Monday, 25 April 2016

Depression Awareness Week: How to help someone with depression

Technically Depression Awareness Week is now over, but there were two other things I wanted to address: the taboo of suicide/self-harm, and how to help someone who is depressed. I've written about suicide before here, so I won't write about that again now. Self-harm is a separate issue really so I shall write about that another time, but for now I want to get some ideas down about how you can help someone who has depression. This can loosely be separated into two categories: things that are a good idea, and things that aren't!

Not helpful
With depression, one good day doesn't mean permanent recovery. Try not to raise your expectations - if you are disappointed that a good day is followed by a bad day, imagine how the person with depression must feel. Also, try to avoid making comments about it to that person. It may sound like you are trying to focus on the positive, but it will be perceived as an accusation that, at the moment, they are not 'good enough'.
If someone opens up to you, respect what they tell you. It's incredibly difficult to talk about things like this when you are depressed. The feelings that person has will be very real to them, even if they seem daft to you. If you don't respect what they are saying, they will not feel that they can trust you. You don't have to agree with them, but you need to respect their opinion of themselves and their situation - try not to tell them flat out that they are wrong.
Related to the above, remember that depression doesn't have to make sense. If someone tells you they are depressed, asking them 'why?' is a bit like asking them why they have flu. Some it will be situational - in which case it's probably obvious why they're ill - but some of it will be beyond their control, and even beyond their understanding. Depression isn't logical. It isn't rational. It doesn't happen neatly as a perfect response to a recognisable stimulus. It's messy and complicated and confusing.
There are certain things which help lift depression, such as a good diet, a relaxing evening, and a bit of exercise. Sometimes, though, it can be incredibly hard to find the motivation and/or energy to help oneself in these ways, and sometimes it can be damaging to insist that somebody use these methods to make them feel better. Imagine that you have sprained your ankle. You want to go for a jog, because you know that exercise is good for you, but you can't because your ankle is painful and you're resting it at the moment. Unfortunately for you, one of your friends keeps telling you to ignore the pain you feel and come for a run anyway. You try to explain to them that whilst you are happy to run most of the time, sometimes you need to know when to rest, and this is one of those times. How annoyed would you be if they kept pestering you? With depression, this conversation isn't straightforward, but sometimes people are too ill to be reached by exercise - or they need some other form of help at that moment in time. Treading the fine line between encouraging people to help themselves and bullying them is extremely difficult, and the depressed person in your life will probably not be very tolerant. Just do your best.
Leading on from this point is probably the most crucial thing you will need to know as the friend or relative of someone with depression: you need a thick skin. It is immensely tiring to be a supportive friend - both emotionally and physically. You may well come in for abuse from someone you love, and that can feel really tough. Bear in mind that they almost certainly don't mean the unkind things they say or do. They are struggling too, and they are feeling really frustrated. It just so happens that every now and then they can take that frustration out on another person, and that might be you. Here's the advice, then: don't let yourself be dragged under. You have self-worth, and you are important. Try not to be thin-skinned. Try not to become consumed by their depression. Look after yourself.
The black dog can breed.
It may sound weird, but avoiding negativity is really bad for depression. In fact, avoiding it is often what makes people depressed in the first place: they ignore bad thoughts for so long that eventually they just overflow and force out any good thoughts and feelings which are left. Therefore, try not to be afraid of discussing negative thoughts and feelings with someone. Try to resist the temptation to turn each one into a positive straight away: give your loved one a chance to say how they are feeling. You are more likely to make them feel better if you give them a chance to explore fully the depth of their emotion, the possible causes for it, the possible ways out of it, and a balanced view on how bad the situation really is, than if you just try to silence any negativity. This is because talking about it gives the person the chance to think about negativity in a more balanced way, and because being listened to and taken seriously (whatever the subject matter) is enormously important for self-esteem.
Cheesy, but I like it.
Don't panic. Having depression doesn't necessarily mean that someone is self-harming. Self-harming doesn't necessarily mean that someone is suicidal. Being suicidal doesn't necessarily mean that they will die. Many people think that discussing self-harm or suicide with someone is generally believed to make them more likely to do it - but this isn't true! Various studies have shown that discussing 'suicidality' has no correlation with suicide rates. In the words of one meta-analysis, 'none (of the studies) found a statistically significant increase in suicidal ideation among participants asked about suicidal thoughts. Our findings suggest acknowledging and talking about suicide may in fact reduce, rather than increase suicidal ideation, and may lead to improvements in mental health in treatment-seeking populations.' If someone talks to you about suicide, don't immediately assume that this is Game Over. At the same time, take them seriously. Discuss it with them and don't be too afraid to show your honest response. People who are suicidal generally think that nobody could ever love them, so try to show them that you do love them - but don't be surprised if they find this hard to understand.
Finally, here is a quickfire, "don't do this" round...
No it isn't.
This is only acceptable if you definitely know how the other person feels - and they will think that you don't.
Man, this woman is annoying. She has no proof that things will get better, and in saying this she makes herself sound as if she doesn't have a clue how the other person feels. I know she's trying to be positive and friendly, but it will not be appreciated.
You might feel angry at depression, and even your friend or relative. Don't worry - so do they. Try not to add to it.
Competitive woe is unhelpful. Do not dismiss people's fears and concerns, even if they can't actually express those fears and concerns to you.
All of these. Urgh!

Helpful things
Enough of the unhelpful things that you can say and do - what you can you do to help without getting your head bitten off?

First: be present. Sometimes you may find that the person who is depressed is telling you they want to be alone. If they are really vehement in this, then listen to them - other times they are trying to punish themselves by forcing you out. If you do leave them for a bit, stay close by and pop back to check on them. They may well soon want you there. You don't have to do anything or say anything. Having somebody nearby can be enough. This pretty much sums it up (nest building is optional):
Feed them. They probably can't be bothered to get their own food, and it will be especially tough to make it healthy and attractive. Try and be imaginative as well, even if you don't get much of a response. Just because people can't say they appreciate it, doesn't mean they aren't grateful for the effort.
Make little decisions for them. The smallest of decisions can be paralysing when you can't leave the house because you can't decide what to wear, what to have for breakfast, or even just when to set the alarm for. Help them out with these things. It makes a surprisingly large difference. Try to help out with medications and therapy.
Be patient - extremely patient! It's tough being around someone who is depressed. They don't always make the best company, and you may be impatient to see improval. You may be impatient with them when you feel they are being too negative, or when you think that they are 'doing it deliberately'. Whenever these thoughts come into your head, try to remind yourself that the person with depression is also a bit fed up with it. People don't get depressed deliberately. If you are feeling impatient, remember that this is completely understandable, and even healthy. If you force yourself to act patiently all the time, you will end up feeling bad too. Treat it as anger management - as you feel things start to get difficult, try to remove yourself from the situation. If you cannot do that physically, try to do it mentally or emotionally to give yourself some space to feel yourself again.
This may be useful.
You may detect something of a theme emerging here: you need to look after yourself. If you aren't well-rested, well-fed, well-exercised and generally in good physical and mental health then looking after someone else will be incredibly difficult - for both of you. You need time out of being a carer. You might want to be there for someone no matter what time of day or night, and no matter for how long, but if this means that you don't take at least some time to yourself every day then you are setting yourself up for trouble.
Not a great state of affairs.
This by no means an exhaustive list of 'dos' and 'don'ts'. That would just be tedious. There is, however, one final thing that needs to be said:

DO know when to ask for help.

You do not have to handle everything alone, or within your family or group of friends. If you are worried and you need more help, these are the people to contact, in ascending order of severity:
  • pharmacist - if you think that some simple self-help ideas from a health professional would be useful.
  • GP (family doctor) - appropriate if your concern is not urgent but you feel they need more help. The GP can refer to a psychiatrist or prescribe medication by themselves.
  • Charities (UK) such as the Samaritans (phone 116 123), Childline (0800 1111) or Mind (0300 123 3393). Most charities can also be emailed and some have live online chat functions if you would prefer not to use the phone. 
  • NHS Direct (UK) - call 111. They can advise you on if the situation is critical enough to seek urgent care.
  • In an emergency (e.g. if you think they are suicidal with an intent to act, or if you know they have self-harmed badly or made an attempt to take their own life) - 999 (in the UK) or drive them to hospital yourself. If they have taken an overdose and you know what they have taken, try to find some packaging to take to the hospital so that you can show the doctors there.
Another part of remembering when to ask for help is to remember that you may need support. Again, mental health charities such as 'Mind' can help you with this, as can charities such as Carers UK and Care for Carers.
By Royston Cartoons
Final thing: if you are supporting someone with depression, you are amazing. I have so much respect and gratitude for the people who look after me and have done so even in really testing times. Remember that when someone has depression it isn't always easy to say thank you, and to let people know how much you love them and are glad that they are around. This doesn't mean you aren't appreciated - you certainly are.

Sunday, 24 April 2016

Depression Awareness Week: Treating Depression

This post is going to be divided into three parts to describe the most common ways of treating depression: 'self help', psychotherapy, and medication. I have decided not to discuss ECT (Electroconvulsive Therapy) on the basis that its use is far rarer than these other forms of treatment. However, if you want to know more, you can read about it here.
Self help
Self help often gets a bad press. People tend to associate it with that section of the bookshop that's full of advice on the healing power of crystals or what colours to wear to improve your mood. I'm not going to judge on the effectiveness of this kind of thing - as far as I'm concerned, if it makes you feel better than go for it. Instead, I want to highlight some of the simple things you can do to prevent depression or to lift yourself out of a bad patch.
Sleep well
If you have depression, this may be difficult. Insomnia or sleeping too much are both common and there isn't a huge amount you can do about them, but giving yourself a fighting chance of having a good night's sleep is sensible. Keep to a routine, go to bed at the same time each night, make sure your room is the right temperature and dark enough, don't eat too late, avoid caffeine, alcohol and cigarettes, keep a notebook by your bed to write down worries so that you don't need to waste time thinking about them. Take time to make your bedroom a nice place to be, but don't spend all day there. Don't sit around or eat in your bed - a bed is for sleeping. Finally, don't panic if you can't drop off. Stay relaxed and remember that you're still getting some rest even if you're just lying down. Breathe deeply and slowly and feel yourself relax into the mattress as much as possible.
Eat well
Eat healthy food at regular intervals. Try not to under-eat or over-eat. Pay attention to what you're eating. Don't eat too late at night (otherwise you won't sleep as well). Keep a good, varied diet - it doesn't have to be perfectly healthy the whole time. Chocolate has been proven by various studies to make you feel better! That said, you still need plenty of vitamins, protein and carbohydrate to give you energy and to help your immune system out. Depression saps your energy and weakens your immunity, so do what you can to attack this.
Don't go mad on exercise, but try to do something every day. It doesn't have to be strenuous and it doesn't have to be a full-on cardiovascular workout each day. Activities such as yoga, Pilates and simple stretching can be as beneficial as going for a run or doing some weight training. As with diet, the key to using exercise to combat depression is to keep it varied and to make sure you don't turn it into a tool with which to beat yourself up. You don't need to get competitive with yourself or others. If you miss a session, have to cut one short, or don't perform as well as you usually do, it doesn't matter! Exercise is a therapy and it should be something that makes you feel better.
Be aware of your feelings
This is something that many psychotherapy techniques pick up on. Learning to judge how you feel and why - and, crucially, whether that feeling is justified or not - is a key part of learning to control your feelings to make you feel better. It's difficult to do and it may feel pointless, but stick with it. If you find yourself feeling bad, grab a piece of paper and write down what it is you are feeling. Then, write down why you think you are feeling that. Next, be as dispassionate as you can - put yourself in the shoes of someone who doesn't even know you very well, or imagine that you are an acquaintance of yourself and you have to comment on your emotion. Ask yourself if what you are feeling is justified and if there is evidence to support your claim that you are (for example) a useless person. Write down an alternative view which is more balanced - it doesn't have to say, 'wow, yes, you're amazing!' If it does, you won't believe it. Instead, find a sensible response: 'I struggled with this today, but that doesn't make me a terrible person.' It will take time before this actually makes you feel better, because in the depths of depression it's hard to believe that you're not a terrible person. Persevere.
Find something you enjoy
It could be that something you enjoy doing is already covered here, such as exercise or cooking. There might be something else you enjoy doing, such as crossword puzzles, reading, arts and crafts, photography, or music. You may also get some enjoyment from watching TV, but try to find something that is productive. If you can see something that you have produced, it makes you feel as if you have achieved something. It doesn't have to be something big or complicated, and it definitely does not have to be perfect. It just needs to be a large enough distraction that it keeps your mind busy for a while.
I made this!
Plan your day
Often, depression robs you of the ability to get tasks done and to organise your time. Write down a to-do list every day. Don't make it too long or complicated, and give yourself a break every time you tick something off. I find that I get really badly organised when I have depression so I just tend to drift from one hour to the next without really achieving anything. In times like these, it's surprising how much of an achievement it feels to do the laundry! When you do a task - whether it's a nice one or not - give yourself a reward afterwards. You can decide what that can be. For me, it's normally just sitting and having a rest... Final important point: a plan is useful, but it is not the be-all and end-all. If you can't stick to it even though you're trying hard, it doesn't matter. It's better that you have a rest and don't feel guilty than you try to force yourself to do too much, get tired, and feel bad for not finishing things.
Talk to people!
People with depression are notoriously useless at talking to other people about how they feel, but talking to someone about it can be an enormous relief. You don't have to struggle alone, and talking to someone about how you feel won't make them think that you are weak, boring, or useless. Most people actually like to feel trusted. If you're happy to drop it into conversation then do so, but if you think you might be tempted not to say anything at all then it's a good idea to ask to meet up specially as there is something you'd like to discuss. This then means that your friend will be expecting to give you time and space, and they will prompt you to tell them what is upsetting you. Remember that you might be able to access help through your work or place of study. Find out what the options are for this - people will be very discreet and will be able to point you in the direction of further help if you and/or they feel it would be helpful.
Go to a doctor
If you still feel rubbish, or if you don't feel that you have a friend or family member that you can talk to about this, go to your doctor. They can then decide on the most appropriate course of action. Don't feel as if you're wasting their time - they are there for you and they see loads of people every day who have depression. It's common, they're used to it, and they can help! It may feel like a big deal to you, and it is - depression is a big deal, and seeking help is a big deal - but don't let that put you off. If it helps, ask someone to go with you to the appointment. It's up to you if they go in too or not.
There are various different kinds of 'talking therapies'. These are just some of the most common ways that a psychologist can help someone with depression.

Cognitive Behavioural Therapy (CBT)
A stalwart in the psychologist's fight against depression, CBT aims to challenge thought processes that are influenced by depression (I'm no good, I'm useless at everything, everyone hates me) and to try to find a more positive way to think. It is based on the premise that how we think directly influences how we feel. CBT is quite hard to engage with if you have severe depression, but it's useful in milder cases. This is because it requires quite a bit of energy and a general readiness to engage with positive thinking, and both of these things are rare in more severe depression. In milder cases, it's extremely helpful and has a good track record. CBT is a standard treatment available for those who want to attend group sessions or who would rather see a psychologist individually. Ask your doctor if they think it would be useful for you. You can find out more here.
This is another therapy that requires you to be consciously aware of how you think and what you are feeling. It involves making yourself very aware of your surroundings and your place within them. For example, you might draw special attention to how your clothes feel on your skin, how your food feels in your mouth, or any noises going on inside the room that you are in. The next stage is to draw this awareness to your thoughts and feelings. Mindfulness isn't really about challenging these things (as CBT is) but rather giving you the space to experience them and to get to the bottom of how you're really feeling. Often, depression clouds our thoughts and judgement so that we don't know what we're feeling - we only know that we feel bad. Mindfulness allows you to take the time to focus purely on what's going on in your mind and your body. Doing this makes you feel calmer and also gives you the power to challenge negative thoughts. You can read more about mindfulness here.
Dialectical Behavioural Therapy (DBT)
DBT is similar to CBT in many ways - having been based on CBT - but is useful for people who experience emotions very intensely. It is especially helpful in cases of borderline personality disorder (BPD). The main similarity between CBT and DBT is that both encourage you to come up with new ways of thinking and behaving. In DBT, however, there is a more personal relationship between patient and therapist, and there is a greater emphasis placed on learning to accept who you are as a person. Click here to read more about DBT.
Ecotherapy - promotes wellbeing through outdoor activities.
Music, art and drama therapies - these use creativity as a means of expression.
'Talking treatments' - discussing mood with a therapist and sometimes other patients
Complementary therapies - e.g. acupuncture, massage, aromatherapy, and herbal remedies.
I think the easiest way to discuss this is to consider some common beliefs people have about taking medication for a mental health problem. Read on...

"I'm worried that the drugs will change me. I won't be the 'real me' anymore.”

Depression changes you. Depression makes you not the ‘real you’ anymore. Medication helps you to become the ‘real you’ again. Medication doesn’t change your personality. It doesn’t change your past, or what you care about, or who you love. Medication gets rid of the evil demon squatting in your mind. It gets rid of the parasite of depression and lets you be you again.
That's me in the middle. And yet, at the same time, it wasn't me.
“I’m worried about side-effects. I would rather deal with feeling down than risk the side-effects.”

This is a valid concern. Side-effects of any medication can be annoying, unpleasant or even dangerous. However, depression is annoying, unpleasant and dangerous too. Some of the most common side-effects that people worry about are those things which tend to happen in the short term. For example, when you first start taking anti-depressants, you may find that you feel quite tired and that you get more headaches than usual. As time goes by, you will start to feel less tired – partly because you get used to the medication, but also because your depression (which causes fatigue) will be lifting. Similarly, side-effects like headaches and nausea disappear after just a few weeks. It may sound difficult to cope with the idea of having headaches for a few weeks, but surely this is better than knowing that you will have depression indefinitely?
“I’ve heard that some anti-depressants actually increase the risk of suicide.”

There is evidence that in certain people, in certain situations, and with certain medications, there is an increased risk of suicide in the short-term. Mostly this risk has been associated with common SSRIs such as fluoxetine (Prozac) when they are being taken by young people (adolescents and young adults) whose depression has involved severe fatigue and suicidal ideation before seeking treatment. In such people, the extra energy that the drug gives them may well come before actually feeling in a better mood, and there is a small but significant risk that this may result in suicide attempts in affected people who may not have had the energy to make an attempt before. Doctors and psychiatrists are aware of this risk. They only prescribe the drug if they feel it will be beneficial. If they have concerns about a patient’s safety, they will ensure that steps are taken to reduce the risk of suicide as far as possible – including placing people under 24-hour observation in hospital.

This is rare and your doctor will introduce you to the medicine gradually to decrease the risk.

“There are too many types of drugs and I don’t know which one is right for me.”

This is why we have doctors! The main types of anti-depressants used to treat major (unipolar) depression are Selective Serotonin Reuptake-Inhibitors (SSRIs), Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs), and Monoamine Oxidase Inhibitors (MAOIs). There are many different drugs within each category – for example, fluoxetine, sertraline and paroxetine are all SSRIs. A psychiatrist can choose the appropriate drug for a patient. This may involve quite a bit of experimentation, since drug effectiveness is hard to predict and many individuals respond to one drug better than another even when both drugs are of the same class or type. Different drugs such as mood-stabilisers and antipsychotics (e.g. quetiapine, olanzapine, risperidone and lithium) are used in cases of bipolar disorder (formerly ‘manic depression’), and these drugs may be used in conjunction with regular anti-depressants.

Finding the correct mixture of drugs for a given patient is difficult and can take a long time. It took three years for my psychiatrist to find something that worked for me, and he still tweaks it regularly even now. I have been on dozens of different drugs; I currently take three different medications to manage my bipolar disorder (lithium, quetiapine and sertraline). It takes so long because you have to be introduced to each drug slowly, then the dosage must be increased slowly until it reaches a level where a doctor can assess its therapeutic effect and then maintained to look for improvement – this process can take months. If it doesn’t work, you then need to come off it slowly and start all over again with another drug.
Some of my drugs :)

“I don’t want to spend months or years finding the right drug. I want to be better now.”
That makes sense. We all want to be better straight away. The problem is that treating depression can be really difficult and it can be really slow. It isn’t like a headache, where you can take some painkillers and it gets better. Treating depression is like waiting for chemotherapy to shrink a tumour. The effect of the drug isn’t instant. The process of finding the right drug and being on the right drug will take a long time, so you can either start it now or you can start it in a few months and be a few months behind. You gain nothing by waiting.
“I don’t want to take medication for the rest of my life.”
You might not have to! Many people are able to be weaned off medication after their depression has improved, stabilised, and maintained a stable state for at least six months. On the other hand, some people do have to take medication for a lot longer. I expect to take it for the rest of my life. This doesn’t bother me, though. Taking medication is a small price to pay for being healthy and content.
“I don’t need medication. I can deal with this on my own.”
Maybe you can deal with it alone – but what’s the point? Depression isn’t a competition. You don’t get extra points for 'going it alone'.If your doctor thinks that medication will help, take it!
Hopefully this post will give people an insight into the ways of tackling depression. Please note that I am not a doctor or a psychotherapist; I am just a patient with a lot of experience! If you are experiencing symptoms of depression - however severe, or otherwise, they may be - then you should definitely go to a doctor. They are there to help. They are not there to judge. They will have seen many patients like you. In fact, there is a pretty high chance that they will have experienced depression themselves, and an extremely high chance that they will have a friend who has experienced depression. They can help. And finally, remember that often the hardest thing for people with depression to do is to help themselves:

Saturday, 23 April 2016

Another new look

The blog has had another face lift. I was bored with the old set-up, and I had fun playing around with making normal pictures of me into funky coloured pictures of me (see left hand side of your page, or below). Enjoy!

These ones made the cut...
Jumping with Rolo at RDA
Dressage competition with Boysie
Vaulting on Boris
Wheeling at the track on a sunny day
Rowing the Great Ouse Marathon
Racing on the River Cam
Wheeling at the track on a chilly winter evening
 These ones didn't quite make the cut...

Dressage with Rolo at the RDA Natioanl Championships
Wheeling at the track
Practising dressage with Rolo in Cambridge
Dressage competition with Boysie
The start of the Great Ouse Marathon
Coxing a race on the Cam