DEFEATING DEPRESSION: Non-medication ways to beat the blues

1. DEFEATING DEPRESSION:Non-medication ways to beat the blues • Bill O’Hanlon • BillOHanlon.com • FREE STUFF • Then Click SLIDES

2. Visiting Depresso-Land My story

3. Challenging Depression Myths Myths about depression: • Cause is known (biochemical and genetic) • Despite the ads one sees on TV, the cause of depression is not known and has not been established as biochemical or genetic • “For most common diseases, specific genes are almost never associated with more than a 20-30% chance of getting sick,” explains Bryan Welser, CEO of gene discovery company Perlegen Sciences. (Quoted in Wired, Nov. 2009, p. 121) • “The strongest predictor of major depression is still your life experience. There aren’t genes that make you depressed. There are genes that make you vulnerable to depression.” –Kenneth Kendler, M.D., Professor of Psychiatry and Genetics Medical College of Virginia, TIME, March, 2001 • Antidepressants are the only effective treatment

4. What This Presentation Offers • The six strategies: New possibilities for effective intervention • These are alternate approaches to use with clients/patients with whom your usual approaches have not helped or to supplement your current methods and approaches

5. Depression can be devastating • Andrew Solomon (author of “The NoonDay Demon”)

6. #1 Walking Out of Depresso-Land Mapping depressed times and non-depressed times • Investigate times and aspects of non-depression while finding out about depressive experience

7. Focus mainly on depression could add to the problem A recent study shows that extensive discussions of problems and encouragement of ‘‘problem talk,’’ rehashing the details of problems, speculating about problems, and dwelling on negative affect in particular, leads to a significant increase in the stress hormone cortisol, which predicts increased depression and anxiety over time. Byrd-Craven, J., Geary, D. C., Rose, A. J., & Ponzi, D. (2008). “Co-ruminating increase stress hormone levels in women,” Hormones and Behavior, 53, 489–492.

8. Acknowledgment and Possibility • Of course, we need to speak about depression to assess and help the person • Move back and forth between discussions of depression and non-depressive moments and experiences. • This moves the person out of state-dependent memories and biases for brief interludes and makes change easier • This not only respectfully acknowledges the person’s painful and discouraging experiences, but gives them a reminder they aren’t and haven’t always been depressed. • It can also illuminate and give hints to skills, abilities and connections that can potentially lead out of depression or at least reduce depression levels.

9. Letter from Abraham Lincoln to Fanny McCullough after she was distraught over the loss of her father in the Civil War Dear Fanny It is with deep grief that I learn of the death of your kind and brave Father; and, especially, that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares. The older have learned to ever expect it. I am anxious to afford some alleviation of your present distress. Perfect relief is not possible, except with time. You can not now realize that you will ever feel better. Is this not so? And yet it is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you some less miserable now. I have had experience enough to know what I say; and you need only believe it to feel better at once.

10. Make maps of depresso-land and non-depresso-land Compare and contrast and build maps of feelings, actions, thoughts, focus of attention, interactions and contexts associated with both depressive experience and non-depressive experience

11. Elaine’s maps Depresso-land Confident/Competent-land Gets out of bed by 9 a.m. Stays in bed until noon Doesn’t have a job or quits job Contacts friends Plays music Eats breakfast foods all day Focuses on good things she has accomplished in the past Stays alone; talks only to depressed friend or therapist Has a job; Goes to work Focuses on bad things happening in the future Spends time with women friends Goes to lunch alone

12. Discover exceptions, resources and solutions • Find out about moments of non-depression • Find out about what happens when the depression starts to lift differently than during it • Ask why the problem isn’t worse • Import strengths and abilities from contexts of competence • Investigate resilience and times of bouncing back from setbacks, tragedies, trauma and troubles

13. Inclusion • Permission • To and not to • “It’s okay to feel depressed.” • “You don’t have to have hope right now.” • Inclusion of opposites • “You can be hopeless and have hope at the same time.” • Exceptions • “You feel hopeless except when you don’t.”

14. #2 Undoing depression • Pattern intervention • Discover repeating patterns involved with and associated iwth depressive experience and help the person change those patterns in small or big ways • Patterns of doing, viewing and context • Highlight any places around depression that the person has moments of choice

15. Undoing depression:Case example Erickson sends a depressed person to the library

16. Undoing depression:Identifying patterns • Location/places • Activities • Timing/Duration • Sequences • People

17. #3: Shifting relationship to depression

18. Mindfulness • Noticing variations in sensations, feelings, thoughts and experiences around depression • Noticing without judging • Witnessing rather than getting caught up in; being with • Get curious Teasdale JD, et al. (2000). “Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy,”Journal of Consulting and Clinical Psychology, 68(4):615–623. Teasdale JD, et al. (2002) “Metacognitive awareness and prevention of relapse in depression: empirical evidence,”Journal of Consulting and Clinical Psychology, 70(2):275–287. Williams, M.; Teasdale, J.; Segal, Z.; and Kabat-Zinn, J. (2007). The Mindful Way Through Depression: Freeing yourself from chronic unhappiness. NY: Guilford. Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Lau, M., & Soulsby, J. (2000). “Reducing risk of recurrence of major depression using Mindfulness-based Cognitive Therapy,”Journal of Consulting and Clinical Psychology, 68, 615-23.

19. Mindfulness Based Cognitive Therapy (MBCT) • MBCT proved as effective as maintenance anti-depressants in preventing a relapse and more effective in enhancing peoples' quality of life. The study also showed MBCT to be as cost-effective as prescription drugs in helping people with a history of depression stay well in the longer-term. • Over the 15 months after the trial, 47% of the group following the MBCT course experienced a relapse compared with 60% of those continuing their normal treatment, including anti-depressant drugs. In addition, the group on the MBCT programme reported a higher quality of life, in terms of their overall enjoyment of daily living and physical well-being. Kuyken, Willem, et. al. (2008). “Mindfulness-Based Cognitive Therapy to Prevent Relapse in Recurrent Depression,”Journal of Consulting and Clinical Psychology, December; 76,(6): 966-978.

20. Mindfulness Based Cognitive Therapy (MBCT) Other studies: • Bedard, M., et. al (2008). “Mindfulness-based cognitive therapy reduces depression symptoms in people with a traumatic brain injury: Results from a pilot study,” European Psychiatry, Volume 23, Supplement 2, April, Page S243. • Bondolfi, Guido; et. al (2010) “Depression relapse prophylaxis with Mindfulness-Based Cognitive Therapy: Replication and extension in the Swiss health care system,”Journal of Affective Disorders, 122(3), May:224-231. • Barnhofer, T., & Crane, C. (2008). “Mindfulness-based cognitive therapy for depression and suicidality.” In Didonna (Ed.) Clinical Handbook of Mindfulness. New York. Springer. • Barnhofer et al. (2009). “Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study,”Behaviour Research and Therapy, May(47)5:366-373. • Bertschy, G.B. et. al. (2008), “Mindfulness based cognitive therapy: A randomized controlled study on its efficiency to reduce depressive relapse/recurrence,” Journal of Affective Disorders, Volume 107, Supplement 1, March 2008, Pages S59-S60.

21. #4 Challenging isolation Depression invites people to isolation and disconnection Connections as essential healing and preventive factors

22. Social Isolation is Becoming More Common Social isolation is up and so are depression rates

23. Social Isolation is Becoming More Common Shared family dinners and family vacations are down over a third in the last 25 years

24. Social Isolation is Becoming More Common Having friends over to the house is down by 45% over the last 25 years

25. Social Isolation is Becoming More Common Participation in clubs and civic organizations is down by over 50% in the last 25 years

26. Social Isolation is Becoming More Common Church attendance is down by about a third since the 1960s

27. Social Isolation is Becoming More Common The average American has only two close friends

28. Social Isolation is Becoming More Common 1 in 4 Americans report that they have no one to confide in

29. Social Isolation is Becoming More Common In 1990, more than 1 in 5 households were headed by a single parent; it is now about 1 in 3

30. Social Isolation is Becoming More Common 6.27 million people in the U.S. lived alone in 1990 and that is expected to increase to 29 million by 2015

31. Depression Invites Isolation When people are depressed, they often pull away from others or put them off

32. Being Connected Helps People with five or more close friends (excluding family members) are 50 percent more likely to describe themselves as "very happy" than respondents with fewer

33. How to translate this into clinical work • Encourage clients to keep, nurture and make social connections • Consider group treatment

34. #5 A Future With Possibilities • Connecting to a future with meaning and hope • Often in depression, there is a collapse of future-mindedness and hope • We can help reconnect the person with future possibilities

35. Future Pull The farmhouse in my future

36. Future Pull • Problems into preferences • Positive expectancy language • Letter from one’s future • Starting therapy from post-depression perspective

37. #6 Restarting brain growth The neurogenic/neuroatrophy hypothesis and how to use it in treatment

39. The New Brain Science • Old view: Brain had fixed structure and set number of brain cells, which declined over the aging process and with damage from trauma • New view: Brain plasticity and neurogenesis • Brain can grow new cells and make new connections throughout life • Brain and body experience alters the structure and connections in the brain, strengthening, growing or weakening them and changing structure

41. Neurogenic/Neuroatrophy Hypothesis Stress suppresses neurogenesis in the hippocampus

42. Neurogenic/Neuroatrophy Hypothesis Experiments have also found evidence that the hippocampus shrinks in people who have had long-standing depression • Altair, C.A. et al. (2003). “Effects of electroconvulsive seizures and antidepressant drugs on brain-derived neurotrophic factor protein in rat brain,”Biological Psychiatry, 54(7):703-709. • Ruso-Neustadt, A.A. et al. (2004). “Hippocampal brain-derived neurotrophic factor expression following treatment with reboxetine, citalopram, and physical exercise,”Neuropsychopharmacology, 29(12):2189-2199.

43. Neurogenic/Neuroatrophy Hypothesis Antidepressants, on the other hand, encourage the birth of new brain cells

44. Neurogenic/Neuroatrophy Hypothesis • Animals must take antidepressants for two or three weeks before they bump up the birth rate of brain cells, and the cells take maybe another two weeks to start functioning • That's consistent with the lag time antidepressants show before they lift mood in people

45. Neurogenic/Neuroatrophy Hypothesis If an antidepressant is given during a period of chronic stress, it prevents the decline in neurogenesis that normally occurs

46. The mechanisms for brain cell growth (neurogenesis) • IGF-1 (insulin-like growth factor) • VEGF (vascular endothial growth factor) • BDNF (brain-derived neurotrophic factor) “Miracle Grow for the brain”

47. Neurogenesis/Neuroatrophy Hypothesis • Postmortem studies have shown that depressed patients had decreased hippocampal and cortical BDNF levels • Several studies have shown increased BDNF when people are treated with anti-depressants for some time • Altair, C.A. (1999). “Neurotrophins and depression,” Trends in Pharmacological Science, 20(2):59-61. • Karege, F. et al. (2002). “Decreased serum brain-dreived neurotrophic factor levels in major depressed patients,”Psychiatry Research, 109(2):143-148. • Sen, S. et al. (2008). “Serum brain-derived neurotrophic factor, depression, and anti-depressant medications: meta-analyses and implications,”Biological Psychiatry, 64:527-532.

49. Exercise and brain blood vessel growth In people ages 60-80, those who aerobically exercised 3+ hours a week over the course of 10 years showed: • An increase in the number of large blood vessels in the cerebral region of the brain • An increase in blood flow in the 3 major cerebral arteries • The cerebral area controls consciousness, memory, initiation of activity, emotional response, language and word associations • Narrowing and loss of blood vessels may be associated with cognitive decline • Rahman, Feraz, et. al (2008). Study presented at Radiological Society of North America; UNC Chapel Hill researchers.

50. SMILE(Standard Medical Intervention and Long Term Exercise) 156 adults, diagnosed w/Major Depression Randomly assigned to 3 treatment groups 1) Exercise treatment • Exercise consisted of brisk walking, jogging or stationary bicycle riding 3x/week • 10 min. warm-up; 30-min. exercise; 5-minute cool down 2) Zoloft treatment 3) Combined treatment “Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder,” James A. Blumenthal, PhD et. al,Psychosomatic Medicine, 69:587-596 (2007).