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Depression and the Problem of Chronicity.

Posted Nov 23 2010 1:19pm

men's blog depression There has been a sea change in the way depression has been conceptualised in recent years.  Depression used to be seen as an episodic acute event.  That is to say, people became depressed, then with or without treatment, got better and it never returned.  The evidence, however, does no bear this out.  If you have had one bout of depression you are much more likely to have another.  If you have had several bouts of depression, you can probably look forward to a lifetime of further bouts.

This information is at first sight depressing!  Indeed it is for the most common treatment of depression, the antidepressant drug.  The widely believed theory of depression is that it is an ‘imbalance in the brain’ of various neurotransmitters such as serotonin.  The antidepressant restores the ‘imbalance’ so relieving the symptoms.

As time passes this is increasingly seen to be a fanciful view of depression.  Evidence in depressed patients is starting to show that serotonin may be depleted in some brain areas, but may also be excessive in other brain areas.  (Neuroscience, vol 141, p. 1047).  The implications of this are that boosting the brain with serotonin may actually cause more problems than they solve.  For example some people on antidepressants feel increased anxiety or increased impulsivity including suicidal thoughts.  This may be because areas of the brain already high in serotonin are given a boost by the drug.  It might also explain why some people get no benefits from antidepressants at all.

The National Institute for Clinical Excellence (NICE) in the UK does recommend the use of antidepressant drugs, but only for the most severely depressed patients.  NICE, however, recommends psychotherapy for all patients with depression however mild or severe.

Perhaps the reason for this is that antidepressants do relieve symptoms in some patients, but when the treatment is withdrawn, patients often fall back again into depression.  The chronicity problem again.

What psychotherapy does is to teach the skills and insight needed to understand the depression proces and so help patients to stay well for longer.  There is a problem with psychotherapy though, in that the mechanisms that make people vulnerable to future bouts of depression are not clearly understood.

One new type of therapy, however, appears to offer a solution.  Mindfulness Based Cognitive Therapy (MBCT) is a relapse prevention approach that tackles one area where people may be vulnerable to relapse, and its in a counter intuitive place.

If we have had one bout of depression and we feel that another bout of depression is starting to come on, the natural inclination is to try to work out what the problem is.  The creators of MBCT (Segal, Williams and Teasdale) suggest that it is just this kind of reflection that triggers a further bout of depression.  Rather than just accepting a low day, depressed patients ruminate about its cause.  It is this rumination that then triggers the depressed memories thoughts and images that the person needs to avoid to stay well.  In trying to solve their problem, the patient just digs themselves a deeper hole.

MBCT advocates a number of ‘mindfulness’ exercises and meditations to help people be more accepting of the constant flow of thoughts feeling and memories they have and not get so caught up with them.  The act of using meditation techniques also has the effect of tying up the very cognitive processes needed for rumination itself.  As a result MBCT claims to help prevent relapse by a double strategy of mindful acceptance and, I suppose, a kind of distraction.

Although MBCT is a relapse prevention program, there is no reason why mindfulness techniques should not be offered in active therapy once the persons mood has returned to normal.  It might also be considered good practice to do so. 

If you are reading this and feel you might be vulnerable to further bouts of depression, you do not need to turn to a therapist in the first instance.  Indeed MBCT is not widely available so finding a class may be tough. You might be better advised to learn meditation from a skilled instructor from one of the many classes that are offered around the country.  Learning to meditate in a group is much more rewarding because you benefit from the experiences of your class mates and you could make much more progress as a result.  Once you have established a mindfulness practice, it is then easy to stop yourself when your mood slips and meditate, even for just a few minutes, and let the feelings and thoughts pass. 

The evidence for MBCT is encouraging.  It is effective at reducing relapse even for patients with a long history of bouts of depression.  Whatever the reasons why mindfulness works at preventing relapse, it is worth giving it a go.


Dr Phil Tyson is a Men's Psychotherapist based in Manchester in the UK.  He offers:

Dr Tyson is also regularly quoted in the printed media and as a guest on local and national broadcast media.

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