For years depression has been seen as a biological condition, with medication a commonly recommended treatment. However drugs don’t suit everyone and now researchers are trying a range of different approaches to treat depression, from clinical hypnosis to brain stimulation. Lynne Malcolm reports.
Depression is the most common mental health disorder in Australia, affecting around one million people nationally, and is a major contributor to the global burden of disease.
What we’ve discovered … is that the drugs have not been nearly as effective as people had been led to believe.
MICHAEL YAPKO, CLINICAL PSYCHOLOGIST
Chrissie, who is now in her 30s, began her struggle with depression when she was a teenager. At the time, her family was grieving over the death of her father, so her condition was not immediately acknowledged.
‘It just kind of turned into this ongoing, untreated issue for me which would come and go,’ she recalls. ‘In my kind of blind way I stumbled through lots of different attempts to sort it out. And when it would go, I’d think, “Okay, now I am a better and I don’t [need to] think about that anymore.” But there was this sort of dread that it would come back.’
Over the years she tried meditation and various forms of counselling, but it wasn’t until after the birth of her first child that anti-depressant medication was suggested. While this helped her get on with her life for a few years, she remembers feeling very flat emotionally.
‘I didn’t laugh. I just went through life like a machine,’ she says.
Chrissie decided to stop taking the medication and another big bout of depression followed—at the same time her marriage fell apart and her mother suffered a major stroke.
‘This is a condition that will play out over a long period of time. It’s not like a cold where the symptoms are sudden, you feel them, you know that you are subjected to this particular illness,’ she says.
‘It can be so vague … I guess people who have very extreme depression can’t get up and they can’t dress … for me I might have a day every now and again like that but that wouldn’t be every day. But still, every day is a struggle. So I’m just trying to swim and muddle through my life during these periods, and it makes it really tough.’
Whilst many people are helped by anti-depressant medication, the treatment doesn’t suit a significant proportion of people, either because it is ineffective or the side effects are too unpleasant. Now, researchers and clinicians are exploring alternative approaches to treatment.
Clinical psychologist Michael Yapko from San Diego, California, suggests that a serious revision of people’s attitudes towards depression is now required, because while people focus on the biology of depression, they miss what goes on at the psychological and social levels.
‘Most depression experts have really stopped talking about the biochemical imbalance and certainly the shortage of serotonin and have started looking at other neurological factors, what are called trophic factors that increase certain proteins,’ Yapko says.
‘But what we’ve discovered, of course, is that the drugs have not been nearly as effective as people had been led to believe. The major medical journals have been publishing article after article about the deceptions of the pharmaceutical industry in deliberately overstating their value in order to sell them. And trying to define depression as a medical illness has really backfired.’
Yapko has been using clinical hypnosis as an effective therapeutic tool for the treatment of depression for many years.
‘What happens in depression is that people tend to focus on what’s wrong instead of what’s right, what has hurt them instead of what has helped them. They focus on things that work against them. Hypnosis is a focusing process … an efficient way of securing somebody’s attention … in the direction of focusing on what is positive, what’s useful,’ he says.
‘It encourages a greater flexibility, a greater willingness to have experiences that go beyond just feelings or just rationality and give people a chance to connect with and develop parts of themselves that are the best parts of themselves.’
Yapko says that there’s now a large body of research which shows the success rates of various depression treatments.
‘There are a number of psychotherapies, cognitive behavioural therapy and interpersonal therapy in particular that have the highest treatment success rates. Cognitive therapy teaches people skills. It helps people with information processing, clearer thinking, and better quality of decision making,’ he says.
‘Interpersonal therapy focuses on the social side, the relationships. Given how often relationship issues lead people into depression—divorces, betrayals, abuses, violence, all the kinds of things that can happen in relationships that lead people into depression—the interpersonal model really focuses on teaching social skills and helping people build more positive and healthier relationships.’
Yapko says it’s also clear that the more actively people are engaged in their treatment, the better they do, and just taking medication alone has the highest rate of relapse of any form of treatment.
Whilst some clinicians are concerned that cultural and social factors have too often been overlooked in past treatments, other researchers are investigating the potential of using techniques based in neuroscience, like brain stimulation.
Professor Colleen Loo from the school of psychiatry at the University of New South Wales and the Black Dog Institute leads a research team investigating transcranial direct current stimulation, or TDCS.
TDCS uses a tiny electrical current, about one 500th of the current that is used in the better known Electro Convulsive Therapy or ECT. TDCS is non-invasive and it gently stimulates the surface of the brain, via electrodes which are placed either side of the forehead.
It’s understood that when people are depressed the frontal part of the brain is under-active, and at the same time there is overactivity in other parts of the brain, such as the areas involved in emotion. Loo says that TDCS can correct this imbalance of activity.
‘It’s exciting because what some of the emerging evidence is starting to show is that effective treatments affect the whole connection, the functional connectivity between these different parts of the brain. So it kind of restores the balance between these different parts of the brain,’ Loo says.
So far the clinical trials of TDCS are looking good for the treatment of depression in people who haven’t responded well to other treatments. Loo says that there are very few, if any, side-effects and some participants have even noticed benefits beyond changes to their moods.
‘We were very excited when we got to the end of the study and we formally analysed the results of the test … it showed exactly what people were saying to us, that after the act of stimulation the actual thinking speed was faster, and that has led our team to develop a whole parallel line of research of using TDCS to improve memory and thinking.’
TDCS treatment is not yet available outside of research trials, but Loo sees promising potential for it in the future.
Chrissie, who has suffered from depression for many years, has been in the TDCS program at the Black Dog Institute since the beginning of this year. She feels that her symptoms of depression have significantly improved.
‘Well, I can function, I feel quite normal. My mood swings and my highs and my lows are manageable … I’m not overtaken by this tide of negative emotion. I think negative emotion is really natural and normal, but in depression it just gets really out of balance,’ she says.
‘The trial has been really great for that. It’s the treatment itself but at the same time every time I go in I have to evaluate my emotion. In a sense there has been this kind of therapeutic response to that too because I now just habitually go—well, how am I today? I’m just a bit more aware of my vulnerability and the imbalances that I can have.
‘It’s such a funny beast, depression, it can really trick you and you can trick it. It’s like flicking switches sometimes, [it’s] very strange.’