy is not possible.

LIGHT THERAPY is based on links between light and serotonin. In winter, due to a shortage of full-spectrum daylight, serotonin activity reduces, and the opposite is the case in summer. As a result, in winter months all of us feel flatter, crave carbohydrates and sleep more. Not surprisingly, 25 to 30 percent of people with depression see their condition deteriorate in winter.

One way of fooling the brain in depression is through the use of light therapy, either on its own or through a dawn simulator. Light therapy, particularly in the morning, increases serotonin activity and is a useful adjunct to other therapies. Light boxes emitting 2,500 to 10,000 lux of light (30 to 120 minutes, depending on appliance) are recommended for routine depression. Many of these boxes are small, portable and easy to use.

Dawn-simulator lamps (which I am a great believer in) fool the brain into thinking it is summertime. When set to come on an hour before waking, they gradually release full-spectrum light into the room, mimicking a summer dawn. This activates a reflex between the eyes and the brain, increasing serotonin and reducing melatonin activity, ideal for boosting mood. Some simulators will include an extra light-therapy attachment for those who would like to boost it further. Those who would like to acquire such devices should see the appendix.

ALTERNATIVE ANCILLARY THERAPIES include acupuncture, hypnosis, energy-field therapies, reiki and cranial manipulation, all of which we have already reviewed. There is little real evidence that any of the above have any real benefit apart from the empathy/placebo effects discussed earlier.

Application of the Holistic Therapy Pathway to Depression

When applying our therapy pathway to treat MDD, there are two key requirements:

  1. Treating acute bouts when they arise;
  2. Putting in place preventative measures to reduce the risk of further episodes.

The treatment of acute bouts of depression depends initially on the adage that the three main treatment priorities are diagnosis, diagnosis and diagnosis. This is of particular relevance where so many laypeople and media figures use the term ‘depression’ to describe everything from unhappiness to panic attacks. The most common cases of ‘mistaken identity’ versus MDD relate to chronic stress, generalised anxiety disorder and the normal causes of human sadness like grief and relationship breakdowns. I regularly see patients who feel they are depressed but are actually suffering symptoms from one of the above. We have already detailed these main symptoms. If in doubt I strongly advise visiting your family doctor. To qualify as true MDD, the symptoms must be present for a minimum of two weeks. In reality, most presenting to their family doctor will have been in trouble for months.

The next crucial step is to find a doctor or therapist who can empathise with you. In many cases, your family doctor is the obvious choice, as you will generally have built up a good relationship with him or her over a period of years. In other cases, you may have a good relationship with a counsellor or therapist and feel more comfortable in opening up to them. If that is not possible: start by sharing your distress with somebody close – a friend or family member.

After that, you must examine lifestyle – take nutrition, exercise (thirty minutes a day), supplements, ceasing alcohol for a definite period, as immediate steps to initiate. Your family doctor can out rule any other physical illnesses and do appropriate blood tests. With him (or her), you will have to make a decision as to whether you require drug therapy as a means of lifting mood and improving key physical symptoms like low energy, sleep problems, lack of concentration, low drive, reduced appetite and poor memory. In some cases, you may both decide that this will not be necessary and that a combination of lifestyle, stress-reducing measures (as already detailed), counselling if necessary, or some simple CBM techniques may be sufficient.

If (as will often be the case) you arrive in to see your family doctor feeling very down, exhausted and struggling to cope with the physical symptoms of this illness, you may decide on drug therapy to help restore normal functioning. The usual duration of such a course is six to eight months. Most will start to feel better with drug therapy within two to three weeks, and many will feel ‘back to themselves’ within six to eight weeks.

In my opinion, this is when the real work must begin. Lifestyle measures like exercise have to be emphasised, stress has to be analysed and appropriate measures have to be taken. Counselling or interpersonal therapy may be required, and negative thoughts and behaviour need to be challenged. This latter is best done using CBT/CBM methods, by working with either a GP or an appropriate therapist.

In some cases where drug therapy is needed and you are adamant that it is not an option, St John’s wort is a possibility. But one has to take into account the concerns expressed about this form of treatment. Some may want to use homeopathic therapies. While I feel that there are major concerns about their scientific basis, some may find them helpful.

As the physical symptoms of the depression, and negative thinking, gradually improve, one can start to examine some helpful alternative therapies, like yoga, meditation, massage and so on, as useful stress-reducing measures.

There is one final step that I would recommend to all who are suffering from depression: to have one’s cardiac risk factors like cholesterol, body weight, blood pressure, blood sugars, and so on, assessed at least once. This is because we now know that there is a significant link between MDD and coronary heart disease, for reasons we have already explained. This can be done through your family doctor. For women who have had a number of episodes of this illness, I would recommend having a DEXA scan of your bones, to rule out osteoporosis (thinning of the bones).

The statistic that only 50 percent of those with this illness will present for help, usually to their family doctor, is of great concern. We have to ask immediately: ‘What happens to the other 50 percent?’ Since up to 10 to 15 percent of the population will develop this illness (which corresponds to a projected figure of up to 400,000 in Ireland), a significant number in distress are not receiving the assistance they deserve. Why do so many not present for help?

The answer lies in negative thinking: they believe the thoughts ‘We are of no worth’, ‘Nothing can be done to help us’; ‘It’s just the way we are’. This allied to a sense of shame and stigma attached to this illness, concerns that declaring it might have an impact on our jobs or career, and widespread confusion in relation to the different therapies, may lead to a great reluctance on the part of the person to come forward for help.

A person who is suffering from such negative thoughts should remember the crucial CBT concept: just because I have a thought, any thought, does not mean that it is true. Nowhere is this truer than in depression. You are like the rest of us, quite special: a ‘Raggy Doll’. It is a false and unhealthy thought that you cannot be helped. In my experience, almost everybody can be helped, often with simple therapies and lifestyle changes. As to the shame and stigma concerns, one has to ask: ‘Would you be as bothered about presenting with a similar physical condition like diabetes or high blood pressure?’

The prevention of further bouts of depression is the Holy Grail. For even when full recovery has been made, this illness tends to recur in a significant number of cases. The estimated risks of recurrence are 50 percent after the first bout, increasing rapidly after this to 80 to 90 percent after the third bout, if the first episode occurs in our teens, or if there is a strong family history. Between 50 and 85 percent of depressed persons will experience multiple episodes. The earlier we can treat an episode and put in place protective measures, the lower the risk becomes, as both mind and brain pathways become increasingly vulnerable to stress, the more episodes we experience.

Learning simple CBT/CBM concepts like the ‘Raggy Doll’ and applying it on a regular basis to many of the situations life throws at us can have profoundly positive effects on our mental health, as we learn to love and accept ourselves for the simple but wonderfully flawed human beings we are. These concepts can also be used to treat another common cause for depression relapses, namely underlying anxiety. Many are in a vicious cycle: anxiety wears them down, so they develop further bouts of depression and then recover, only to return to the world of anxiety again.

CBT can also be used as an adjunct to counselling for abuse, where we shed ourselves of the corrosive effects of hurt and anger, further triggering depression relapse. There is a significant role for meditation, particularly mindfulness-based cognitive therapy (MBCT), for those experiencing regular relapses.

The twin approach of ‘active’ CBT challenging negative thoughts and behaviour, and (seemingly) ‘passive’ MBCT assisting us to become more mindfully aware of our thoughts, emotions, physical reactions and behaviour may be the real secret to reducing the risks of MDD returning to our lives. We have already dealt with these in detail.

A sensible combination of these therapies will reduce the risk of depression relapses in a significant number of cases. But there is definitely a cohort of people with recurrent severe depression who will require maintenance drug therapy for long periods of time, and in some cases for life.

We have already examined the loss of brain neurons, dendrites and support cells in the logical and emotional brains, and the reality that repeated episodes of depression seem to increase the vulnerability of brain pathways to become dysfunctional as a result. We now know that drugs like the SSRIs have the ability, through their effects on BDNF, to nourish and protect the neurons of the mood system. Unfortunately, they do not, on their own, regenerate the tissues lost, but they do protect the remaining neurons. This is the basis for their use in the prevention of relapses.

One has to also wonder if we should, in such cases, be considering adding mood stabilisers. By increasing the neurons’ production of neurotrophic factors like Bcl, we can help regenerate parts of the mood system and prevent further neurons from dying. I deal with this area in more detail in the technical section.

Combining a mood stabiliser like Lamictal with an SSRI-type antidepressant when depression, despite our best efforts, is constantly recurring is often of benefit. There is a huge amount of research into new therapies that will target the second messenger or neurotrophic systems, and maybe, in time, new therapy approaches will become available.

There are definitely situations where this approach is the road to travel, but the more we introduce lifestyle/CBT/mindfulness preventative measures at as early a stage as possible, the less likely it is that such drug-therapy combinations will be necessary. Also, I have no doubt that even where such drug therapy is being used in this way; the rest of the holistic path cannot but help reduce further risks of relapse.

There will be some who may feel that staying permanently on herbal treatments like St John’s wort is the best route to travel. Although this may seem like the ‘natural’ route, there are significant side effects and drug interactions, which are not often discussed, and also concerns about the actual contents of many preparations, where many other herbs may be used. Once again, I counsel discussing it with your family doctor. Light therapy, in its various forms, can be a useful adjunct in the winter months to protect mood in those who note major drops at these times of the year.

Let us now meet a number of people presenting with depression at different stages of life and examine how their lives have been transformed by applying various parts of our holistic therapy path to their lives. As with anxiety, we do show the place of CBT/CBM in these stories; but once again advise that one must work with a trained health professional like a therapist/doctor to learn how to apply such concepts to oneself.

John’s Story

‘I feel weighed down by hopelessness and sadness. It is a physical pain in my heart, and no one understands how terrible it feels.’

John is a nineteen-year-old undergraduate student who develops depression after moving away from his family to live in a flat in Dublin. He successfully hides his depression from family and close friends. He uses copious amounts of alcohol to relieve the pain for short periods: its embrace, however, is fleeting and illusory. Thankfully, he opens up to a college counsellor. On his advice, John shares how he was feeling with his mum and dad. To his surprise, he feels better for doing so and, on their advice, he attends the family doctor.

He finds it difficult to explain how he feels but, with encouragement, admits to the exhaustion, sleep difficulties, anxiety, and loss of appetite, drive and concentration, which, along with a low mood, has turned his previous three months into a nightmare. He finds it helpful to discover that his difficulties with studying and retaining information are due to his memory and concentration being impeded by depression and that the suicidal thoughts he has been experiencing were also part of the condition. He has no plans to harm himself but has been distressed by the thoughts themselves.

John shares with his doctor that his mum suffered from depression in her earlier years, something she revealed following his own admission of difficulties. On probing, it becomes clear that he has become very isolated in Dublin. He has also begun to doubt (due to problems retaining information) whether he is suited to his course, and he is misusing alcohol to deal with his low mood.

Following discussion, the following treatment plan was drawn up, where John would:

After four weeks, John was starting to feel a little better. His blood tests were normal, he was exercising (weightlifting and walking), was off alcohol, was eating a little better and was starting to sleep again. He had, with the help of his family doctor, organised his medical exemption, calming many of his fears.

After eight weeks, he felt more hopeful, his interest, energy and mood were better, and his suicidal thoughts had gone. Two problems remained: firstly, he was still feeling very negative about himself, and secondly, he was uncertain as to whether he should return to his course. His doctor recommended a guidance counsellor for advice on the road he should travel and did some simple CBM on his negative thinking. He started by asking for an example of the latter. John replied that he felt both ashamed and depressed because he had developed depression in the first place, had to pull out of college for the year and in his own words, had ‘let everybody down’. His doctor asked him to choose which of these was bothering him the most. John replied: ‘The depression.’

His doctor then explained the ‘ABC’ concepts to him, and together they drew up the following analysis of his problem:

His doctor challenges some of the above. Firstly, he explains how our behaviour can, in depression, further isolate us from the love and friendship of those with whom we normally associate with, worsening the illness. They agree that he will begin to change some of the unhealthy patterns he has become embroiled in.

He challenges John’s unhealthy belief that because he had developed depression, he was ‘of no value as a person’. He introduces him to the Raggy Doll Club (Figure 35) and its rules of admission: that we cannot rate ourselves or accept other people’s rating. He helps John see that if he became a Raggy Doll, he could not rate himself because he had developed depression, or indeed for any other reason, nor could he allow other friends and colleagues to rate him.

The key message is that, if he could learn to become a Raggy Doll and accept himself without conditions, his negative personal assessments of himself would give way to more realistic ones. He would realise that he was a special human being, just like the rest of us.

He then gives John some homework. He asks him to begin doing some ABC’s in situations where he found himself interpreting events (both internal or external) in a manner where he found his mood suddenly falling, and to return after a further two weeks to see how he has got on.

After another two visits, John is starting to feel much better, with an improvement not only in his physical symptoms and mood but also in his thinking. He has discussed his course decision and has realised that it was not the course but the way he had been feeling that was the problem. He is going to return to finish it.

After nine months, John is well, off all medication, exercising regularly, more careful with his diet and moderate in terms of his alcohol intake. He is back at college, involved in a lot more student activities and has a girlfriend. He has also, on the advice of his doctor, decided to join some of the student mental-health groups at college, where he learns about mindfulness and begins using it in simple ways in his life. He has put in place all the pieces to protect his mental health. Most importantly, he has become a Raggy Doll.

Mary’s story

‘The simplest of tasks drains me of all my energy. I just want to sleep all the time.’

Mary is a twenty-seven-year-old mother with two small children. She has developed symptoms of depression following a series of stressful events: her partner losing his job, leaving her as the main breadwinner, her mother developing early dementia, and finally losing a close friend to cancer.

Increasingly exhausted, she eventually breaks down in front of her family doctor on a routine visit with one of the children. She admits to her mood being down for six weeks before her friend had died, and having deteriorated since. She also admits to sleep, appetite, sex and memory/concentration difficulties and to a loss of enjoyment of her life. She was starting to have relationship problems as her negative rating of herself spread to her partner, whom she felt was responsible in part for the problem. She was also drinking more than usual, struggling to deal with the way she felt, and becoming increasingly isolated from close friends, as she simply did not have the energy to relate to them.

Her doctor examines her and arranges for blood tests to be done. He explains that her fatigue stems from depression and gives her some useful information. He sees her the following week, when her tests are reported to be clear. She is now happy to accept that her fatigue and other symptoms are due to depression, triggered by a number of life stress triggers and loss. They agree on the following treatment plan, where Mary would:

She returns after four weeks feeling a little better, with her mood definitely lifting, and some improvement in appetite and sleep, but her fatigue remains a major problem. She has managed to improve her diet but is really struggling with exercise. ‘I can’t motivate myself,’ she explains. ‘I plan to go for a walk every day but when the moment arrives, I just find any excuse not to go. I feel such a failure; I cannot even manage half an hour of exercise.’

After eight weeks, she is feeling much better; her fatigue is improving, but only gradually. She is now attending the bereavement counsellor, is off alcohol and is getting on much better with her partner, especially after having admitted her problem and looked for assistance. She is taking more care of herself, has booked in for weekly massages, is meeting up with some of her friends, with whom she shared her difficulties, and is receiving great support from them. She has enlisted help from her wider family, and they, together with local community services, have arranged for her mother to receive help. She no longer feels so isolated in relation to this issue.

She has two problems remaining, however. She still struggles with the fatigue and exercise part of her therapy and still feels very negative about herself, believing that she is a ‘failure’ for not being able to take regular exercise. At this stage, her doctor feels that she is well enough to do some CBM exercises with her and explains the ‘ABC’ approach. They use this on the above issue and together draw up the following analysis of her problem:

Her doctor challenges some of the above. Firstly, he explains how, in depression, our behaviour, particularly in the area of exercise, can actually worsen the problem. By not exercising, we miss out on a proven therapy to help our mood and also isolate ourselves from the socialising benefits of meeting friends and neighbours when doing so. He gives her the following behaviour tips:

He then moves on to challenge her interpretation that she cannot exercise due to fatigue. Is this true or just a thought? Finally, he challenges her assertion that just because she is unable to exercise, she is a failure. He introduces her to the Raggy Doll Club and its rules. She is very affected by the latter and vows to become a member.

After nine months, Mary’s life has been transformed. Her symptoms of depression are now just a memory, with even her fatigue clearing up. She is now exercising regularly and eating well. She has taken up yoga, is moderate in relation to her alcohol intake, is off her antidepressants, is taking supplements and is socialising again on a normal basis. She is back working, her relationship is back on an even keel, and she has come to terms with the loss of her close friend.

Paula’s story

‘I’m sick of people telling me to “cheer up” or that “it can’t be that bad”. But it is, and much worse than they can imagine.’

Paula is a twenty-eight-year-old single woman with a history of depression for the previous ten years. She was sexually abused by an uncle (who is now dead) at the age of nine. She has successfully hidden this from her friends and family, only confiding it to her older sister Ann after a night of heavy drinking, in an unsuccessful attempt to lift her mood. She has tried all types of alternative natural therapies and is afraid to go to her family doctor for fear he would suggest drug therapy, and due to her embarrassment about her previous abuse, which she had always felt responsible for.

She had found alternative therapists to be kind and understanding but had never admitted to the fact that she had been abused. Following brief lifts in mood, she would quickly return to the way she was. Finally, she breaks down in front of her sister Ann, the one person she feels safe with, and reveals the pain and distress of the previous few years. She also shares her fear of medication and her concern that if she admitted her symptoms to her doctor, he would feel that she was mad.

Ann empathises but convinces her to attend the family doctor, to whom Paula explains the way she is feeling. On probing, she admits to extreme fatigue, sleep, appetite, sex, memory and concentration difficulties, and to a complete loss of enjoyment of her life. She finds it easy to talk to the doctor and before she knows it has poured out to him the pain and distress of her previous sexual abuse. She also expressed her concerns about drug therapy (that they were addictive, that she would be on them for life, and that she would become a zombie on them).

Her doctor explains to Paula that all her symptoms were due to depression and that it was quite likely that the source of them lay in her childhood abuse. Together, they decided on the following treatment plan, where Paula would:

Paula returns at four and eight weeks to see her doctor and is now feeling better. To her surprise, apart from an initial nausea, which quickly subsided, she has experienced no significant side effects from the medication. She is now sleeping better, with fewer nightmares, is eating well, is exercising daily (something which she has come to enjoy very much) and has admitted to her doctor that it was the first time in years she had felt ‘herself’.

They then decide that now she is feeling better, it is time to begin the crucial talk therapy necessary to help her get better. The doctor refers Paula to a counsellor who specialises in sexual abuse but continues to follow up with her in relation to her mood.

Six months later, Paula, on a follow-up visit, looks for further help as she has encountered a ‘roadblock’ in her work with the counsellor and it is starting to bring down her mood again. The problem turns out to be Paula’s difficulties in dealing with the original abuse, which leads to her becoming increasingly distressed during counselling sessions. At this stage, her doctor explains the ‘ABC’ approach, asking whether she would like to use this CBM approach to deal with her hurt. She agrees. Together, they draw up the following analysis of her problem:

Her doctor challenges some of the above. Firstly, he explains how our behaviour can, in depression, further isolate us from the love and friendship of others, worsening the depression itself. They agree that she will begin to change some of the unhealthy patterns she had become embroiled in.

He then queries how her uncle’s behaviour could make her ‘damaged goods’ or a failure. They agree that it would be better to say ‘I have had damage done to me’, rather than ‘I am damaged goods’, and introduces her to the Raggy Doll Club. He helps her to see that if she becomes a Raggy Doll, she cannot rate herself for having being abused by her uncle.

After a number of such sessions, she returns to her counsellor, the roadblock gone, and successfully completes the course. By the end of the year, she is off all medication, exercising, eating well and enjoying life for the first time in five years. She has taken up meditation on the advice of her counsellor, bought herself a Raggy Doll and, most importantly, finally surrendered to the embraces of a man she had been interested in but had been afraid to ‘go there’ with. She now has a much more informed attitude to the place of alternative and conventional drug therapies and their role in depression.

Thomas’s story

‘The simplest of tasks drains me of all my energy. I just want to sleep all the time.’

Thomas is a thirty-two-year-old, highly successful businessman suffering from undiagnosed bouts of depression for over a decade. His first bout came after a particularly stressful period in his life where the underlying anxiety that had been with him since the age of ten came to a head and his mood fell.

Since then, he has lived a double life. On the surface, those who knew him could never get over how cool, calm and controlled he seemed to be, no matter what business emergency arose. On the inside, though, he was in torment. For long periods, he would experience complete exhaustion, and the pain of low mood. Problems with sleep, appetite, sex, memory and concentration led to a complete loss of enjoyment in his life and increasingly negative thoughts about himself and his future, despite all his successes as a businessman. Suicidal thoughts and even some definite methods of ending it all were starting to dominate his thinking during recent episodes.

When his mood lifted, the gnawing anxiety and the demand for total perfection would return. This would eventually trigger negative thoughts, and his mood would fall again. As a man, Thomas felt that to reveal such emotional symptoms would attract derision, and he was therefore avoiding admitting his difficulties and accessing help. Only women, who were ‘more emotional’, could possibly admit to such feelings; ‘real men don’t’.

But the exhaustion became worse, and his partner, who has been with him for five years and yet is completely unaware of his difficulties, becomes concerned. Eventually, he agrees to come with her to the local doctor, looking for ‘blood tests’ to out rule diabetes.

Thomas explains his physical symptoms to his doctor but omits the emotional ones. His GP asks about any stress problems; Thomas denies these but mentions briefly his difficulties on occasion with concentration. His doctor decides to refer him for blood tests. A week later, he returns on his own for the results and, to his surprise, is told that he is completely healthy.

‘But why am I so tired?’ he asks. His doctor then suggests the possibility of depression, and initially Thomas is almost hostile. When his GP asks him to answer a series of questions to rule it out, he agrees. After replying yes to all twelve symptoms, he is forced to open up and admit how he is really feeling. He breaks down and pours out all the years of pain and hopelessness, and his increasing wish to end it all.

Following this outpouring, Thomas feels that a weight has been lifted off him for the first time in years. His doctor explains that his present symptoms are due to depression and that it was also likely that he had been suffering from anxiety since his teens – a primary trigger for his depression. He offers him the option of seeing a psychiatrist, but Thomas requests that his doctor, with whom he has shared so much, help him instead. So together they decide on the following treatment plan, where Thomas would:

Eight weeks later, Thomas is feeling better: his physical symptoms are settling and his mood is improving. His partner turns out to be a rock of strength. He is now ready to begin the journey back to getting better. Initially, he attends a counsellor to delve into his past and identifies some issues to deal with. He also begins to work with his doctor on his negative thinking, in particular a return of the anxiety symptoms he has experienced since childhood. His doctor asks for an example of something that is making him anxious, and Thomas replies that he is worried because his boss is aware that he is suffering from depression, and he feels that his career prospects might suffer.

His doctor then explains the ‘ABC concepts to him and together they draw up the following analysis of his problem:

His doctor challenges the above, in particular his behaviour in avoiding discussing the matter with his employer, explaining that this is only leading to a worsening of the problem. He also helps him see his physical symptoms of anxiety as uncomfortable but not dangerous. He then challenges his demand that his employer must not treat him differently. Does this demand prevent his boss treating him in this way? He introduces him to the ‘Big MACS’ – in particular to the ‘land of must’.

Was there any law that gave Thomas the capacity to ‘control’ how his boss ‘must’ behave in this or any other situation? And wouldn’t it be more acceptable to use the term ‘prefer’ rather than ‘must’? One would obviously prefer that his boss would not treat him differently, but he could not control what he would in fact do.

He then queries how his boss treating him differently could make Thomas a failure, and introduces him to the Raggy Doll Club. He also shows how this demand increases his anxiety, making it more likely that his boss will treat him differently.

He asks him to begin doing some ABC’s in situations where he finds himself interpreting events (internal or external) in a manner where he becomes anxious or his mood suddenly falls. This starts a process of teaching him to deal with his negative thinking, demands and rating, all of which is predisposing him to anxiety and depression.

Nine months later, following a lot of homework and visits, Thomas is back at work, feeling well, off medication, using alcohol in moderation, exercising daily, eating and sleeping better, enjoying life again, and learning to come to terms with his anxiety. To his great surprise, his boss turns out to be very supportive, and Thomas begins to suspect that his boss might have suffered from depression in the past himself. He has also become involved in a mindfulness program, finding this of great assistance in learning to let go of his negative thoughts and emotions. Most of all, he is now a fully fledged member of the Raggy Doll Club.

Susan’s story

‘I feel so guilty’

Susan is a twenty-six-year-old teacher who develops postnatal depression within four weeks of having her first baby. Following a normal delivery, she tries – unsuccessfully – to breastfeed. The baby fails to thrive, and Susan’s mood begins to drop. She has no previous history of depression but her mother had suffered bouts after each pregnancy. Susan becomes increasingly exhausted, enduring sleep, appetite, sex, memory and concentration difficulties, and a loss of enjoyment in her life. She eventually breaks down in front of her practice nurse on a routine visit at eight weeks for childhood vaccination, and is referred to the family doctor. The nurse has also noted that the baby is not thriving and seems withdrawn.

Susan opens up to her doctor, in particular to her feelings of guilt that she ‘should’ be feeling wonderful but instead felt ‘crap’, as she put it. Didn’t she have a wonderful husband, a beautiful baby boy, and no other problems in her life? She breaks down crying and admits that she cannot bond with her baby and is pushing her husband away, causing difficulties in her relationship. Her doctor explains that her symptoms are due to depression, the source lying in stress and hormonal changes which occur following pregnancy. He also notes that it is completely normal to feel lost and stressed in the postnatal period. Susan is very anxious not to use any form of drug therapy, despite her doctor’s advice. He understands her reluctance, so they decide on the following treatment plan, where she would:

Despite the above, after another three weeks, her mood is deteriorating and the baby is still not thriving. Her doctor once again suggests a short course of antidepressants, explaining that they are safe to take while breastfeeding and that it might be better for both the baby and herself, as the baby seems to be picking up on her depressed mood. She has a chat with her husband, and finally agrees.

Susan returns six weeks later: she is now feeling better and, to her surprise, is tolerating medication well. She is also sleeping and eating properly, and exercising daily. Her mood is almost back to normal, she is less anxious, and she is bonding with her baby son. Her thinking, however, remains very negative and she admits to her doctor that she felt guilty and down because she had developed postnatal depression and that her baby had failed to thrive. Her doctor explains the ‘ABC’ approach, suggesting that they use this approach to deal with her negative thinking; she agrees. Together, they draw up the following analysis of her problem:

His doctor challenges the above. He firstly examines her behaviour, explaining how our behaviour in depression can actually worsen the problem. She agrees that constant rumination and scanning of her environment are not helping. He also explains the dynamics of postnatal depression. Most mothers in the period following the arrival of a new baby develop the ‘blues’, feel exhausted, stressed, anxious and overwhelmed. This is a normal state, but some mothers feel guilty and excessively anxious about feeling this way, viewing themselves as abnormal in comparison to other mothers. They start to feel more exhausted and down, starting the cycle of depression detailed in the ‘ABC’ above, and eventually become depressed about being depressed.

He then challenges her absolute demand that she should not feel this way. He asks ‘How could developing the symptoms of depression make her a failure?’ and introduces her to the Raggy Doll Club. She suddenly realises that she has indeed been very hard on herself and resolves to become a fully fledged member. After that, she never looks back. After nine months and a number of visits, she is off all medication, is exercising, is looking after her diet, has taken up meditation and yoga on the advice of her doctor, is back relating normally to her husband, and has now bonded fully with her son, who is thriving both physically and emotionally. She had also acquired a Raggy Doll.

Jane’s story

‘She has just lost interest in everything’.

Jane is a sixty-seven-year-old widow whose husband died three years previously. She is now living alone. In the past six months, her family have noticed her withdrawing, becoming more forgetful, losing interest in food and losing some weight. She doesn’t seem to be enjoying anything, even the visits of her grandchildren, whom she is very close to. She has also stopped reading newspapers and novels (she had previously been an avid reader) and her family have noticed her drinking more.

Eventually, her daughter manages to persuade her to attend her family doctor. ‘I am not sure if she is getting dementia, or just needs some blood tests,’ she explains, ‘but she is just not herself. Maybe it’s just “old age”.’

Jane’s doctor has a chat with her, and following examination, sends her for some blood tests. On review, he is happy with most of her results, in particular that he has ruled out any thyroid gland problems, but he notes that her blood cholesterol and blood pressure are a bit high. He also decides that she displays no evidence of senile dementia but is suffering from depression. He explains that because she has no prior history of depression, the most likely cause of her illness is a mixture of the loss of her husband, combined with ageing changes in the brain and blockages in the small blood vessels supplying it, with her blood pressure and cholesterol findings contributing to the latter. Together, they draw up the following treatment plan:

Six months later, Jane is a changed person. She is back to her old self, is eating and sleeping better, has ceased taking alcohol completely and her memory, concentration and reading have returned to normal. Physically, she has regained weight, her blood pressure and cholesterol are normal, and she is getting plenty of exercise and emotional nourishment thanks to her new dog Paddy, named after her late husband. She has finally finished grieving for him after some bereavement counselling and is back fussing around her young grandchildren. She has also made many new friends in the local community-care centre. She is still on drug therapy and may have to take it for some time, but she and her family are happy with the improvement in her condition. It wasn’t just ‘old age’ after all.

Catherine’s story

‘I’m just not hungry any more. Food does not look appetising, and it’s too much energy to eat. Hopefully, I will waste away into nothing.’

Catherine is a twenty-four-year-old single parent, living on social welfare in a small, poorly equipped flat, coping with a small child and a ‘partner’ who abuses alcohol (and her). The stress of this has triggered a bout of depression. She has lost more than a stone in weight. Her father (now dead), an alcoholic, had been physically and verbally abusive to Catherine and her siblings. Her mother had suffered from anxiety and postnatal depression.

Catherine has not known much love in her life and as a result has developed low self-esteem. Unfortunately, she has become infatuated with her present partner, a carbon copy of the father she both loved and hated. She becomes pregnant and has a baby girl. Following this, her partner’s drinking and abusive behaviour has deteriorated. By the time the child is fifteen months, Catherine’s coping mechanisms are exhausted, and she becomes depressed. As her mood falls, she begins to loathe herself, losing interest in her appearance, food and sex, and becoming increasingly isolated from friends and family. The more her mood drops, the more she relies on cigarettes and coffee to make it through the day. She drinks more and, on a number of occasions, becomes extremely drunk. This often ends in her partner becoming insulting and abusive. Her weight continues to fall, and she becomes anaemic as a result of a lack of iron in her diet.

On two occasions, she walked by the river bank, fantasising about how easy it would be to jump in, and that the world would be better off without her around. Her mother, increasingly concerned, offers to take the child for a period, and Catherine agrees.

Eventually, things came to a head: her drunken partner beats her up and she responds later that night by drinking half a bottle of vodka and swallowing twenty paracetamol tablets. Luckily, her sister calls to the house and finds her in a semi-comatose state. She calls the ambulance and Catherine is admitted to hospital.

After spending a few days in intensive care, she is assessed by a self-harm liaison nurse and social worker (but hides the abuse from both). She refuses to see a psychiatrist, receives some advice and is eventually allowed to go home. Thankfully, her mother insists that she goes to see her local doctor, with whom she has a good relationship, looking for further help.

There, she explains how she has been feeling for the previous few months, discussing her fatigue, lack of interest in food and sex, poor concentration and memory and thoughts of self-harm. On probing, she finally breaks down and reveals her domestic difficulties and abuse. She also admits to misusing alcohol and to her fear of becoming addicted, like her father. Her GP, who is concerned about her physical and mental health, explains that she is suffering from depression and offers to help. Together, they draw up the following treatment plan, where she would:

Eight weeks later, she is feeling much better, begins a course of counselling and has ceased drinking alcohol. She is eating well, regaining weight, exercising regularly and even considering stopping smoking.

After twelve weeks and some counselling, she faces down her partner, breaking off the relationship and returning to live with her mum until she sorts herself out. When he threatens her, she is strong enough to seek help, in the form of a protection order.

Through counselling, she begins to deal with issues from her past, even having a frank conversation with her mum as to why she had not stood up for her against her father’s abuse. This resulted in an emotional and healing embrace.

After five months, she is back with her doctor, who is very happy with her progress. Her weight is normal and she is off cigarettes. She mentions feeling very negative about her decision to return to live with her mother, and that this was bringing down her mood. On further probing, this was just one of many negative thoughts which she was experiencing. At this stage, her doctor explains the ‘ABC’ approach and asks whether she would like to use this CBM approach to deal with this issue – to which she agrees. Together, they draw up the following analysis of her problem:

   BEHAVIOUR: She was avoiding friends because she felt that they would only confirm her own assessment of herself.

Her doctor challenges the above. Firstly, he explains how her behaviour is further isolating her from the love and friendship of those she normally associates with. So they agree that she will begin to change some of her unhealthy behavioural patterns.

He then moves on to challenge Catherine’s unhealthy belief that because she has returned home, this means that she is a failure. He introduces her to the Raggy Doll Club.

He then gives her some homework: to begin doing some ABC’s in situations where she finds herself interpreting events (internal or external) in a manner where she finds her mood suddenly falling – thus starting the process of helping her deal with her negative thinking and low self-esteem.

After a year, Catherine’s world has changed dramatically for the better. She is off drug therapy, is exercising and eating well, is off alcohol (and has decided, in view of her family history, to stay that way), is still off cigarettes, and is fully engaged in looking after her little girl. She is also planning to do a computer course and has become a fully fledged member of the Raggy Doll Club.

Noreen’s story

‘I have become increasingly forgetful, I have difficulty remembering the simplest of things, like what I did yesterday.’

Noreen is single, very busy twenty-seven-year-old manager who is struggling to cope with her day-to-day duties due to a depression triggered by a prolonged period of sustained stress. She has always suffered from anxiety and had a previous minor episode of depression in her late teens. Her mother and sister also have a history of depression. Following a difficult period at work, she begins to develop exhaustion, sleep difficulties, anxiety and loss of appetite, and poor drive, memory and concentration, which, together with her deteriorating low mood, makes her job almost impossible. She has always been an advocate of alternative versus conventional therapies and, with increasing desperation, tries one after another. But when trials of energy-field therapy, homeopathy, acupuncture, cranio sacral therapy, and reiki, among other things, were unsuccessful, she decides to visit her local family doctor for some blood tests.

When she explains her symptoms to her doctor, he agrees, but suggests that the most likely explanation was depression. Noreen dismisses this possibility, explaining that she was just a little bit stressed. Her GP gives her some information to read on the subject and arranges to see her after the tests.

When Noreen arrives home, she begins to reflect on his words, reads the booklet on depression, and consults with a close friend, who, to her surprise, agrees with her doctor’s opinion. On her next visit, her tests are negative and she accepts his diagnosis but immediately states that drug therapy is not an option. She would be prepared to consider any other therapy ‘There is no way I am going to endure all those side effects or be turned into an addict,’ she explains, He tries to convince her that this is not the case but still offers to do something to help her symptoms. After examining all the options, they agree on the following treatment plan, where Noreen would:

After six weeks, she has some improvement in mood but, to her surprise, develops some side effects from the St John’s wort – which she informs her doctor about. ‘I thought it was completely natural,’ she queries. He explains that it is still a drug very similar to the ones she wanted to avoid, and therefore had similar side effects. She decides to continue the course of St John’s wort for the time being. She is eating better, is exercising and is off alcohol; she has also begun a course of reflexology and decides to take up some pilates classes. She returns to work after eight weeks, attends a work counsellor and begins the stress-management course, but she is still struggling with her concentration and memory and finds that her thinking is continuing to be extremely negative. She decides to revisits her doctor.

He suggests some memory work for her in the form of crossword puzzles, reading the paper (something she had ceased doing) and joining the library, explaining that her memory muscles were weakened by bouts of depression and needed exercise, both physical and mental, to strengthen them. In relation to her negative thinking, she offers a typical example: the previous week, her boss had avoided giving her a job she would normally have been asked to do. She has become quite down as a result.

Her doctor then explains the ‘ABC’ concepts to her, and together they draw up the following analysis of her problem:

Her doctor challenges her belief that because her employer has apparently passed a task on to another colleague, this could possibly make her a failure and an awful person. He then introduces her to the Raggy Doll Club. He helps her see that if she becomes a ‘Raggy Doll’, she could not rate herself or be rated just because she had seemingly been passed over for some task, or indeed for any other reason.

Over the next few months, he works with her, using examples she provides him with, and using the ‘ABC’ concepts to help transform her thinking. This helps her deal with the barrage of negative thoughts underlying her anxiety and depression. After twelve months, Noreen’s life has been transformed. She is no longer taking St John’s wort and is exercising and eating well. As a result of her stress-management classes, and becoming a Raggy Doll, she is now less anxious and is coping much better with her work/life balance. On the advice of her doctor, she has taken up mindfulness meditation classes and, although she is still a fan of alternative medicine, she has accepted that conventional medicine has its place too.

Carl’s story

‘I am ashamed of the weak, useless, boring, incompetent failure I am. People hate spending time with me.’

Carl is a twenty-four-year-old mechanic whose quiet disposition and extreme shyness has disguised his inner torment from those close to him. Depression visited him first at the age of seventeen and has been an unwelcome but frequent visitor ever since.

He suffered from anxiety from an early age. On reaching his teens, he was badly bullied but managed to hide it from his family. His sense of self-worth took a major hit, and by seventeen his mood had begun to drop significantly, with fatigue, poor concentration and a host of other physical symptoms arriving in his life. But he bore them stoically: ‘Wasn’t he worthless anyway?’ He came from a loving, caring family. His mother had suffered from depression following his birth and on a number of occasions since. His older sister was like her father, a complete extrovert – unlike his mum, who was of a quiet disposition. He had always loved cars and was happiest when he was tinkering with engines. Although an excellent mechanic, he still felt useless, finding fault with his own work at every opportunity.

Bouts of depression came and went, and he found solace in alcohol, which provided only a temporary relief. He found it difficult to relate to girls, feeling awkward and uncomfortable in their presence. Eventually, at the age of twenty-two, he met a lovely girl who helped him emerge from his cocoon. He started to feel better, and after two years they became engaged. Then, with the stress of trying to organise a new home and a wedding, his depression recurred with a vengeance.

Negative thoughts now rush like a torrent through his emotional brain: ‘I am not good enough for her, she deserves better. She only agreed to marry me because she feels sorry for me.’ Bit by bit, they wear him down and he becomes physically and mentally exhausted. He is making mistakes at work and receives a warning from his boss. He becomes withdrawn and morose and his drinking increases. As he starts to push his fiancée away, she feels very hurt and withdraws from him, unsure of what has changed. Eventually things come to a head and he breaks off the relationship, telling her that it is for the best: that she deserves more out of life than him.

Following this, Carl’s mood drops further, he begins to feel hopeless and starts to plan his departure. On the night before he plans to end his life, something happens that will change his life. The girl who loved him had earlier that day come to see his mother, looking for some insight as to what she had done wrong in the relationship. As she was describing the sudden changes in his mood, his mother suddenly put everything together as a result of her own experience with depression. She shares her insight with Carl’s fiancée. They both decide to tackle Carl that evening.

As a result of their intervention, and his mother’s descriptions of her own battles with depression (and the love and warmth from them both), Carl opens up to the pain and mental distress he had been hiding. After some persuasion, he agrees to come with them to see their local doctor. That night, through their acceptance, he began his journey back to mental health.

Carl asks his fiancée to come in with him to see his GP, as he isn’t sure he will be able to describe how he feels. Then, with her help, he pours out all the physical and mental symptoms he has been experiencing. His doctor asks some questions and slowly the pattern emerges: it had started with the initial bullying. He proceeds to explain that Carl is suffering from depression.

It turns out that he is not sleeping, is not exercising, is drinking too much, is eating poorly and is suffering from extreme fatigue. When his doctor inquires about suicide thoughts, Carl is silent, not wanting to upset his fiancée, but is relieved when his doctor explains that these things are normal in depression. He finally admits to his plans for suicide and feels much better for having shed light on this dark place in his mind. He also admits to being still affected by the school bullying, the memory of which remains.

His doctor then explains how depression can completely distort our thinking and lead to all the physical and emotional symptoms Carl is experiencing, and that appropriate treatment can successfully deal with the problem. Together, they draw up the following treatment plan, where Carl would:

Eight weeks later, Carl is feeling better, is exercising regularly and is eating properly. He is off alcohol, has reunited with his fiancée and is ready to begin counselling to deal with some of the issues from his early teens. After four months, and some counselling, he has begun to come to terms with the bullying and relationship issues, but he is still plagued by the thought that he is inferior and not ‘good enough’ for his girlfriend. His doctor decides to do some CBM exercises with him. His doctor then explains the ‘ABC’ concepts to him, and together they draw up the following analysis of his problem:

His doctor challenges some of the above. Firstly, he explains how, in depression, our behaviour can further isolate us, thereby worsening the problem, as in how Carl pushed away his fiancée. His doctor challenges Carl’s unhealthy belief that he is a failure and of no value. He introduces him to the Raggy Doll Club.

He then gives him some homework: to begin doing some ‘ABC’s in situations where he finds himself interpreting events (internal or external) in a manner where his mood suddenly falls, thus starting the process of dealing with his negative thinking/low self-esteem.

Nine months later, Carl is well, off drug therapy and looking after his lifestyle. He has finished his counselling and, due to the work he and his doctor have done on his thinking, has become a true Raggy Doll. He is finally ready to marry the girl who stood beside him in his hour of darkness.

Jill’s story

‘Here we go again’,

Jill is a forty-six-year-old mother of two who holds down a part-time job in a local hotel and has suffered depression since the age of sixteen. She had a normal, happy childhood but found her early and mid teens to be a very stressful time, and her mood began to fall. She experienced multiple subsequent episodes of depression, including two postnatal bouts and one trip to hospital. She is becoming increasingly frustrated and hopeless because, no matter what she does, her depression seems to recur. Her husband has been wonderfully supportive but is finding it increasingly difficult to cope with her continuous relapses.

She has attended her family doctor and a number of different psychiatrists over the years, finally ending up on maintenance drug therapy in the form of a modern SSRI. She has also tried one alternative therapy after another, desperately looking for the ‘magic cure’, but despite this search she continues to relapse.

She finally comes in to her GP, feeling very down that once again her mood is falling, despite her maintenance therapy. She is not exercising and is eating poorly. She is drinking wine excessively and is struggling at work. She reveals that her suicidal thoughts are coming more to the fore and that the ‘river’ is very much in her mind. He empathises with her, and after a long discussion they draw up the following treatment plan, under which Jill agrees to:

Ten weeks later, she has been reviewed by the specialist, who decides to put her on Lamictal (a mood stabiliser) also. She is now exercising regularly, is eating and sleeping better, is off alcohol, is no longer having suicidal thoughts and is generally improving. She revisits her family doctor, who is pleased with her progress. He feels that she is well enough to begin some CBM therapy. He starts by spending some time explaining that, just because we have a thought, this does not mean that it is true, and he gives her some examples. He continues that when we have suffered recurrent bouts of depression, we retain the memory of these negative thinking patterns. He gives her some information on the differences between CBM, which he suggests they begin, and mindfulness, which they might explore later. He then asks her to return to begin CBM. He explains the ‘ABC concepts, and they decide to do one on her commonest negative thought, namely ‘here we go again’:

Her doctor then challenges her unhealthy beliefs: firstly, her demand that she must not get depressed again, and then her belief that she is a failure and of no value. He introduces her to the ‘Big MACS’, challenging her demand for 100 percent certainty, and noting that it would be better to use the word ‘prefer’ instead of ‘must’. He introduces her to the Raggy Doll Club. He then gets her to begin doing some ABC’s in situations where she finds herself interpreting events (internal or external) in a manner where her mood suddenly falls.

Nine months later, and after a number of further visits to both her GP and her psychiatrist, she is much more confident that the risks of her depression recurring are receding. She is also more accepting of the fact that this could happen. Her doctor now introduces her to the concept of mindfulness. She quite quickly grasps the concepts behind mindfulness and its role in the prevention of depression. He recommends some reading material and a CD on the subject and explains the Three Minute Breathing Space meditation, saying how useful it can be in assisting us to become more aware of our negative thoughts and emotions.

Jill finds mindfulness and in particular the above exercise extremely useful. She starts to become more confident about coping with the normal stresses of life. She and her husband join a meditation group, gradually becoming more adept in day-to-day mindfulness. The addition of the mood stabiliser to her maintenance-drug therapy, together with becoming a Raggy Doll and her work with mindfulness, has transformed her life.

Jack’s story (and the smile that saved him)

‘The world will be a much better place without me. I am a burden on everyone and they won’t miss me at all.’

Jack, a twenty-nine-year-old computer whizzkid, has already quietly planned in great detail how he will end his life. Because his depression has not been recognised and remains untreated, he is about to put these thoughts into action. This course of action has been made more likely by a dramatic increase in alcohol consumption to numb the pain associated with his recent break-up from his girlfriend.

He started to get into difficulties in his late teens and early twenties, struggling with bouts of major depression. Each time these occurred, negative thoughts roared in, swamping his logical brain. He has already taken an overdose in his mid-twenties following a night of heavy drinking.

When feeling well, he enjoys his work and is successful, but at a cost. Even when he seems to be completely on top of things, it requires a tremendous effort for him to remain so. The consequences of this are serious bouts of low mood. During these episodes, suicide thoughts come with increasing frequency, and more recently he thinks about the method he might use. The latter is assisted by information downloaded from an inappropriate site on the Web, where he finds his emotions and feelings of self-loathing mirrored.

He has managed to hide how he feels from those close to him, including his girlfriend Clare, who regularly feels upset and rejected by his sudden withdrawals into himself. Things come to a head when he lashes out verbally one night while going through a period of self-loathing, and the relationship ends.

He drinks heavily that weekend and his mood sinks further. The Monday following the departure of Clare, he begins preparations to end his life. He rings in sick to his workplace and calls his mother to tell her that he loves her. He texts Clare, apologising for his behaviour. He feels a huge sense of relief; the pain will be over at last. He leaves to travel to where he has decided to end his life, with what he needs in his backpack.

On his journey, by chance, he makes eye contact with a face in the crowd, a young mother gazing lovingly at the baby in her arms. Jack’s eyes settle on the baby and then at the mother. She smiles at him and in that moment something lights up inside him. For a split second, the love of the mother for her baby, and the unaffected warmth of her smile, pierces the darkness and pain within like nothing else so far has managed to do. Suddenly an image of how his own mother would feel if he went ahead with his plans bursts into his consciousness. He sees her love mirrored in the smile of the mother with her baby, and the tears start to flow. Before he knows it, the phone is in his hand and he is calling her, pouring out his pain and distress. He has just begun one of the most important journeys of his life: the one back to mental health.

The following day, Jack, accompanied by his mum, comes to see his local family doctor and opens up to the decade of hell he experienced; the classic mixture of the physical (fatigue, poor concentration and memory, sleep, appetite and drive difficulties) and psychological symptoms (extremely low mood, anxiety, negative thinking and suicidal thoughts). His doctor is extremely empathetic, explaining that Jack’s symptoms are due to depression and that he has taken the first and most important step towards recovery: sharing his pain. With Jack’s help, he reviews his past, searching for any sources of his problems, but apart from a history of his mum having depression during and after his birth, there are no obvious causes. They did identify the role of stress in the generation and maintenance of his depression. Together, they draw up the following treatment plan, where Jack would:

Within six weeks, and after a number of visits to his doctor, Jack is already seeing the benefits. His mood is up, his suicidal thoughts have begun to recede, his energy and concentration levels have improved, and his anxiety has lessened. He is exercising regularly, is eating properly, is off alcohol and has begun taking supplements. He has started the counselling provided by his company.

After ten weeks, he is feeling well enough to begin some CBM on his negative thinking with his doctor. Jack gives an example of one of the most common thoughts that have plagued him in social situations: ‘If people knew how weak and useless I really am, they will, quite rightly, want nothing to do with me.’ His doctor then explains the ‘ABC’ concepts to him, and together they draw up the following:

His doctor challenges his unhealthy belief that he is a failure and of no value. He introduces him to the Raggy Doll Club. For Jack, this is a profound revelation. The Raggy Doll, like the smile from the lady who indirectly saved his life, touched something deep inside him. He really wants to join the club. His doctor asks Jack to begin doing some ‘ABC’s in situations where he finds himself interpreting events (internal or external) in a manner where his mood suddenly falls, and to return to see him.

Within a year, Jack’s world has, like Alice in Wonderland, been turned upside down. His mood is fully back to normal, his physical symptoms have settled, he is back at work, and he is enjoying his life for the first time in a decade. He has also, on the advice of his doctor, learned to include some mindfulness exercises, like the Three Minute Breathing Space, finding them so helpful that he has embarked on a journey into the world of meditation. In his social life, there have also been major changes: he is now engaged to Clare. He mixes more with friends, and has learned to do so without the crutch of alcohol.

He still has a constant battle with the negative thoughts that keep rearing their ugly heads, especially when he is under stress, but with the help of his doctor and work on the ‘ABC’ concepts, he has gradually changed his unhealthy thinking patterns. He decides, with his doctor, to come off his drug therapy as a trial. Two years later, happily married and with his wife expecting their first child, Jack remains well.

There are some important lessons to learn from Jack’s story:

Seasonal Affective Disorder (SAD)

For some people, particularly in more northerly climates, the darkness of wintertime creates a unique depression. People with SAD develop all the symptoms of depression, together with a craving for food, and accompanying weight gain and hypersomnia. There are some links between SAD and bipolar disorder.

Some experts maintain that darkness encourages the brain to make a neurotransmitter called melatonin. This has the general function of helping us to sleep at night. On the other hand, light encourages the production of serotonin. There is an important neural connection between the eyes and a part of the hormone control box which, as we discussed earlier, controls all our body rhythms and biological clocks. As daylight arrives every morning, it penetrates through our closed eyelids, activates this pathway (leading to increased serotonin cable activity in this box) and prompts us to wake up. When darkness falls, this neural pattern is reversed, and the brain produces melatonin to encourage us to sleep.

Artificial daylight (through our narrow-spectrum light bulbs) simulates much of this natural pattern. Real daylight is up to twenty times more powerful than artificial light, however. Melatonin and serotonin are intimately interwoven into the normal circadian rhythms of our lives.

SAD seems to be caused by an excessive production of melatonin and a lack of serotonin. Of great importance is the seasonal difference in the production of serotonin, with higher levels in the summer and lower levels in the winter It may be that this exposes a general shortage of serotonin in those with this condition. This may explain why these people recover during the bright summer months and slip back into trouble in the winter.

It is also felt that a shortage of serotonin in the hormone control box in particular leads to a craving for carbohydrates, with resulting weight gain during SAD episodes. It is believed that the disorder is linked to problems with specific serotonin receptors.

We have already discussed the usefulness of light therapy and dawn simulators in depression in general. In SAD, this is especially the case, with up to 70 percent responding; the remainder may require serotonin-boosting drug therapy (SSRIs) as an adjunct. Talk therapies and alternative therapies have little function in this illness.

Bipolar Disorder (Manic Depression)

This illness is often confused with unipolar depression. In unipolar depression, mood can swing from normal to low and back again but does not become elevated. In bipolar, intermittent bouts of low, normal and elevated mood may be present.

The traditional view of bipolar mood disorder is that it is a completely distinct disorder from simple unipolar depression in its causes, genetics, presentation and treatment. While this is still the accepted norm, a body of opinion is viewing recurrent severe MDD and bipolar as part of a ‘spectrum’, varying from mania at one end to severe MDD at the other. This shift is happening due to the increasing overlap of neurobiological findings in both. Only time will reveal if this is true. Bipolar mood disorder can be divided into two main groups:

BIPOLAR DISORDER, TYPE 1: Here, the person will have suffered at least one manic episode, usually associated with periods of low mood or depression. They suffer the usual symptoms of depression already dealt with, including:

Mania is the opposite of depression. It is defined as a distinct period of abnormally and persistently elevated mood lasting at least one week, which sometimes requires hospitalisation. During this period of elevated mood, the person will display the following:

A very unpleasant form of type one bipolar disorder is dysphoric mania. This is where the person gets a bout of depression during an episode of severe mania in which, instead of the person feeling ‘on top of the world’, they becomes extremely distressed, irritable and agitated, with racing and suicidal thoughts. It constitutes between 30 to 40 percent of instances of mania, is more common in women, is associated with a high suicide risk and a higher rate of familial depression, and will usually require hospitalisation. It can be a very distressing condition for both the person and their family. It can also be present in a lesser form as dysphoric hypomania, where depression is present during an episode of hypomania (see below).

BIPOLAR DISORDER, TYPE 2: Here, the person suffers mainly from bouts of depression, interspersed with periods of hypomania. Hypomania is a distinct period of euphoria lasting for at least four days. During this period of elevated mood, the symptoms of mania emerge, although they are not as obvious, usually do not cause major difficulties in the person’s ability to cope with normal activities (in fact, many feel that they cope better during this period) and seldom require hospitalisation. The person will rarely suffer from delusions or hallucinations. A person with hypomania will have periods where they experience the following:

In future, we may be including a third type, namely antidepressive triggered bipolar disorder, where a latent illness is unmasked by medication.

Bipolar disorder (BD) sometimes appears in the teenage years and, even when the condition is observed, it is often misdiagnosed as normal depression. Only when the periods of elevated mood are either admitted to or noticed by others, does the real diagnosis emerge. Bouts of low mood, periods of normality and occasional bouts of elevated mood merge to create the distinct pattern of this illness. Unfortunately, there is often quite a delay in diagnosis due to the erratic nature of the illness. In some people, the condition may (through a combination of not presenting early enough and a delay in accurate diagnosis) remain undetected for up to ten years. Only one in four bipolar sufferers are diagnosed within three years of onset of the condition. Over their lifetime, a bipolar sufferer will typically suffer eight to ten episodes of mood swings. Untreated episodes of mania may last from four to six months. In practice, mania symptoms are so severe that help is usually received quite quickly, so episodes may last only weeks. Episodes of hypomania are much more subtle and are of shorter duration, so they often go undetected. Bouts of depression, if untreated, can last up to nine months. One of the difficulties with this condition is that patients treated with antidepressants may develop a subsequent bout of hypomania or mania as a result of the medication. A particular concern is where a person with dysphoric hypomania presents with what may appear at first glance to be simple depression, and is treated with antidepressants. This can create more agitation, and suicidal thoughts or actions may increase.

The risk of suicide in general in bipolar disorder is greatest in the early stages of this illness (which is why early diagnosis is vital) and more often occurs in the depression or mixed-mania phases. There can be a delay of four to five years between the first and second episode. Following this, the length of time between episodes will gradually begin to shorten. In some cases, the severity of the illness, especially if it is untreated, will worsen. If one looks at the probability of recurrence, some estimate it at 50 percent for the first year, 70 percent by the fourth year, and 90 percent by the fifth year.

This illness is not as common as unipolar depression, and affects both men and women equally. The incidence of bipolar type one is 1 percent, and bipolar type two probably between 1 and 2 percent. Some experts believe that the true incidence of type two may be considerably higher.

The Bipolar Disorder Pathways

It is now accepted that MDD and bipolar disorder (BD) pathways are similar, as both involve:

  1. malfunctions within the internal workings of the neurons (and glial support cells) themselves and in their connections (synapses) with each other
  2. a breakdown in some key brain systems/circuits as a result of this
  3. the mood, behaviour and thought difficulties and physical symptoms already outlined

Just as in MDD, it is now felt by most experts that BD is primarily a disorder affecting the second messenger system in the neurons themselves, leading to changes in the mood system, in a way that is similar to, but distinct from, MDD. We discussed the role of the second messenger system in bipolar disorder earlier (see page 140).

There is a large amount of research going on (some of it here in Ireland) into identifying the genes underlying BD, and the main culprits involved. When we have built up a total genetic picture, we can reveal how such genes lead to individual malfunctions within the second messenger system. We know that malfunctions within the internal cascade of second messengers can lead to either deterioration in the function of, or the death of, individual neurons, which in turn can lead to the widespread disruption of the brain’s mood departments and circuits that is so prevalent in BD.

It is now felt that major stresses in early life, through epigenetic mechanisms, lead to a later triggering of BD. When the illness is actually triggered, it is felt that the second messenger system becomes increasingly maladaptive, making further episodes more likely. This system is also highly sensitive to sex hormones and glucocortisol, which explains why stress and pregnancy can trigger BD. Abnormalities of this system in other parts of the body are the probable explanation for the concomitant presence of coronary heart disease and diabetes in both MDD and BD, probably through genetic links.

The role of the mood system in bipolar disorder is one of the most important findings in this area in the past ten years. Through research into those suffering from recurrent bouts of BD (and MDD), the subtle loss of neurons, dendrite connections and support glial cells scattered throughout key parts of our mood system, was discovered. It now seems as if these losses of crucial neural connections, and indeed of neurons themselves, most likely arise secondary to malfunctions occurring within the second messenger system, leading to a loss of the vital neurotrophic proteins already mentioned.

Of particular interest has been the finding of brain tissue loss in the logical brain, most notably in the logic, social behaviour and attention boxes (particularly on the left side of the brain) – all key players in our ability to control thoughts, emotions and behaviour. Similar loss of grey matter has also been discovered in parts of our emotional brain, particularly in our memory and stress boxes. This leads to a breakdown in both the functioning of these boxes and in key circuits connecting the logical and emotional brain, which results in the symptoms of BD. The result of all these changes in BD is a more profound disruption of the mood system than in MDD. We will discuss this in more detail in the technical section.

So, in summary, the bipolar pathway:

The Role of Our Holistic Therapy Pathway in Bipolar Disorder

Foundations

The same rules apply in the areas of empathy, exercise and nutrition as in MDD. In terms of supplements, I would particularly recommend Omega 3 fish oils in BD, as they seem to have useful effects within the cell membrane/second messenger system and in the brain and heart. I would use up to 1000 mg of EPA, which I find to be useful in BD when taken in combination with other drug therapies. Moderation in the use of alcohol and drugs is another important area in this illness. It is crucial that we deal with this, as otherwise recovery will be blocked. Stress reduction is a vital area too, as stress is often a trigger for relapses. Meditation is useful, but only when mood has been stabilised. Relaxation therapies like yoga, massage and aromatherapy are useful short-term anti-stress measures when the person is stable. The placebo effect is less important in BD, owing to the more extreme neurobiological underpinnings of the illness.

Main Structure

Conventional drug therapies lie at the heart of the therapy pathway in BD, even more so than in MDD. Without them, recovery would be very difficult. Four groups of conventional drugs are used in BD:

LITHIUM is the most commonly used mood stabiliser, particularly in bipolar type 1. It has been extensively researched, with most of our information on internal cellular changes emerging from these findings. It has multiple positive effects on the second messenger system, which I will detail in the technical section, but the primary mechanism involves regulating Bcl 2 and BDNF. It not only safeguards neurons and dendrites but regenerates both in various parts of the emotional and logical brain, particularly in the attention box. Shown to be effective on its own in both the manic and depressive phases of BD, Lithium can be also used in combination with other mood stabilisers and antidepressants. It can cause weight gain (by stimulating appetite in the brain), slight tremors (alleviated by small amounts of beta blockers), is contraindicated in pregnancy (for the first three months) and requires regular blood-level monitoring to out rule toxicity.

ANTIEPILEPTIC-TYPE MOOD STABILISERS, which are routinely used in epilepsy, are also useful in BD:

EPILIM is an anti-epileptic-type mood stabiliser, extremely useful for treating bipolar type 1, and has similar effects on the second messenger system and BDNF and Bcl 2 as lithium, both medications being neuroprotective. It is primarily used in mania, Epilim can cause weight gain (by stimulating appetite in the brain). It is completely contraindicated in pregnancy.

LAMICTAL is another antiepileptic mood stabiliser, increasingly seen as an excellent treatment of bipolar type 2, and occasionally, when combined with anti-manic drugs, in bipolar type 1. Its great strength lies in its ability to prevent depression relapse. It does not lead to weight gain, can occasionally cause severe rashes and was initially thought to be safe in pregnancy (although now it is thought to increase the risk of cleft palate slightly). It can be combined with Lithium.

MAJOR TRANQUILLISERS have become increasingly popular as another type of mood stabiliser, but mechanisms of action are different to the above. They are used both to treat and to prevent mania in particular.

ZYPREXA is a popular choice but does have significant side effects, particularly marked sedation and extreme weight gain. It is quite effective and can be used in combination with any of the above.

SEROQUEL is another commonly used drug and one I personally prefer. It has fewer side effects than Zyprexa.

The main concern in relation to these drugs is their propensity to increase weight markedly. They lead to an excessive build-up of abdominal fat, which is the main cause of diabetes and accelerated atherosclerosis, with risks of heart attacks and strokes. They do so by stimulating appetite centres in the brain. BD is already associated with an increased risk of all of the above due to constant high levels of glucocortisol. Many experts are concerned about the overuse of these drugs because such side effects may accelerate these risks. If you are concerned about these things, never stop taking them unilaterally, but don’t be afraid to discuss the issue with your specialist or family doctor, and make sure that you have regular checks on your weight, blood pressure, cholesterol and blood sugars.

ANTIDEPRESSANTS are of great help in MDD but their use in BD is more complex and controversial. The older antidepressants (Tricyclics) were renowned for tipping those with BD from depression into mania. The newer SSRIs are less inclined to cause this ‘switch’ but in the absence of a mood stabiliser can increase the risks of it occurring. Drugs affecting the noradrenalin mood cable, like Efexor/Cymbalta, behave like the older drugs and should be treated with more caution. The real problems occur when somebody who seems to have simple MDD is in fact a latent BD sufferer. In such cases, antidepressants may trigger a bout of elevated mood. They have a role in type 2 BD, but only if combined with a mood stabiliser, and should be withdrawn as soon as possible, to reduce the risks of a switch to mania.

ALTERNATIVE DRUG THERAPIES include herbal remedies like St John’s wort and homeopathy. I strongly discourage the use of such remedies in BD. This is an extremely complex illness, which requires conventional specialist help. The use of Omega 3 oils is one area where both conventional and alternative practitioners agree. The consensus is that they are extremely useful as an adjunct, but probably not when used on their own.

TALK THERAPIES are also important in BD, but perhaps not as much as in MDD. This is due to the extreme biological nature of the former, where drug therapy is the cornerstone of treatment. Often, there are major issues in the life of the person with BD, and these may require counselling. Sometimes, this will involve relationship counselling or interpersonal therapy; other times, it may involve addiction counselling. In my opinion, there is little place for psychoanalytical psychotherapy. Of all the talk therapies, CBT is probably one of the most useful, but it can only be applied when the person’s mood state has been stabilised. It can be used to assist with the negative thoughts and behaviours that might occur in the depressed phase of BD and in teaching others to recognise and moderate symptoms of elevated mood. Such work can only be done by a highly trained CBT therapist who has experience in the field.

Ancillary Therapies

This relates to those therapies, mainstream and alternative, which are also used to treat BD.

The Application of the Holistic Therapy Pathway to Bipolar Disorder

BD is a much more complex disorder to deal with than MDD and should be managed by a psychiatrist and family doctor, working with other mental-health services. The modern approach revolves around the use of mood stabilisers and major tranquillisers in different combinations to manage moods, with all other drug/talk/alternative therapies only relevant when mood control has been achieved. I deal with some specific details in the technical section, but include the following examples to illustrate how the condition operates in practice.

‘I just can’t sleep’

Peter comes to see his family doctor, complaining of low mood and difficulty in sleeping for the previous three months. He is a twenty-four-year-old postgraduate student struggling with bouts of low mood, fatigue, poor concentration and anxiety since his late teens, but had not looked for assistance. There were some occasions when his mood would briefly become elevated and his thoughts would race, but to his doctor he only reveals his low mood. His GP asks about suicidal thoughts. Peter admits to these, and says that he drinks heavily to help him sleep and has a stream of negative thoughts that he is worthless and the world would be better off without him. His mother had suffered from depression and, unknown to Peter, his uncle has suffered with bipolar disorder type 2. His present episode began with a period of prolonged stress, including a break-up with his girlfriend.

Together, Peter and his doctor draw up the following treatment plan, where Peter would:

After six weeks, Peter notices no improvement, is still agitated and is unable to sleep. His doctor, concerned about his agitation, makes an appointment with the local psychiatrist, who reviews him two weeks later. The psychiatrist traces his history from childhood and notes his mother’s history. He particularly inquires about periods of racing thoughts.

Peter admits to short periods of feeling ‘high’, where he would feel full of energy and nothing would be a problem. He also reveals that during such periods, he sometimes went on shopping sprees. He notes the presence of suicidal thoughts but the absence of specific plans to act on them. The psychiatrist concludes that Peter is going through a bout of bipolar disorder type 2 and explains what that means. Together, they draw up the following treatment plan, under which Peter will:

Eight weeks later, Peter is feeling better and is sleeping. His mood has improved and he is calmer. His psychiatrist (now acquainted with Peter’s family history of BD) lays out a plan where his antidepressant would be gradually reduced to a minimum dose, with a view to phasing it out. The specialist continues him on Lamictal. Six months later, on review by his family doctor, all is well. Peter is able to focus and concentrate on his studies, is off alcohol, is exercising and is eating well, and his mood has settled. He is still on his mood stabiliser, but he is off antidepressants. He has joined an Aware self-help group at college, and he finds that sharing his illness with others of his age group is of great assistance. He has worked with a CBT therapist on the advice of his psychiatrist and is also involved in a mindfulness program.

We can learn the following lessons from Peter’s case:

‘I feel so down’

Caroline, a thirty-year-old single insurance company executive, attends her family doctor on the advice of her sister, who is increasingly concerned about her mental health. Caroline explains how depressed she has felt for the previous three months, but becomes irritable when her sister comments in particular about her journey into the world of alternative therapy and the fortune she has spent on such treatments.

She admits to restlessness, insomnia, exhaustion, loss of interest in food and sex, suicidal ideation, and previous bouts of depression since her late teens. There were no obvious stress triggers, and there is no family history of depression. She was not coping at work and was also misusing alcohol. Her family doctor diagnoses depression but is uneasy about her irritability and suicidal thoughts, and also about her starting antidepressants without specialist review. Together, they draw up the following treatment plan, under which Caroline will:

One week later, Caroline is assessed urgently by the local psychiatrist. She is now feeling terrible: her mood is deteriorating, she is extremely agitated and unable to sleep, and has increasing suicidal thoughts. Her detailed history reveals distressing, racing thoughts, which are driving her to distraction. The psychiatrist thinks that Caroline is suffering from a dysphoric bipolar episode, and agrees with her family doctor’s decision to withhold antidepressants. He explains the diagnosis to Caroline and her sister and they draw up the following treatment plan, under which Caroline will:

Eight weeks later, following a number of visits to the psychiatrist, Caroline is gradually improving: her racing thoughts are decreasing, her sleep is returning to normal, and her suicidal thoughts have gone. She is also less irritable with her sister.

We can learn from Caroline’s case that in dysphoric bipolar disorder:

‘I feel embarrassed’

Anne attends her doctor feeling embarrassed about her behaviour during a particularly difficult bout of elevated mood, when she had spent a fortune on a shopping spree and made sexual advance on her friend’s partner. She had spent some time in hospital, had been diagnosed with bipolar type 1, was now well on Lithium and Seroquel and was attending the local psychiatrist regularly for blood tests and check-ups. He decides, with permission from the specialist, to send her to a senior CBT therapist for assistance.

The therapist over a period of time teaches Anne to deal with her elevated phases of mood (where she feels invincible) by introducing her to a ‘stay safe’ program devised by therapist Enda Murphy. This involves the person agreeing to liaise with three close friends where, if one of them notes that her mood is beginning to elevate, she checks with the other two as to whether either agrees that this is so. In such cases, Anne agrees to go for help and to become, with their help, more careful about her behaviour. After working with him for some time, Anne feels much more comfortable with what she needs to do at such times.

Her doctor carries out a full cardiac screen, discovers that she has elevated blood pressure and cholesterol and deals with these in the usual way. He also gives her advice on the risks of osteoporosis.

The lessons we can learn from Anne’s case are: