Depression — One size does not fit all
It is well accepted within the medical community that a “one size fits all” approach to treating depression is not effective. One third of patients with depression will achieve remission upon starting antidepressant treatment whilst another third will require 1–3 more changes to their medication; a final third do not get better at all. Although I believe in the benefits of antidepressants, I have also seen it fail to adequately treat many of my patients.
Psychological therapy, in particular Cognitive Behavioural Therapy (CBT), is recommended as a first-line treatment in mild to moderate depression by the American Psychological Association (APA) and by the National Institute of Health and Clinical Excellence (NICE). CBT is one of the psychological therapies that has gained widespread popularity worldwide and is considered the “Gold Standard” of psychotherapies for a variety of reasons; its underlying principles resonates with many, it is easily accessible due to the number of trained practitioners, it is time limited and faster than other forms of therapy (usually 10–12 sessions) and it is also the therapy with the most robust research backing its effectiveness.
CBT has been found to be more effective than pill-placebo and equally as effective as antidepressants. What most people do not realise is that this means the failure rate of CBT is similar to antidepressants. Another thing to note is that clinical trials are helpful in showing if a treatment will work on an average population and not on an individual. So it is not surprising that many people who have tried CBT do not find it helpful.
The National Institute of Health and Clinical Excellence (NICE) has always acknowledged depression as a broad and heterogeneous diagnosis, and that a wide range of biological, psychological and social factors are not captured well by current diagnostic methods. These factors directly impact how the illness is manifested in an individual and the response to treatment.
Despite this acknowledgement, the current guidelines do not fully address the complexity of depression. In the last year, NICE has been heavily criticised by clinicians, MPs and mental health campaigners for their 2018 draft depression guidelines. A coalition of 35 health organisations released a position statement expressing their concerns about significant flaws, lack of transparency and inconsistencies behind the guideline. The main criticisms were:
There are insufficient studies with long term follow-up data, which could mean current recommendations do not accurately reflect effectiveness in treating depression.
Patient and carer’s experience were not considered or incorporated into the guidelines despite a voiced preference by patients for more rather than less choice and for longer-term rather than shorter-term therapies.
Chronic and complex forms of depression have been separated into misleading categories which have in turn affected treatment guidance.
Inadequate methods were used for determining “clinically significant” treatment and disregarded partial recovery, despite an improvement in symptoms being beneficial to people with severe or complex depression.
Primary recommendations were based on results of a Network Meta-Analysis (NMA) that compared 351 heterogeneous studies of 81 different treatments (or combinations of treatments). NMA is considered an experimental statistical technique that did not address age, sex, socio-economic factors, therapist factors, treatment dose and other confounding factors.
The guideline does not consider non-symptom outcomes, such as quality of life, relationships and ability to participate in work, education or society.
The statement concluded that if these criticisms are not addressed, treatment recommendations cannot be relied on.
So what does this all mean for people with depression?
Despite the criticisms of the NICE guidelines, it still serves as a good basis for a treatment programme. Antidepressants, psychotherapy and engagement with a mental health team remains the mainstay and most effective way of treating moderate to severe depression. Besides psychotherapy and antidepressants for mild depression, NICE also recommends counselling, sleep hygiene and physical activity programmes.
Mental health services struggle to cope with the rising number of people presenting with mild or “persistent subthreshold” depression due to lack of funding. This means having to allocate resources by offering the most cost-effective treatments available and unfortunately, this is not helpful for the many who do not find the common therapies effective.
For people with mild or subclinical depression who do not find CBT or medication helpful, it may be wise to consider a tailored, personalised approach to your mental health. Everyone is unique and it is important to find out what works for you, in your current situation and circumstance.
Listed below are a number of ways you can improve your mental health.
Complementary therapies are therapies that you can use alongside conventional treatment and typically take a more holistic approach to your physical and mental wellbeing. Whilst they are generally not available through the NHS, it might be worth considering them if current treatments have not worked, if you are currently on a waiting list or if you want to try something different.
Art and other creative therapies such as music and drama therapy provide a safe environment for people to engage in a relaxing activity whilst address their struggles without actually talking about them.
Yoga and Tai Chi are also excellent ways to improve both your physical and mental health.
Other complementary therapies include aromatherapy, hypnotherapy, reflexology and reiki.
Mindfulness and meditation
Mindfulness and meditation have gained widespread popularity in recent years for good reason. It trains you to be more self-aware and focus on the present instead of worrying about the past or future. It has been proven to reduce stress as well as regulating emotions. You can learn more about mindfulness in general on the NHS page, courses through MIND Charity or simply search “guided mindfulness meditation” on Youtube.
Recording your mood in a diary (physical or digital) is a great way of tracking changes on how you feel as our memory and perception is easily distorted. It is also very useful in noticing triggers to feeling worse or situations that make you feel better. Incorporating this into your mental health journey will make it easier for you to figure out what is working and what is not.
The mind-body connection is very powerful and each one directly impacts the other.
Eat a balanced diet with plenty of fruit and vegetables.
Fix your sleep with proper sleep hygiene.
Physical activity — Plenty of studies have shown that regular exercise reduces the risk of depression. Even a simple 30 minute walk every day can boost your mood.
Avoid recreational drugs and excessive alcohol — many people self-medicate with recreational drugs and alcohol which provides immediate and short-term relief; however, this is usually an unhealthy coping mechanism that can be harmful physically and psychologically in the long run.
Besides physical activity, other forms of activity can be very helpful in redirecting your thoughts, boosting your self esteem and at the same time connecting with others.
Try joining a group of an existing hobby of yours, or perhaps something you’ve always wanted to try. Changing your routine in this way can boost your mood and break negative patterns of thinking or behaving.
Try volunteering. A review of evidence by Exeter Medical School found that volunteering led to increased wellbeing and improved depression. Taking positive action and helping others provides a sense of achievement, increases self esteem and can even change your perspective of yourself and your life.
There is a school of thought that psychological symptoms are caused and affected by relationship difficulties such as grief, interpersonal disputes or deficits (inadequate or unsustaining relationships) and role transitions. Interpersonal therapy, which is available through the NHS, is a form of psychotherapy based on this principle and has been found to be effective in treating mood disorders as well as eating disorders.
If formal therapy isn’t for you, try improving your relationships around you and you may find your mood lifting. Spend time with friends and family, practice open communication, do not be afraid to admit when you need help and know when to cut toxic relationships from your life. Read more about this here.
If you have been struggling with mild depression and regular treatment has not been as effective for you, or if you want to improve your wellbeing, try the suggestions in this article. You may discover that certain things work better than others. The trick is to keep an open mind, be patient (you may not feel a difference immediately), and not try too many things at once. Every small change may have exponential benefits to your wellbeing and life.