Posts on depresssion

Posts on depression

These are posts specifically about mood disorder - unipolar depression in my case.

How to help recovery from depression (29 November 2022)

I have been overwhelmed by responses to my previous post on the experience of being anxious and depressed.

The comments fell into four broad categories:

1. Commiseration and agreement. The most common response, and I thank you all. It helps to feel supported and that others feel similarly.

2. I should turn to God. I realise this works for some people, but it is not for me. I am not though going to talk people out of it, or try to persuade them that they are wrong (even if I think they are). If you have faith, and it helps you, I am pleased for you.

3. You should choose to make yourself feel better. This sort of comment is fortunately rare, but the underlying belief is unfortunately quite common in society more widely, and misunderstands the nature of mental illness. It essentially says we are choosing to be ill; to use my favourite analogy, would you say that to someone with cancer? Pull yourself together and snap out of it? It is the sort of belief that stigmatises depression because it’s essentially saying that we are weak and can’t be bothered to help ourselves. It’s all our own fault. It just makes me annoyed.

4. It’s depressing. What did you do to feel better?

I’m going to focus on the final point. I’ve covered many of these things before but I’m putting them altogether here. This list covers how, with much help, I’ve made myself better from the nightmare described in my previous post. Note I say better, not well. Rather like an alcoholic, I fear I always be on the edge.

1. Seek help. There is no need to suffer alone. Call your GP or other health professional, call NHS Direct, or, if you are desperate and thinking about suicide, call the Samaritans. They are wonderful.

2. Remember that there should be no stigma attached to mental illness. You might meet the odd person who tells you to pull your trousers up, or that you brought it on yourself, or whatever, but they are wrong (see above). It’s not easy, but just ignore them.

3. Take medication. You’d take medication for flu, or TB, or cancer, wouldn’t you? Yes, many psychoactive drugs have side effects. You might have to experiment, and go back to your GP and psychiatrist, but remember it takes time for some medication takes time to work and for side-effects to settle down. A bit of constipation is a price worth paying for not feeling suicidal, but remember the extent and severity of side-effects varies from person to person. Consult your GP or psychiatrist if you are worried.

4. All things must pass. You will feel better, eventually. When I am bad I always remind myself of this fact.

5. Exercise as much as possible. I know it’s what everyone says (“when I feel down I just go out for a run”, a doctor once helpfully told me), and when you’re really depressed it’s one of the last things you’d rather do, but it does help. Even a brief walk will make a difference.

6. Go outside as much as possible. Nature makes you feel better.

7. Get as much natural light as possible in the morning. If necessary get a SAD light box.

8. Eat well. Eat for the brain, heart, and against inflammation. See below for some links

9. Stick to a routine you have worked out in advance. Routine might be a bit dull, but it helps mental health, minimises stress, and helps you sleep properly. Talking of which …

10. Get enough sleep at all costs, but not too much. Find a schedule that works for you. I swear by an afternoon nap.

11. Avoid toxic people like the plague. Do not make the mistake I have made many times of believing that you can reason with them or get them to change. Do not perseverate about what they say and just do not engage with them.

12. Consider getting a dog. A dog increases your lifespan by over a year. You have to go outside and exercise ever day. And it releases so much oxytocin. Beau (above) has been a lifesaver for me, perhaps literally.

I should say that of course I don’t have any magic bullet for depression, or any form of mental illness. If I did I’d be well myself, and probably rich. These things have helped me though. I apologise if it all sounds a bit trite and simple.

Links to healthy eating sites

The Mediterranean diet for general good health and increased longevity.

The DASH diet for hypertension.

The MIND diet for a healthy brain and reducing risk of Alzheimer’s.

What does it feel like to be depressed? (20 October 2022)

People who don’t suffer from mental illness often think that being depressed is a bit like being sad, that being anxious is like having a touch of nerves before an exam, and that having a compulsion is simply an urge to do something. They’re all much worse.

Depression is very different from feeling a bit down, or having a moment of passing sadness. It’s an extraordinary “pain in the mind”. Imagine feeling sad, but much, much sadder than you’ve ever felt before. Imagine all the lights being turned off in your head. Imagine your mind turning black; black is the colour of depression. You’re living in a monochrome world where all feelings except pain have been turned right down. Imagine a dark ball at the centre of your being that is so cold it hurts. It’s like an icy knife in your soul; it’s worse than any physical pain. You just want to go to bed and cry, to fall asleep, or even die. Death would be a relief, because death is an end to the misery. In any case, who cares: alive or dead, what’s the difference in the end? And who would miss you anyway? You hate yourself and your life. The idea of doing anything is impossible to contemplate. There’s nothing to look forward to, and nothing gives you pleasure, not even the things that in better mental states you can rely upon to excite you. Your despair is utter. Everything is hopeless; and you are sure you’re never going to get better. You feel a terrible sense of doom, foreboding, and fear, not just that you’re never going to get better, but that the universe is a threatening, mysterious, evil place. And everything is such a fight; everyday life is exhausting. You can’t concentrate long enough to be able to complete simple tasks, and in any case you forget what you were going to do nearly as soon as you form the intention to do it.

Managing to do the little things can wipe you out after you’ve used up so much energy making yourself do them. You feel exhausted all the time; deep fatigue goes with severe depression. You make mistakes in the simplest tasks. You have no motivation do to do anything anyway, and no interest in anything. You feel nothing other than total despair, and feeling amazingly, incredibly guilty about everything, as though you’re lazy, incompetent and everything wrong with the world is your fault. So you deserve to suffer so much. Everything is overwhelming, and you are paralysed. You don’t just have very low self-esteem, you are also full of self-hatred. You are the lowest of the low and completely worthless; the world would be a better place without you. If you‘re depressed for any period of time self care tends to go out of the window: what is the point of shaving? Can you really be bothered to wash your face? Who cares if the kitchen sink is filthy? You overeat and overeat convenience food, because that’s all you can be bothered to cook. You sit, finding yourself in tears, and you’re not sure why. You feel completely alone; no one can possibly understand how you feel just now. You can’t bring yourself to speak to other people anyway. And in one final little trick of the mind, time slows down to prolong the agony. Every second is torture. So you try to sleep for as much of the day as possible, and you drink wine and take pills to try to ensure that you can sleep. You feel physically ill as well, with aches and pains exaggerated to distraction. There’s a tickle and lump in your throat. You perpetually tug at your eyebrows, and occasionally pull them out so that they contain strange bald patches. And the ear-worms - those annoying tunes stuck in your head - drive you even madder. You also worry that you’re a black hole of misery, sucking in joy around you, ruining the lives of others - so it’s fortunate that you prefer to suffer in isolation. It is paradoxical that you are lonely and yet want to be alone at the same time, but depression is full of paradoxes. When you’re severely depressed you can’t do anything. You just want to sit still and let the pain wash over you. Some people kill themselves because they can’t take the pain any more; and some people are so ill they can’t even initiate the act of suicide. You have contemplated suicide many times because everyday life hurts too much, and often you really don’t care if you wake up tomorrow morning or not.

That’s what it’s like for me at its worse, but fortunately therapy and medication has helped me enormously. It’s been a while since I’ve felt that bad, but I still get occasional relapses, occasional inklings of those feelings.

I find severe anxiety more difficult to describe. It is a bit like being anxious before an exam, or giving an important presentation or wedding speech, but much more intense and persistent. It is also highly visceral; it gets to your gut. You can’t concentrate on anything, but instead worry about everything. You’re completely on autopilot.

Anxiety often goes with depression, giving a condition imaginatively known as “anxious depression”. There is also agitated depression, which is similar but with more activity - of a bad sort.

It is my misfortune to suffer from obsessive-compulsive disorder (OCD) as well (which is occasionally co-morbid with depression). An obsession is not just like a pre-occupation; it is all-consuming, and you can think of nothing else. A compulsion isn’t simply an urge to do something, or check that you really did lock the door; you must do it, usually many times. My OCD started when I was about 11. I would repeatedly get up in the night to check that my bus pass was in my jacket pocket, and go downstairs to check that the front door was shut. I think it was about fifty times a night, possibly more. Why didn’t anybody notice? Then when a passenger in the back seat of my uncles’ cars I would worry that passing drivers would be able to read my thoughts (even though I knew that was impossible), and might be insulted by them, so I had to apologise to them by saying “sorry” mentally - in powers of three. Occasionally I would reach 243 sub-vocalisations. I suffered greatly performing these compulsions, but the prospect of not doing them filled me with even greater pain. Performing these compulsions also releases the mental pressure somewhat, perhaps in a similar way that self-harm makes some people feel a little better. Eventually the compulsions faded away, to be placed with slightly less compulsive compulsions, such as hand-washing (but much less excessively). I still tend to do things in multiples of three (such as checking the front door is locked behind me nine times), and I am still a very obsessive person, with curious obsessions like having to have complete sets of things such as books all in the same format.

Please pass details of this blog on to anyone who might find it useful. There is no need for anyone to suffer in silence. If you are depressed, anxious, or suffer from OCD, contact your GP, or NHS 111, or a psychology or medical practitioner, or call Samaritans or Samaritans USA.

Ups and downs (22 August 2022)

It is some time since I have written about mental health and after comments and questions from several people have decided that I should add something to this blog.

Things have been up and down, and I fear that is the best I can hope for. I noted some time ago that no matter how bad I feel, I will always feel better, eventually.

I have noticed two sorts of variation in mood over time.

The least surprising is variation over days. There are periods of many days, even weeks, when I feel depressed, or very depressed, and then I recover and feel normal or even better than normal for a while. A bad phase typically happens for two to four weeks once or twice year. The curious thing is that although I am very depressed for weeks, there is the odd day in which I feel fine.

Then there is the second sort of variation, which is that within a day. Broadly I have identified the following pattern. Immediately on waking (typically 7.15 - 7.30) I feel fine, as though I don’t yet know what I think or how I feel, or perhaps just haven’t had time to think about it yet. Then within ten or fifteen minutes I realise I feel very, very depressed. This period is usually the worst of the day. Generally it lifts a great deal around 11 am, and as lunch time approaches I can feel quite good. By mid-afternoon my mood can be quite reasonable. Then in early evening it’s though I collapse, and feel bad again, but usually now as bad as first thing. I then improve and by the time I go to bed might be really good. It amazes me that I can fall asleep very happy and wake up and within a few minutes extremely depressed.

Doubtless there are good biological reasons for this short-term variation, but I can find little research on the topic and I can only speculate that it has something to do with the interactions of several factors, including neurotransmitter levels, hormone levels, the sleep-wake cycle, and even blood sugar levels.

Of course when we talk about major swings of mood we must think about bipolar disorder. With bipolar, how order, each extreme lasts weeks, maybe longer, and I don’t experience mania (I think). I swing between depressed and normal. There is a phenomenon in bipolar disorder called rapid cycling, but even then we are talking about several swings a year; it’s defined as four distinct mood episodes a year. I can experience four distinct episodes a day, so I don’t think what I have is rapid cycling, at least as not normally conceived.

I have found this online:

Borderline personality disorder (BPD): BPD is a personality disorder characterized by difficulties regulating emotions, as well as extreme mood swings. These mood episodes are easily triggered and can last from minutes to hours.

(See:

https://www.verywellhealth.com/rapid-and-extreme-mood-swings-5193418

A personality disorder as well! That's all I need.)

My advice is to keep a diary of how you feel. I just score every day between 1 and 7. It enables me to test ideas like "I always feel bad n a Sunday" (I don’t, in fact).

Withdrawal: Duloxetine discontinuation syndrome (June 2021)

I am not sure how long I had been taking Duloxetine (Cymbalta). I think about it was about ten years at a daily dose of 120 mg.

I thought I wasn’t getting the benefit I used to. Now I know it’s complicated, many things can change, and so on, but one hypothesis was that the antidepressant had stopped working, or was no longer as effective as it had been. Others have noted a decline in the efficacy of anti-depressants with time: antidepressant treatment tachyphylaxis is the name given to the problem. (It’s been reported with at least SSRIs and MAO anti-depressants, and doesn’t appear to affect everybody.) There’s a limit to how much you can increase the dose to overcome this tolerance, so the main method of dealing with it is switching to a different drug. With my psychiatrist I decided to move to Venlafaxine. You can’t just stop taking one and start the other; you need to stop taking the Duloxetine gradually, wait a bit, and then start Venlafaxine on a relatively low dose. We agreed on a programme of a relatively slow taper, as this method is called. Things were then delayed by my being hospitalised with pneumonia. I knew that stopping anti-depressants is not something to be suddenly or lightly, and I knew that Duloxetine is widely regarded as one of the more problematic, so didn’t think it was wise to start in a period of serious ill-health.

Eventually I started, and went down from 120 mg to 90 mg for a week, and then 60 mg. Things were OK. I don’t remember any obvious symptoms, and my mood held up well. And then I went down to 30, and the withdrawal side-effects began, first when the famous brain zaps kicked in. It’s difficult to describe these to someone who hasn’t experienced them. It is as though you’re brain is sneezing, or you experience a big mental shiver - it’s most unpleasant. Sometimes you feel as though you’ve been moved against your will. I also had an upset gut, but still I didn’t feel any different, mentally: I wasn’t depressed, or at least I wasn’t noticeably more depressed. So after anger two weeks or so I went down to 15 mg. (This point is where cutting tablets up and slicing capsules open comes into play). After two weeks, maybe a bit more, or I went down to 0 mg.

My records show that withdrawal was worst after going down to a quarter of my original dose and lower for about eight to ten weeks. It was really bad: brain zaps, upset stomach, frequent migraines, extremely vivid dreams starting early in the night, a feeling that I was still dreaming when awake. Even after three months or more I didn’t feel right. My gut hadn’t returned to anywhere normal. Most noticeably after a couple of weeks at zero my mood started plummeting. Low mood, anhedonia, no energy, recurring thoughts of suicide - all of course classic symptoms of depression. It’s interesting my mood took so long to fall, and that the lowering of mood correlated with the discontinuation side-effects starting to fade. The half-life of duloxetine (the time if takes for the body to process half the dose) is about 12 hours, but it must cause longer lasting changes to the brain’s neurochemistry (or perhaps the brain itself). Looking at the research literature I don’t think these things are very well understood.

I know there was a class action started against Eli Lilly in the States about what is called duloxetine discontinuation syndrome (DCS), but it was dropped because there was no evidence that Eli Lilly knew about the possible problem before they marketed the drug. I don’t blame anyone. I started taking it on consultation with my psychiatrist and I was aware that there might be withdrawal problems, as there are with many medications. I suppose I thought it wouldn’t be that bad, having come off other anti-depressants before. Even now I think there must have been many people worse off than me.

What is "normal" for a depressed person? (August 2017)

“Dysthymia, now known as persistent depressive disorder (PDD), is a mood disorder consisting of the same cognitive and physical problems as depression, with less severe but longer-lasting symptoms … dysthymia is a serious state of chronic depression”. Wikipedia.

As part of my mental maintenance, I keep a mood diary. I’ve experimented with several kinds, including apps, but now just use the very simple system of noting one number at the end of each day, on a scale of 1 (extremely, suicidally depressed) to 7 (ecstatically happy), with 4 being “average”. Here is my chart for the last 18 months or so.

The first point to note is that this graph is by no means representative of my life. It begins in April 2016, when I had already been in weekly therapy for well over a year and had at last found the medication that worked (to some extent) for me. I’ve shown the trend line (a guess at the average) which shows a continuing slight improvement over time, although I think this is line is affected by a prolonged and severe relapse I had in the summer of last year. To complete the statistical background, my scores do seem to follow an approximate Gaussian (“normal”) distribution, with my mean score in the middle of the range, at about 4. (Actually it’s very slightly beneath, at 3.8.)

It’s the word “normal” that causes me trouble. What is normal? How can I gauge my mood and experience against what other people feel? And is it reasonable to expect mood scores to follow a Gaussian distribution, and if so what will the mean be?

To give a concrete example, consider someone with PDD (persistent depressive disorder). Their daily mood ratings will presumably be low every day, for long periods of time. Hence compared with people without PDD you would expect their mood rating, if they were comparing themselves with the rest of the population, to be low (as they’re not severely depressed, probably in the 2 to 3 range).

But how do people give ratings of their behaviour? Maybe, completely reasonably, people compare their mood with what they think other people experience – so the moods are relative to the population rather than the individual. But how do we know what others feel?

I use a strategy between the two. And I’m not happy about treating a rating in this inconsistent if not incoherent way. I think a 7 should be “extremely, unusually happy”, although no one should expect to be ecstatic all day long. A 4 should be average for me but not too bad. When I rate a day as “average” I mean I’ve been a bit depressed that today, but no more so than average for me

If you have PDD, your normal is low. I don’t know how other people feel most of the time, but I suspect it must be better than I do. Do you wake up looking forward to the day? Does a day pass without you thinking about suicide and death? Does your day bounce along when you’d say you feel happy? Does your life have meaning? Can you sleep naturally? Do you feel like you have the energy to do everything you want to do? Does the thought of emptying the dishwasher or taking a shower fill you with despair? If so I envy you. Your 4 is not my 4.

The opposite is also presumably true: someone who isn’t depressed has no idea how those of us who are feel. So please keep your comments about “when I’m down I always find going for a good run sorts me out” to yourself.

As I have said before, being depressed steals your life.

Hubris: Collapse (June 2016)

After my last blog on how I have fought to cure my depressive illness, the gods would have it that I have had a relapse; it was in fact not so much a relapse as a collapse. Things have been pretty damned awful.

It was triggered by a life event, the details of which I’d rather not go into. It wasn’t unexpected and it wasn’t objectively that bad. But I switched from a state of feeling good and optimistic about everything, to total suicidal despair and extreme anxiety, within a few hours.

Of course being very depressed is incapacitating, and it has really put back the writing. I couldn’t have written this blog from scratch, but fortunately I had some of it ready and am just filling in the gaps. Blogging by numbers. I have written before about how one of the worst aspects of depression, and one that is rarely mentioned, is how it steals our life and our time. I occasionally wish that I was bipolar, when I would have highly creative, fertile periods between the down times. But for me it’s just all time wasted.

I suppose no one is depressed in just the way the textbooks say a person is. We each have our own way of being mad. I have written about what severe depression feels like to me in the book I am currently writing on the science of depression, No birds sing. (Note to publishers and editors: I am looking for someone to publish this book.)

Imagine feeling sad, but much, much more so, sadder than you’ve ever felt before. Imagine all the lights being turned off in your head. Imagine your mind turning black; black is the colour of depression. All of sudden you’re living in a monochrome world where all feeling and emotion except pain has been turned right down. Imagine a dark ball at the centre of your being that is so cold it hurts. It’s like an icy knife in your soul; it’s worse than any physical pain. You just want to go to bed and cry, to fall asleep, or even die. Die; don’t care if I do. It would be a relief. Death is an end to the misery. In any case, who cares: alive or dead, what’s the difference in the end? I hate myself and my life and I want to die. The idea of doing anything is impossible to contemplate. There’s nothing to look forward to, and nothing gives me pleasure, not even the things that in better mental states I can rely upon to excite me. My despair is utter. Everything is hopeless; I’m never going to get better. I feel a terrible sense of doom and fear, not just that I’m not going to get better, but that the universe is a threatening, mysterious, evil place. And everything is such a bloody fight; everyday life is exhausting. Managing to do the little things can wipe me out after I’ve used up so much energy making myself do them. I feel exhausted all the time. Imagine not being able to concentrate long enough to be able to complete simple tasks, and in any case often forgetting what you were going to do nearly as soon as you form the intention to do it. I make mistakes in the simplest tasks. I have no motivation do to do anything anyway, and no interest in anything. I feel nothing other than total despair. Oh, I do feel amazingly, incredibly guilty about everything, as though I’m lazy, incompetent, and everything wrong with the world is my fault. I deserve to suffer so much. Everything is overwhelming, and I am paralysed. I don’t just have very low self-esteem, I am also full of self-hated. I am the lowest of the low and completely worthless; the world would be a better place without me. If I’m depressed for any period of time self care tends to go a bit out of the window: what is the point of shaving? Can I really be bothered to wash my hair? Who cares if the kitchen sink is filthy? I overeat and overeat convenience food, because that’s all I can be bothered to cook. I sit, finding myself in tears, and I’m not sure why. I feel completely alone; no one can possibly understand how I feel just now, and even it there is a person who can, I couldn’t be bothered to speak to them. And in one final little trick of the mind, time seems to slow down to prolong the agony. Every second is torture. So I try to sleep for as much of the day as possible, and I drink wine and take pills to make sure I can sleep. You feel physically ill as well, with aches and pains exaggerated to distraction. There’s a tickle and lump in your throat. I perpetually tug at my eyebrows, and occasionally pull them out so that they contain strange bald patches. And the ear-worms – those annoying tunes stuck in your head that drive you mad. I also worry that I’m a black hole when I’m depressed, sucking in joy around me, ruining the lives of others – so it’s fortunate that I prefer to suffer in isolation. It is paradoxical that I am lonely and yet want to be alone at the same time, but depression is full of paradoxes.

Most people who aren’t depressed think that being depressed is like being very sad, as though a loved one has just died. A sense of strong sadness and a sense of loss pervade depression, but there is much more besides that to it. Anhedonia is the inability to gain any pleasure from anything; the things that normally give me pleasure, such as reading, watching movies, my garden, and music, give me nothing at all other than a sense of profound boredom. I get up in the morning and I see the day stretching ahead with nothing to look forward to other than being able to go back to sleep again. But what most people don’t seem to understand is the pain of depression: it is mental torture. It is a knife being stuck in your mind and being turned around and around so that you want to scream with the pain – or more realistically just kill yourself so that you can get away from it.

I wake up every morning filled with dread. I have great difficulty in getting going. Often I find that the murk lifts for a few hours around 11. I usually have coffee then, which helps even more, but I get the uplift even if I miss coffee out. I haven’t seen a great deal about this 11 am effect in the literature, but I know from speaking to others that I am not alone in getting some relief then. When I was an undergraduate at Cambridge I was taught about a distinction between reactive and endogenous depression (a distinction that no longer stands up), with endogenous (or psychotic) depression being the worse, and characterised by particularly low mood early on in the day.

And then throughout the day there is panic. There is a persistent low level of anxiety that’s worse before 11 but to some extent there every day. Then there are occasional panic attacks; today I had a panic attack while in a car in a tunnel. I just wanted to escape. I wasn’t driving, it was dark, and I could sense all these other cars and people around me, and I just needed to be out of there. I couldn’t breathe. My heart felt ready to explode, and I was drenched in sweat. When you’re really anxious consciousness seems to shrink to a pin prick; the reduction in awareness feels physical, as though your sense organs have been eviscerated. We now at least understand how depression and anxiety are two sides of the same coin.

There is a huge literature out there on OCD, but I find while I get very obsessed, I no longer suffer much from compulsion. (I did when a teenager.) I can find very little on thoughts just taking over our minds, other than rumination, the idea of going over and over some thought, such as the meaning of life. I find that I just can’t stop thinking about something. The thought is all consuming but there is nothing I can do to release it. I think I’d rather the O be accompanied by a C so that at least I could discharge it occasionally. Instead the same thought, image, or just idea, goes round and round in my mind.

I seem to be very prone to ear worms – tunes stuck in the head. I think I get these worse immediately before an intense depressive episode, but I don’t know of any research on this speculation. But when a song gets stuck in my head – and I mean stuck! I can hear it with crystal clarity, at loud volume, every intake of breath and strum of guitar – I know I’m in trouble, And there’s a limit to the number of times a chap can hear John Denver sing “Annie’s song” and stay sane.

How to cure yourself of depression (June 2016)

That’s a big claim to catch your eyes and score highly on the search engines. I hope.

To be honest I don’t think you can cure yourself without help from others or drugs or both. I didn’t. And in fact I don’t think you can be cured of depression: I’m not. In fact this blog has been delayed because I’ve had a relapse, and have been feeling extremely depressed this past few days. At the moment (who knows in the future?) depression is a life sentence without a cure; the best we can do is keep it in abeyance for as long as we can, and if we’re very fortunate, that might be for the rest of our lives.

But there are many things we can do to help to help ourselves, and I’m going to talk about some of the things that have helped me. I think everyone might find them helpful; if you’re not suffering from depression, then maybe these will help you to live just a little better life.

And apologies if they seem blindingly obvious to you; they weren’t to me. I’ve learned them the hard way.

Drugs.

If you are really depressed, and if it has been going on for any period of time, you almost certainly need them, and you have to see a medical practitioner to get them. In the UK that means your GP or a psychiatrist, who then writes to your GP. They will almost certainly start you off with an SSRI. Do some research: there are many anti-depressants out there, and they work in slightly different (and mysterious) ways. They take time – weeks, months – to take effect though, so don’t be too dismayed if nothing has happened the next day. You should hopefully start to see an improvement within a few weeks. If the first one doesn’t work, then you will need to try another. It’s preferable that you have someone to monitor your mental state and behaviour, because you are often not the best person to judge if you are getting any better. Different drugs have different side-effects on different people, and if you find yours unbearable, again you should discuss changing drugs with your medical advisor. There are alternatives you can get without prescriptions (e.g. St John’s Wort, SAM-e), but these had no discernible effect on me. If you’re interested, after many years and changes of medication I have settled on Duloxetine (Cymbalta) for depression and Quetiapine for anxiety.

Other people.

You cannot fight severe depression alone. You hopefully have already seen your doctor, but probably should be seeing a psychiatrist as well. I have tried different sorts of clinical psychology and therapy, and have eventually found a cognitive-based therapy system that looks at your childhood, attitudes, and relationships to be a revelation. Different things though seem to work for different people. You will need your friends too, and need to be open with them that you are depressed. Fight that stigma!

Changes.

There are many changes I have made that I think have contributed to my shift towards wellness.

Work.

For want a better name – that thing that someone else pays you to spend your time doing. In the first instance you might need a period of time off work – look into your sick leave entitlement. Contact your HR department.

I took a long hard look at my academic job and decided I had had enough. There are many things I liked about it, but an increasing number of things I no longer enjoyed and that seemed to me to be pointless. On the other hand I love writing and journalism, so I decided to “retire” and become a full-time writer. It’s a financial risk. It might not work out. I might be poor for the rest of my life. But at least I feel that I am in control, and doing only what I think is worthwhile.

You might say I’m lucky being in the position to retire and become self-employed, and you’re probably right. But what is your health worth? What big changes can you afford to make? Is the big house and fast car really worth what you’re having to endure? And big changes don’t apply just to work either: is that toxic relationship really worth staying in?

Exercise.

I think you have to be starting to get well to make some of these changes, or at least not in the pits, but I decided I had to lose weight and get fit. I, like many depressed people, am pretty useless at self-discipline. So I joined a gym and signed up with a personal trainer. It’s one of the best calls I’ve ever made. I’ve lost over 25 pounds so far and my weight is still going down. I feel so much better; I have more energy and after each exercise session my mood is lifted. There’s plenty of evidence for the positive effects of exercise so get to it. And no, I still don’t really enjoy doing exercise, particularly cardio, which I find painful and boring.

Fresh air and light.

Many of us who are depressed really benefit from more light. I try and maximise my exposure to sunshine, even sitting outside when it’s sunny but in the cold depths of winter. I have a light box that I use even in summer when it’s dull. I try and get as much fresh air and to get outside as much as I can even when I’m busy working at home.

Diet.

I have tried many diets (in the sense of modes of eating) and as I have blogged before find the science complicated, confusing, and contradictory. One certainty is that you have to cut sugar and refined and processed food right out of your diet. I have also greatly decreased the amount of carbohydrates I consume. My breakfast will be something like prawns, berries, another piece of fruit, and nuts; my lunch fish, sweet potato, and home-made baked beans; dinner lean white meat or fish, lots of vegetable, and nuts. It’s a bit boring and expensive, as I don’t like spending large amounts of time cooking for myself, but I see no alternative. I also take good quality fish oil supplements. I have cut back on the amount of wine I drink but still find some each evening calms me down; fairly harmless self-medication in moderation.

Mindfulness and meditation.

I find meditation difficult – sometimes it hurts my mind too much to sit still with nothing but my thoughts, even for as little as ten minutes – but I try. And I do gain a great deal from being mindful – trying to live in the moment and be present. The evidence suggests that mindfulness training might be as effective as medication. There are many good books and resources on mindfulness training, so give it a try.

Thoughts.

I have tried to change my cognitive structure – saying “I am not my illness”, working out what the really important things are in my life and changing those things, trying to be honest with myself, and trying to be kind. I accept responsibility for things I do wrong and acknowledge the role of others when things go well. Or rather at least I am trying to do these things!

Routine.

I have written about my search for a perfect routine so many times before (blogs ad nauseam). How can the writer find a perfect day when they can write something good every day and yet fit everything else in? But a routine of some sorts is essential if you are or have been depressed. It’s boring and others might mock you for it, but you’re the one that’s ill or have been ill.

Sleep.

My problem, particularly under medication, is staying awake at night and waking up in the morning. However I used to have terrible trouble getting to sleep. The most important thing is to choose regular times and stick to them, come what may. I have a particular problem with waking in the morning, so I set my alarm for 7.20 and get up at 7.30. Occasionally I really struggle, but I will always be out of bed by 7.55.

Gratitude diary.

My friend Ian Jay swears by a gratitude diary – somewhere towards the end of each day you list three things that day for which you’re grateful.

It’s important to do the things you have decided help you, particularly if you feel yourself becoming ill again. If you’re getting a bit down and start skipping your exercise you’re going to be in trouble. So write out a list and tick the things off every day.

Winter is coming (October 2017)

Winter is here – almost.

The autumn equinox this year was 22 September. From then on the sun peaks at midday overhead somewhere in the southern hemisphere until the spring equinox late next March. In practice, day and night are of equal length on the equinox, or would be if our earth fortunately didn’t have an atmosphere. In London, on 21 June the sun rises at 4.43 and sets at 21.21; on 21 December the corresponding times are 8.03 and 15.53. That’s nearly nine hours more light in the summer. With such a dramatic difference at this latitude, no wonder so many react to the difference.

Light plays a central role in regulating our biological clock. We live on a natural rhythm called the circadian rhythm, and our internal clock is set by the action of light on the retina of the eye, transmitted by special tracts of nerve cells to the pineal gland. The pineal gland, situated near the centre of the brain, manufactures a hormone called melatonin. Melatonin helps send us to sleep, so much so that in some counties it is available without prescription as a sleep aid, and melatonin is also used in overcoming jet lag.

Light then is essential for keeping us awake, and sleep plays an important role in maintaining our mood. Most people have heard of seasonal affect disorder (SAD). The definitive mental illness diagnostic system, the American Psychiatric association Diagnostic and Statistical Manual of Mental Disorders (DSM, now in its fifth edition) officially classifies seasonal effects on mood as “recurrent major depressive disorder with a seasonal pattern”. In winter people with SAD are – well, sad. Some people become depressed only in the winter months, and maybe autumn and spring too, and for some people their pre-existing depression becomes worse. Unsurprisingly, given that in winter days are shorter the further north (and south in the southern hemisphere) you go, there are substantial geographical variations in the incidence of SAD, In the USA, in Florida the figure is very low, just over 1%, and in Alaska nearly 10% of the population is affected. Pity the three hundred thousand inhabitants of Murmansk, situated north of the Arctic Circle, which does not see the sun at all between 2 December and 10 January.

I should point out that not ever researcher accepts the existence of SAD. Some studies have failed to find any correlation between mood and time of the year. As with all studies on this sort of subject, much depends on the detail of exactly how mood is measured, how many people are studied, and whether or not they are receiving any treatment.

If people’s moods are affected by the amount of sunlight available then you would expect the suicide rate to vary with the seasons. It does, but not in the simple way you might expect. In the northern hemisphere the suicide rate increases dramatically in May and to a lesser extent June, and in the southern hemisphere in November. This pattern is strange and there is no accepted account of why it happens. One explanation is that when people are very depressed they are too ill to kill themselves, and need the upsurge in energy when they are starting to feel better. I don’t find this explanation wholly satisfactory because I have always felt most suicidal when I feel most depressed; it’s then that I want the pain to end. Most people when they start to recover feel relief. Another possibility is that when people are improving there is a surge in the chemical, or neurotransmitter, serotonin in the brain, and serotonin is associated with aggression as well as mood. In depressed people aggression can be directed towards themselves, leading to self-harm and suicide.

Suicide rates also vary across regions. If you look at a map of Europe there is an increase as you go from the south and west to the north and east, and again it is not simply the case that suicide is always more common in cold, dark regions; socio-economic and cultural factors play a large role too,

I graph my own mood, as I suggest everyone with a depressive disorder does, and have noticed a slight seasonality effect, but it is much less pronounced now I that I am on fairly effective medication.

We are not completely helpless when the nights start drawing in. Those fortunate to be able to overwinter in southern California should now start thinking about packing their bags. Those a bit less fortunate should book their winter holidays, going somewhere likely to have as much sunshine as possible. For the rest of us, there are still things we can do. SAD lights, which emit very bright light (look for at least 10,000 lux) and which produce light in the shorter, bluer frequency range, are now cheaper and much more widely available than they were just a few years ago. But one of the best therapies is free: being outside in natural light as much as possible, particularly in the morning, especially if it’s sunny. Wrap up and get outside.

Student depression (September 2017)

University terms are starting all over the country. When I was an undergraduate, the Cambridge term started late, in early October, and our terms were only eight weeks long. That first one was seven weeks six days too long for me.

I have had several responses from students to my blog on dysthymia – low-level persistent depression, or what is now called persistent depressive disorder. The people who contacted me are just the tip of the iceberg. In your class of a hundred fellow students it could be that as many as nearly twenty of them are mentally ill, to some degree, right now. That’s a lot of sick people; imagine a class where twenty people were sneezing and coughing non-stop. Who are these people? Can you tell? Are you perhaps one of them? And a couple of lecturers are probably depressed right now, too.

What’s the leading cause of death for young people aged 20-35 in the UK? Those risky boys speeding round blind bends in their sporty cars? Drugs? Falling under a bus blind drunk? Being mugged and murdered? No, by some way, it’s suicide. Suicide is also the leading cause of death for men under 50. And most people kill themselves because they can’t take the hopelessness and pain of depression any longer. And if suicide doesn’t kill you, depression is associated with a host of disorders, such as heart disease, cancer, and dementia, which might get you later.

Depression and anxiety are closely related, and usually go together. Epidemiological studies show that anxiety and mood disorders are remarkably common: it’s estimated that one in three people will suffer in their lifetime, and between one in six and one in ten are ill now. The reporting of mental illness has increased, but whether that’s because of better understanding of the disease, better diagnosis, reduced stigmatisation of the ill, increased pressure of contemporary life, or, most likely, all of these, is unclear.

When I was young (under twenty, say), I didn’t know what depression, anxiety, and obsessive-compulsive disorder were, although in retrospect I suffered from all of them. I was aware of something my relatives talked about in rather hushed tones called “a nervous breakdown”. I’m still not entirely sure what one of these was, but I think it was a sudden mental illness requiring some kind of treatment, and even incarceration in an “asylum”. Treatments were very limited back in the 70s; remember that chlorpromazine wasn’t released to the market until 1953, the first benzodiazepine, Librium, in 1960; and the first antidepressants in 1957 (iproniazid, a MAO inhibitor) and 1958 (imipramine, a tricyclic), although these drugs have many serious side-effects. The relatively more benign Prozac (fluoxetine) wasn’t available until 1987. I don’t think I knew about these drugs until I switched as a student from Natural Sciences Physical to Psychology. Indeed when I was a teenager, I thought of treatment as shock treatment; that’s about all there was.

Attitudes started to change when Prozac became widely available; perhaps that’s generally true – diseases only begin to lose their stigma when there is some hope. When I was young “cancer” was another dirty word, sometimes just called the “c word”. Don’t ask my younger self about swearing though; when I was ten, I thought the filthiest word in English was “pub” (where my father went Sunday lunchtime).

I was the first person in my family to go to university, and I had no idea what was involved, no idea really what a degree was (although I knew students “read” for it on University Challenge), no idea how to manage money (fortunately credit cards weren’t available then), no idea how to manage my time, no idea how to study independently, no idea how to live, no idea how to make use of what was available, no idea what a girl was, and no idea of how to cope when I was a raving loony without realising it. I was extraordinarily shy, which didn’t help. I wasn’t lazy; I tried my best, but I had no idea how to organise my time. I expected university to be like school, which of course it isn’t.

I stuck out the first year, mostly because I drift through things and staying was the easiest thing to do, and I was just clever enough to get by in spite of my deficits. The turning point was joining a society where I met other people. I still can’t say that I felt at home, and at the end of the first year I got a summer job where I did. I was earning good money, I had friends of sorts, I seemed to have some purpose, I felt like I was part of a community, and I wondered why go back to Cambridge. At that point I nearly gave up.

I don’t really know why I didn’t; it was easier to stay than not. And when I went back to Cambridge I discovered psychology, and things started to look up.

If I knew then what I know now I would have got professional help. I would have started with meta learning rather than learning. I would have been bolder about asking questions. Mostly I would have realised that I was ill, I wasn’t alone, and that I should talk to people.

Hubris: Collapse (June, 2016)

How to cure yourself of depression (June 2016)

That’s a big claim to catch your eyes and score highly on the search engines. I hope.

And apologies if they seem blindingly obvious to you; they weren’t to me. I’ve learned them the hard way.

Drugs.

Other people.

Changes.

There are many changes I have made that I think have contributed to my shift towards wellness.

Work.

Exercise.

Fresh air and light.

Diet.

Mindfulness and meditation.

Thoughts.

Routine.

Sleep.

Gratitude diary.

My friend Ian Jay swears by a gratitude diary – somewhere towards the end of each day you list three things that day for which you’re grateful.

I hope you find some of these ideas useful. Good luck with the fight regardless.

Internet resources on depression (March 2016)

I’m a little short of time this week, so for inspiration I decided just to Google “meaning of life depression” and see what came up. The first hit was this page:

Depression and the meaning of life

That’s a very interesting page but the whole site is full of useful ideas and information. As the page points out, there are no easy answers. The authors view depression as a challenge for us to make meaning: that “Some people think that the pain of depression can be seen as a kind of ‘signal’ to ourselves to take stock and reassess our lives. At the very least, we may need to recognise and change unhelpful habits like depressed thinking. It may also be the opportunity to think more deeply about how to make our lives more meaningful.”

Spot on! I wish I’d written that myself. But the main theme of my blog is HOW do we make our lives more meaningful? I’ve considered so far that there is a distinction between meaning in life and passing one’s time in a fulfilling way. It’s relatively easy to do the latter, but in the absence of religion, there is no meaning in life. We have to make our way as best we can in what we have to accept is a meaningless world.

One of the few good things about being depressed is that there are a lot of web sites, such as this one, and resources out there for us. It must have been awful to be alone and depressed twenty years ago. (Actually I remember what it was like.) At least we need not feel quite so isolated right now. There are quite a few forums for depressed people and in forthcoming weeks and months I hope to try some.

Giving up (February 2016)

Surely everyone who has ever been seriously depressed has felt at some time like just giving up. I don’t just mean committing suicide, although that is often not far from the backs of our minds; I merely mean throwing our hands up in despair and sitting on the ground, like rebellious toddlers, and refusing to take part in life anymore. Sometimes this feeling comes from some silly event. The other day I knocked over a glass of white wine. It wasn’t simply that I couldn’t face clearing it up, but the event was imbued with some great significance. I am reminded of the scene at the end of the movie 2001, when the ageing Bowman eats his solitary dinner and then knocks over the glass on his table with his cuff; that clearly means something (although I have never been quite sure what). My broken glass signified for me that everything is pointless; all things come to an end, usually rather quickly. I just wanted to sit down and cry. I had had enough.

Sometimes I do some mundane repetitive task and think there must be more to life than this. I know I’m thinking a cliché, and that in fact my life is relatively comfortable, interesting, and good, but that knowledge doesn’t help. Doing the rubbish, collecting the trash, can often bring me to total despair. Looking at the toilet thinking I should clean it again. It’s the again bit that gets me most. Emptying the dishwasher. Washing the bedding. I feel despair wash over myself as I think, not again. This daily routine is killing me. On a good day I will wonder how many more times I will have to empty the dishwasher or clean the toilet before I die; on a bad day I think I can’t face doing it one more time. It is all ultimately so pointless.

The final words in the great Kenneth Williams’ diaries were “Oh, what is the bloody point?”. It is still debated whether his death was suicide or an accidental overdose, but for me that last entry can have only one meaning.

When the world ends I will have a cold, so I won’t be able to treat even Armageddon with the concentration and focus it deserves. Big Things always happen when I feel unwell. The rest of the time it’s the accumulation of little things, the endless repetition of life, that gets me down. Doesn’t everyone worry that at the very best, when they brush their teeth they’re just going to have to do it again a few hours later, and at worst, this time might be the last that we ever do it? Or does everyday life just pass most people by?

When you’re depressed, every day seems the same. There’s no colour. There’s nothing to look forward to. What is the bloody point?