Depression: Medication? Talking Therapies? The Ongoing Debate | Dr Miriam Kennedy

so thanks very much for asking me when I I think about depression medication talking therapies you know what about it the ongoing debate just taking a straw poll when anybody here hears on television or radio drugs they only are interested in drugs or talking therapies you know that's the way forward any immediate things that spring to your mind that concern you or that interest you mm-hmm absolutely anything else other therapies yeah so hopefully tonight when we look a little bit at depression is it medication is it talking therapies or other therapies as you say and if we are considering the important thing of our own mental health and if we're going through a period or a loved one is going through a period of depression and suffering intensely as one does with depression we want to have the best don't we we want to have the best advice we want to have the best professional service we want to have the best hope the best outcome and as we all know depression isn't just a bad day or a bad mood depression is a pretty awful state of mind where one is really low not enjoying normal things in an absolute agony you think of JK Rowling said you know she'd give up or less anything to do with all her fame and fortune because she'd never experienced anything as devastating as depression and you know this is real and the pain of it is real so it's very important as we hopefully know more about treatment and hope and the future that we become as informed as we can be and that's not easy I think we'll all realize that I mean we're in a nice facility here we have an opportunity to be able to look at online information we're in a country where people are now talking more openly about it but even with all of that I can think depression and I think you know in all my years of experience each person is also different so it isn't a matter of one size fits all it isn't a matter of popping into a GP and perhaps you'll have a GP you will have time and interest to be able to talk through what you're experiencing but then you may also have somebody that says you know that there's the service they belong to it gives them something like eight minutes per person and all of a sudden you're supposed to spear out the appropriate symptoms get the appropriate tablet and we know that that's actually unlikely to work or is it and hopefully we'll broach that a little bit today also side-effects and I suppose one of my thoughts in depression and treatment is yeah we need to know about side-effects and we need to know about benefits and we need to know about side effects of tolkien therapies or alternative therapies and we need to know about benefits one of the things I say to people when if we're coming to a decision about taking something like lithium where you need a blood test and you need to check your kidneys and your thyroid one of the things I say and people get a surprise where I say well actually it's thought to be neuroprotective in that I remember and running a lithium clinic for older people every three months and I used to be fascinated as to how little memory problems people were encountering and my supervisor at the time said well actually there seems to be evidence and some evidence that it's neuroprotective so that you're less likely to get a dementia syndrome and said well how come we never tell anybody the good news as well likewise you can have a depression but people have this idea that I'm with mental illness or I'm stuck with staying on well because I've had a few boats and actually we now have knowledge the particular type of psychological therapies or with trauma particular type of other therapies lead to a change not just in the way we think or in our brain chemistry but in the way we react and think about ourselves so that there can be more hope at any stage we don't have to be stuck in a rush and I think it's very important I know Pat McKellen who started aware many years ago he's always said to us as si chose he'd say always keep going there's always something you're finds which can turn the thing round that's terribly interesting for me so depression medication talking therapy is an ongoing debate if you're like me and and I feel passionate about the fact that people can recover when people can live with things that are difficult and have a quality of life if you're very passionate about that so when I hear Blythe answers oh no no no book yourself up and you shouldn't be taking a medication as if there's some blame or no no no you know talking therapies are useless it's all in X if it sort of angers me because it's not that simple and people's lives are not that simple and you don't go to a doctor at a point or a psychiatrist thinking okay it's going to be that simple because actually if to say well why have I got sick now or why again or what is happening for me right now and we know that is person we've relationships as a society we have work money issues all of that so all of that comes to bear on whether we can recover well and that's important so why and I'm allowing myself a slow start so to speak before we get into the evidences because for me after many many years decades as a doctor I am constantly fascinated by no matter what you do or what you actually work with with a patient and indeed with anybody is that no matter what's about your outcome is very determined by whether a person feels in a safe place whether you feel you can trust the person that you're disclosing your inner world to I don't know if you agree with that but I think Trust is kind of vital in in the 80s I was working in something called biofeedback clinic where we literally wired people for sound so you had a skin response which people would call is that you know the lie detector test but for for stress little EMG on your neck to see how are you for muscle tension this is a skin temperature to see you know your gosh responder or what way do you respond and I used to be fascinated that no matter what a person suffered with her what kind of personality they were there was one particular technician who used to put the month of people always did well with they always began to feel better the stress went down you could say was it because she gave a half an hour or was it because she was an empathic person so at the end of the day it's terribly important actually to have some kind of sense that one is understood that can be a friend a partner but when it comes to the doctor-patient relationship or the therapist patient relationship I think that's terribly important because there is a power to that I'll come back to the the picture there which I thought I'd show that's over the side so it's science involved in mental health but it's also an art as well because the very fact of having a safe place to process and make sense of what it is you're experiencing that in itself is very powerful in healing and you know I don't know I think it was last year the National Geographic to the front cover on placebo works and actually when you went into it you could say to somebody I'm giving you a placebo but you know take it for a while your field and they began to feel better in many cases why not because it's voodoo or you're just whatever but actually their very safety creates his own physiological response of ease lack of stress the way I look at it is you know if a single bar of chocolate can give you an endorphin what can that feeling of interest safety we can get through this this will pass remember Christie more describing after being a year in bed in he said its publicly it being a year in bed with depression the very fact that his wife thought will get through it was that thought or that thread with hope and then he'd always be asked about it afterwards and I remember he's at my amusement when he said the worst thing about depression is having people to keep asking you about it when you've actually want to leave it out of your head but it's an interesting one and for us it matters so what I think is Believe It or Not haven't been in Kruger Park in South Africa for the first time just a few months ago a wonderful sense of space and looking at the giraffes it reminded me that many years ago I worked in something that was called giraffe therapy of all things and it was because the giraffe has the biggest heart in the animal kingdom the longest neck up above the foliage and the trees two ears and one mouth in that order and many times when we use what we call giraffe language bit of heart to be in the space as I say to people don't just do something be there stand there to ears to listen are we truly listening because remember the first time somebody said to me my father died and I was going to and I said I kind of ever I said are we going to Sarah I'm terribly sorry I said oh I'm not he was really harsh and it taught me to listen to wait for the response to know that so my experience of somebody is not somebody else's experience and to be able to listen very important because sometimes with depression we shut off from people why and what is happening so before ever we think whether we give a tablet or create a space or have a particular type of talking therapy or alternative therapy we have to have in itself that connection and that heart now we all know a care assistant a nurse therapist CBT therapist whoever it is may be the person that helps change things around because they get us or they get something and that's very powerful so again you know there are different strokes for different folks some people say I just can't get you know you might like Authority and therefore somebody who's a little bit authoritative or bossy just creates a block so have a quiet confidence in oneself in one's ability to process and know and be open and to think this helps or this works or this team works with me or that doctor works and that psychologist but the other thing doesn't and we don't have to overthink it you know to have a quiet confidence that your gosh tells you certain things years ago I worked a lot on medical education and so it's interesting because therapists empathy is the key in the active participation of the patient and treatment and a predictor of successful outcomes that's the reality as well you know the instrument has to be good you're kind of a blunt instrument or unless you like long to instruments and a gun that's very important so we need shared decision-making shared emotional and physical space psychiatry is one of the things that the great Anthony Claire said to us when we were learning he said if you can ask something tomorrow put it off until tomorrow and listen today now that fascinated me because I think it's true we can't hurry along Jolley to conclusions we must get the story right to start with and I thoroughly believe that somebody is suffering from depression requiring a psychiatry and an assessment then time thinking letting the story emerge is important and with oneself to have patience massive amounts of patience as one works through what is in fact misunderstood by many people and sometimes in our own heads were full of judgments you know you should have got to past this now oh that's very silly those of you have experienced compassion focus therapy will no Gilbert has written a lot in it about it that actually you know you may not even realize that you're putting yourself down criticizing yourself the inner teacher or the inner whatever punitive dad or a mom or critical or something else and that just think if you're constantly putting someone down if you're constantly putting an animal down it's going to sit down and cry and cower and lose confidence so we have to fascinatingly work as well on creating if you like different I call them different neuronal pathways than that critical inner sense so we have to have shared decision-making shared emotional and physical space and there's psychological reactions to illness isn't there there's a lot of studies that say for example people who have been diagnosed with say breast cancer that actually those who either get really mad and angry immediately or maybe deny it have better outcomes then the people who hear it and say it's alright are very stoic I'm fascinated by that because again you know why sit I'm sick now allowing us a certain space but we may also need treatment even though you understand why you feel that way because I've just had a hard diagnosis I've just had to get my head around something a wonderful lady through through my day hospital recently and you know at 55 she got a whole rake of physical illnesses which meant she loved playing an instrument she couldn't use her hands like that she loved walking she couldn't do fast she planned her retirement she couldn't do that and people were thinking with gosh that's terribly understandable but just cuz it's understandable doesn't mean doesn't one doesn't need help or treatment to work through her transition the grief with regard to health that was gone the loss of that and any link or opportunity to what I can link with now to give me quality of life and actually she's gone on as her head is fine to study something that she always wished she did to start with and is getting hours of pleasure out of it but it doesn't come overnight one has to be able to have a space to process some of this and there are therapies that look at depression that work better for loss then for other things so it's been interesting there are psychological reactions to illness physical or mental how did I end up like this what about you know you can have a depression with psychosis what psychosis it's a total break with reality people absolutely tortured with it is totally my fault it's my guilt a delusion of guilt isn't very hard remember treating somebody whose father had taken his life and she said I killed him she believed she did because she had a minor minor irritable reaction for months before that happened a sensitive person who was always kind and good she could not forgive herself for that and then when you're in a low mood you've got a black view of everything to a point where you believe it's so fixed and in those ones it can be very useful to have a medication which dampens down the intensity of that self-hatred and then we worked on psychotherapy and you know she's doing very well but that fixed quality you've heard people who have terrible delusions they're being persecutors people who feel you know that definitely my signs are rotten I am doing I am rotting it's a total belief what would the man in the street view be and I always think of those kind of sentences for people say he's not himself at all he needs a spell in sight he's not well she's back to herself and they're kind of nice phrases actually because they're a bit more accepting than we can be saltiness of ourselves the wider context of reality yes illness suffering and death they're part of the story of life do you ever think looking at magazines and you sort of say to yourself oh God has everybody got the perfect life with the 2.1 kids the mortgage the house and I don't know what else and then you look and so you know and you think behind people's lives there are so many stories so that story of life I have an occupational therapist and she looks as a treatment for depression at meaning at context what's the meaning for this some people have a spiritual meaning some people say there's nothing I could do about it but it is my life and they become an agent in that so how do we fit that in the hopelessness when you can't lift somebody else out or something how do we get back a sense of control and these are ways I mean when we lose control and we feel helpless and we feel hopeless that's when depression is maintained Seligman has a book authentic happiness which you know sometimes when I hear that I think oh my god and I hope you know no offense to Americans would be very positive but is it an American book authentic happiness but actually it's really good when I was reading it it made me think that when I went to college the same Seligmann talked about helplessness as a model for depression what maintains you depressed was this helpless it's out of control hopeless feeling and how to break it and again some of you will have heard of some of his studies I mean you think oh I'm sorry for the actual animals involved but he had animals in Agra cage and they had to jump they were trying to jump out of it and they got electrocuted because it was some clear glass or clear something so every time they tried to jump if they got a bang and they ended up back in again and in the end even when they took away the exits think the the the thing that was blocking them when they took it away the poor animals didn't jump they were depressed and he it was quite a good model to understand that if you get a lot of knocks one after the other you can become quite helpless and quite hopeless or bullying is a very hard appellant's fair isn't it it's a very very insidious kind of experience but if and so that was a model of depression that we use in CBT IPT and others to help people get a sense of control get back that's some agency however years later he went back to look at the fact that there was a large number there was something like a third of those animals who when he took away the glass think they're Georgia they never gave up hope so this was an interesting thing because he's written about resilience you know that as we say there's illness there's suffering there's death but I've got through this as I said to people when you're in recovery that was in the past I have a distance travelled now you can have a bad day but you're not going back to where you were before you have different tools you have different skills you have different access so it's very important to have a sense of agency control and hope that there are things that can break that if you have a well-meaning friend who says just snap out of it and you think what I can't wash my hair I can't get up I can never mind one down the road within what you need is a therapist who works in something that gives you again a feeling for the first time with it in a long time that actually are not helped us so they might say I just want you to get up and I just want you to pick the comb and comb your hair that's all I want for this week and maybe you say well that's what I did you said well I did that it might be the first time in a long time they might do anything else sounds simple sounds crazy sometimes but there's a story there's behavioral activation or that goal been looked at as a model and if we do it within two weeks of somebody being an acute inpatient or if we do it at outpatients it cuts recovery rates completely by half people would cover faster so there are psychological reactions to illness anxiety states depression uncertainty we all say we can deal with stress believe it or not if we know what we're dealing with but you're uncertain you don't know if the job is coming or going of the mortgage is coming or going so we search it's a loss of control sensor failure stigma do you think stigma is big or important isn't it yeah because it can be very subtle you know it can be very subtle and we like to think that we're open but I suppose what strikes me again and again is like I would said work in the independent and private sector who worked in the HSE as well but you see maybe more doctors or nurses and and really it's very hard because they're saying well imagine if I admit to this then I look like I'm failing or I look like I'm failing somebody else or I have to report myself to be in a section of the Medical Council and you know so that's difficult but then you have others saying oh I always thought you were well able for it and it sort of looked as a sign of weakness our or you think I don't want to be like my father or a mother because I remember them lying in bed a lot so we'll give ourselves that statement so stigma and overcoming that mark that seems to be there when we had it maybe 20 or 30 years ago for for cancer didn't we and then you know if people thought I've catched that but actually as we know it's not a diagnosis of fatal diagnosis in many cases now that we can do a lot for us but you don't blame somebody for it secretiveness and collusion if we could break isolation we wouldn't need half the amount of things that we take so is that kind of secretive sisal ation I find group work is fabulously powerful not because of group psychoanalysis or group psychotherapy no it's because the person says do you know what I'm not I'm depressed alright OCD you might have had a psychotic episode but do you know what I'm a normal human being this doesn't define me this is something with an illness very very important so overcoming that so there's a powerful effect of simple psychological intervention facilitating self-disclosure exploration of emotional issues any acute stage of illness so that's protection against later emotional distress remember Anthony Claire saying to us don't take away one defense I'll tell you of something else to replace it in other words don't analyze something well actually you know there's the overprotective husband and you know there's the dependent wife we said well actually if it's working for 20 years maybe he's only stopped working because she's depressed why what is that you don't suddenly because during that dark period you may have an insight into things that have changed but you may just be looking at them through dark glasses so it's terribly important to explore the emotional issues and look at that and think why you know that worked well before I find that people have experienced childhood sexual abuse may have coped and then they blame themselves when they get depressed depressed by saying oh well you know that was all in lies you know it wasn't a lying it was a coping but maybe it was a secrets and isolation and how do we work through that now and it might be that the person only now be is able to look at it because their child is the same age that they were or they've heard something on the radio or television I've heard people in their 60s and 70s only have a language now at a 70 year old man recently who said I'm enjoying things for the first time ever and I admire him because of his capacity to enjoy things now and were building off his physical health is no better than average was so it's important that there's a powerful effect sometimes of that psychological intervention of having a name for things because fears can run into obsessions or anger can run into depression whereas if we see I'm happy I'm sad I hold it I learned the skills to manage that it won't define me and I can begin to move forward so there are a specific behavioral and cognitive strategies her deep muscular relaxation can control anxiety now some people say I don't believe that that's too simple I think there was something that they have I don't know if the Old Testament the New Testament or something in the Bible about a guy who went for miles and miles and miles to get some cure and instead he was told to go down and bathe in the river and his leprosy would go and he go raging raging because he was ready to give gold and silver and cows and sheep and I don't know what else and somebody said well if I asked you to do something difficult you do it and he went and bathed and he got better and I think sometimes you know the actual break people wake up in fear of the day people have anxiety and haven't learned this is my body building up and building up a next minute I've just blown up with something so the actual thing of relaxation itself but I call to people square breathing breathe in to counter for hold it for for breathe out for for comeback for for there they are square breathing I new are breaking the hold of that fear that's driving the obsessions and so because you can't really concentrate in your breathing and concentrating the thought in your head I think is you're saying very much that you know next month or something on mindfulness now it's not the answer to everything it doesn't suit everybody but it does really help in a lot of cases and it's because he said don't believe everything you think I think that's what doesn't what you're going to hear about next month so are giraffes with their long neck to take their time above all the foliage to look here listen respond giraffe language is the opposite of jackal language you never do this you never do that biting biting back and having the same conversation in conflict it reminds me South Africa so I'll have to go again sometime with a beautiful space so stay human as I said translate a person's anger or aggressiveness into unmet needs you know you may have a friend who's suffering from and because they haven't jolly de long and got better because you've suggested X no point getting angry come on I've spent that with her and not spending anymore just recognize you need a bit of time for yourself sure but we don't help in order for the outcome you get better this way so translate anger into an unmet need underneath yeah what's happening for the person stay connected because we need empathy and other people need empathy so depression look you know very well but I think when we say it's a state a low mood has to be a couple of weeks the icd-10 international classification of diseases says a couple of weeks at a time but only a couple so people spend years in bad states before they recognize that they need help thoughts emotions behavior sense of well-being sadness anxiety hopelessness guilt worthlessness sleep appetite memory concentration and energy loss of pleasure negative thoughts about oneself the others in the future suicidal thoughts self-harm delusions and hallucinations do people relate to that as a sense of depression so it's not very nice is it and just three of The Simpsons being no mood or a pervasive sense of sadness what I find a huge huge help in picking it up in people it's just not enjoying things that you normally do because recovery isn't about getting a Nobel Prize or you know flying to the moon recovery can be to go out and say come skies blue but that was a good cup of tea well that's interesting I might do that I'm fascinated by that every lovely farmer comes to me they always know I can't remember the names of my cows now I couldn't remove the name of the cow to save my life but he loves his animals and he not getting the same yen or interest when he goes out in the day and when it gets better he knows them all again and he's interested so it's really fascinating you know what your quality of life is for you so I think again you know it's not nice people I sleep saying like sleep goes off early-morning waiting I can get you sleep but I wake up and in the day it's just horrendous because I'm fearful and fearful of everything in that day and I always think again we're animals as well you know you want to be healthy animals so that's why with some people they say oh I don't want a tablet somebody might need a tablet for a couple of weeks to break the cycle around around you sleep because you know when we don't sleep we get pretty irritable and low and depressed and we are physiological animals now don't mean like a sleep because you've stayed up all night doing video games I mean sleep or you you know can wake up and you're terrified of the day terrified and you know that's a horrendous and that's the time when your cortisol or your hormones are at their lowest than the rise during the day so again you know that the lack of appetite the loss of weight or the putting on weight your are were physiological animals so depression is not a very very nice thing and in the old days we talked about biological depression and then we talked about reactive depression and it was a bit like biological was the real thing and reactive wasn't so much the real thing but human you can have both and if I feel low and back poor mood and no energy and disinterest in things I am going to isolate myself and if I isolate myself I am going to feel I'm kind of unlovable and nobody's interested and then somebody comes along and asked me to do something with the phone rings or something and I react or something bad happens and I've no strength aversion so I prefer to think as our Depression as that state of low mood and sadness for weeks at a time with disinterest which can affect you in your body can affect you in your thoughts can affect you in your brain I remember a young fellow saying to me he said what dr. Kennedy nothing bad happened to me in my childhood so I'm really really guilty about putting this on my parents but he actually had a very strong family history and he was beginning college so there was a change so sometimes it's the combination of a particular stress on top of a particular vulnerability but he did well and went on to do very well so no mood can be a normal reaction to certain stressors and life events and it might take a few weeks to get one's head around something grief normal I always think why are we back in a few days yeah sure we're back in a few days but I mean you don't stop missing somebody in the matter of a few days but then the psychiatric syndrome which we were talking about is a depressive disorder affecting your functioning affecting more than three of those symptoms for two weeks or more at a time so clinical assessment depending severity and duration of signs and symptoms they say I think that's evening out now more you know because men in the past have tended to take alcohol drown it in different ways people with childhood adversity are more susceptible to anxiety and depression again it can lead one to have an approach of whether it's drugs or whether it's talking therapies because learnt patterns have to be unlearned if I think every time I have a stress I get into bed and lie there well then that I may have learned so the unlearning of that becomes very important in treatment whereas giving a heavy dose of something which leaves somebody sedated and more sedation is not the best way maybe a small part of something but it's not the best way anxious impulsive or obsessional traits and we know sometimes we try to keep safe by doing cleanings and you know by trying to keep safe not be contaminated and that can become a problem and again I'd they're going back to that fear Drive in the obsession a cognitive behavior therapy strategy would be better there even though SSRIs of serotonin uptake inhibitors have been shown to help I've had you know childhood trauma and people were terrible intrusive images and there is some evidence that something like mirtazapine which helps sleep decreases the intensity of the images so maybe then we can do the therapy without agonizing somebody because you have to be aware as well can I tolerate this teaching people when the distress comes can I have and that's diet if I'm impulsive I go from nought to a hundred really quickly can I understand that can I get skills to know that I can bring that down I can my mind can bring on a panic attack just as with therapies I can self soothe I can self-care it doesn't get a rid of the original problem but it brings me back into a sense of control myself it's more common is that it says single divorced or widowed I think there's nearly everybody you know at some stage married men have some protection but single single single men tend to do less well and those who have been widowers and again you know maybe that's indicative of our society that people express things in different ways and maybe it's a bit stigmatizing and you know I like to see the sports guys and the polo Connells and all that coming out with sharing and the GAA their expression or their experience of depression because we have too many young men and older men who think it's failure and shame and then that locks in that thinking so is recovery possible without medication this was a focus group I had thinking but it takes longer it can take longer take yours one lady said it's like a crutch but you're so far down the bottom of a hole in the corner just meant that I can gaze up and see the sky but it took me two years to take the medication I thought well maybe there's a stigma about medication as well I know what I should be doing but you don't do it it becomes overwhelming how to break this down it's good to know you're not the weirdo in the corner so it's common treatment with antidepressant showeth Herta people can get to complete remission a 30 or partial remission third fear to respond now look there's a lot of pros and cons and an awful lot of these studies on somebody say pills bad taco therapy's good The Lancet which is reputable journey in January last year managed to do a meta-analysis looking at that's putting together whole load of trials on 21 different antidepressants and it had previously done one on 12 and it did show that antidepressant work moderately it wasn't a massive strong effect but they did work and they worked better than placebo if you google Lancet 2018 it'll pop up for antidepressants interesting a lot of stuff you know when do you get side effects you do so who drops out who doesn't why do placebos work was it because they were all double blinded randomized control trials in other words the people taken the thing the the substance the people measuring it didn't know whether this was an active ingredient or not so perhaps sometimes the people with placebo thought they were taking something so there's all of that in it but you know there were things like 1.5 times odds ratio that it would help so again they can help and they can work but not for everybody and there are side effects so what another trial looking at medications was the star G which for example looked at citalopram reciprocal in pure form is lexapro escitalopram American Journal of Psychiatry now why we take that is because a lot of ducks look at that as its outcome because again 2876 people 62% psychiatric care for up to 15 years so it wasn't as simple straightforward once-off depression and 75% had recurrent it was coming back and we know sometimes if take two antidepressants is is resistant and again you know they're not blinding they're not blindingly brilliant results however people did remiss in other words thing is these studies only answer for eight weeks so they're not long enough but the remission rate 27:28 did well taking about six point seven time to response now what does that mean that's currently takes a little bit of time to look at but it's where we would say and the when we're trying to look at algorithms about what works and what doesn't we try to follow the evidence where one has it one doesn't always have it and each person is different so citalopram worked in 28% of the outpatients with this major depression going on for years but if it didn't and the others had failed sometimes you could either switch to something like venlafaxine another 24 percent improved be appropriate Sipan for anxiety 21 percent days sertraline nostril 17 or you could add in and be appropriate at bas pearl and then you move things up to thirty point one percent more and then what some people do and you'll know with with doctors can augment and they might add lithium 15 percent t3 which is thyroxine used to be all the go and then we thought well it's kind of weak not really working too much but this study found another 24 percent improved with it nor tripling an old-fashion try cyclic which was considerably the gold standard improved another another nineteen point something but of course tricyclics cause constipation they cause dry mouth say to us better sedation might cause eye problems no the drug companies push the SSRIs big-time ensure they don't give you that but they can give you over activity they can give you in some people and young men i've seen their excessive activity so they've got energy and that's where i say watch out in the first couple of weeks because you might have energy but not a better mood and if you've had suicidal ideation that can be difficult because it's very hard so i say watch out for those periods it's not that they caused it or that they're having it and suddenly you'll have the energy sorry but again they can work so you've got an overactive person you might give them the nortriptyline two cameras a little bit mirtazapine 12.3 is this pyth I find that very good and PTSD when it's added into them the fact scene it's called the Californian cocktail I must but is that one of my patients said you know she got a lift sure but she said how depressed can you be every morning she's you know finished work in four hours and she's looking at the golden gates and the sea and I said well actually it can be but the Californian cocktail is is working tranel sip Ramin you know the old mao I said don't so much like to do them but they were useful for people who had maybe over sleeping the obsession let not Leslie over sleep overeating personality maladaptive things they do the officer to what you'd expect but you have a lot of dietary restrictions so then they said we'll look for something Rima and Micawber might which is exactly the same but you don't have the dietary restrictions it's nearly exactly this it's a pure form but then they processed it and got that on the market and they did it probably a - it's a terribly mild so the work in some but not in others and you know and then third but basically I suppose what the star D trial said was that if you followed through where you may have you know these biological features of depression you'll have people who also it's going on for a while you want to try and see can you lift mood by any means possible you want to give them that leg up that if you follow through on their sensibly now I don't don't believe in given a bit of this and a bit of that B the other it might work but you may lose track of where are we on the evidence base so we try in so far as we can to follow you know what we what has been shown in trials to to work and be honest with people my goodness if it takes six weeks and I have to switch and six weeks I have to switch and six weeks apps which you can imagine you need a lot of support and hope and working it through but that was for the more severe end of the spectrum I've had loads of people who have done well but nobody has tried them on I remember this young gentleman very well he had about three years of panic attacks anxiety of course he did loads of therapy before he went to his he didn't get go for interviews because he'd be so anxious it was law and then I was listening and I was thinking this guy it's a brilliant culper you know he's trying everything his mother had he's looking out he and his young wife we're looking after both sets of parents with illnesses and had a young baby and I thought this guy has plenty of resilience so I asked him about his father and his father had had had exactly the same pattern but used to drown it a little bit and drink so I said you know I'm looking at something that probably started as a social anxiety youngster 14 or 15 but actually grew into this consistent avoidance and depression and mood and I just gave him an asset album and I promise you he didn't think it would work but six to eight weeks he was fine and he was so sorry that Sony hadn't tried it for him earlier so again everybody is very very different behavioral based non drug treatment what do you think what do you think of talking therapies why would they sound good you're yes exactly you're being open yep you're open and relating yeah yeah and that's an important thing isn't it because sometimes you know we may have some people who there isn't a cause but other times I keep saying why now why now something is triggered something this calm something one is facing so you may find the cause and that's terribly important actually yeah anything else absolutely important absolutely important and I think that's one of my book bears because I know which is true that in the country they say I'm going to regulate in therapies which is important all right or at least that whoever is going to have some training and skill in it because there are not a lot of excellent therapies and an awful lot of excellent therapists actually but I have come across in my work at times things that really frighten me and I realize that somebody who hasn't any particular training has something that they're projecting onto the patient you know maybe they had a bad experience with an alcoholic dad so you must leave this situation right now or they impose because if you're not trained with then you're dealing with strong emotions and strong emotions will have some effect on oneself that's where the training comes in what's the transference use it positively I may not have experienced that but something similar so I can be empathic but I have to watch out I may have somebody who's training with me and I teach them hopefully to be reflective about their own feelings because they might say we'll look I am great with x y&z but don't give me anybody with alcohol because it's just too strong alright remember when I was training and you know you're working in forensic and you had to learn and most of us found something like a child murder so difficult because you still have to assess what is happening here and you cannot have your own emotion projected onto you know that terrible feeling that you you know feel of anger or whatever it may be so it's very important to get the right person for both because we're all not like you know we don't love off each other easily it's going to be a very powerful tool but it has to be safe it has to be trusted and hopefully it has to have an evidence for work so I think as we say being open yeah and and we know where we feel safe and open to relationship again you know you could have an it could be a young SH o or somebody who's good but I remember when I was training they were saying well remember to work with exits this therapy will come to an end therefore you must model for the person the fact that you care for that the therapy will end so they will acknowledge a certain grief know that you care would be able to move on because it's a therapeutic relationship not a detached one as such the therapeutic one and that's very powerful again I remember when I learned that because we're always moving when we're training every six months every six months and I remember there is somebody who had done well with me who was a powerful powerful self Harmer she really really and she would be so powerful in it just when you think something is grand go out the door and then do something so it was very difficult for nurses who were long hours with her and it came to March and I was leaving in June I don't remember we had our own supervision with a therapist and she was saying and I was saying well what about X and then I was saying well you know this nurse is very good this nurse is very good said no stop why why why are you saying that have you told her yet because if you don't tell her yet should think the first person said I like her she said yeah she'll pick that up so the first person that actually liked her hasn't given her the respect of saying bland moving job in June you must do it I thought oh my goodness SOI did and the anger was huge and it rained down and how terrible I was and disappear mice will change now etc etc and I had learned through the therapy supervision to hold that to hold that strong powerful emotion of where that might be coming from and so she came back after three weeks sat down and said well okay so if we only have this time left what are we going to do with the time left and in fact it was a much more powerful intervention because she had a she knew something was going to end she had the respect of knowing that she used the time she got knowledge of her own emotions and I was not the terrible experience that she had in childhood of somebody who was supposed to care for her I ultimately hurt her in the worst possible way so that's where I come in that you know I'm very very strong on that yes there are different therapies CBT will work for anxiety disorders and OCD very well and all of that interpersonal for grief and so on but actually people are too important to just think any therapy will - it has to be suitable and again who you both trust so they're different ones behavioral activation CBT interpersonal psychotherapy they're the three that in England the nice guidelines that say they're evidence-based for depression yes they work but you know sometimes things are a bit more complex than that somebody said about alternative ones mindfulness bibliotherapy nature role of the environment creative arts music and art terribly important um you know I remember when I was working at one stage we were able to refer books and some people like we were actually prescribing books and that was great people got them belfort pay for them then were the days but actually self-help people worked it through torture bowser's came back and asked first asked for help and you know and and it can work mindfulness as we said there as well I'll come back to the nature role of the environment and again I've worked in so many so many places around the country at various times over the years and sometimes I sit somewhere and I think Juno would I'd be really depressed if I was actually coming in here and having to talk about my problems I do believe in life and I do believe in our environment I do believe it should be advocating for services that actually have green you know that are respectful across the way remember a man with dementia and depression and he was sitting in the middle of a very busy Dublin Hospital saying why did you put me in the supermarket doctor who is looking around and was trolleys and everything you know how are you going to get better there I don't know so behavioral activation that was basically things like life events things can happen inside tired workers stay home stay in bed watch TV with draw a rumination rumination again and again and again loss of friendships could be conflict with supervisor financial stress poor health and I don't mean just on a bad day I mean this has taken hold hold to the point that the person is suffering from depression so that's like what I was saying earlier having a nurse a therapist somebody to look at what's my mood to do a day to do a date how you feel what can I go I made a cup of coffee that was good not I ran down the road and did X Y and Zed fix the socks drawer but we begin to actually break down small goals and activities to break the helplessness and that's terribly important because it does bend up well and the studies for that again they would be available through aware and the website with this various studies some older ones newer ones about behavioral treatment for major depression disorder which again works CBT many people will have found that helpful and what is it reduces emotional reactions and self-defeating behavior and a Beck started at back in 1976 or more and I admire him heard him speak and he said he'd been using group psychoanalysis for years and then he thought do you know what the people who drop out her doing better than the people who stay in and he looked at it and he looked at the suicide rates and he was already in his 50s and he said actually what's happening is I'm finding the cause but I'm not leading to a way forward to manage the present and that is a very powerful thing but CBT you understand the past in order to manage the present so I might think you know think the simplest mom goes home and the kid has thrown the clothes on the ground and some people think I'm a very bad mother other things so that's my Johnny he's exactly like that here he goes I'll have a job with this fellow very different because one things I'm never a good enough mother and this is the standard and somebody else thinks this child has some responsibility for his own stuff too you know so CBT looks at our negative automatic assumptions about ourselves it's collaborative active open-ended questions you know why what would that mean to you what would that mean to you what might be going on for you it's very structured very focused people like who like structure and focus that helps them that works so you know on the environment you might have thoughts are my crash then I feel anxious then I seek reassurance and the more you seek reassurance it only lasts a couple of minutes a next minute you're off it and heart race and palpitations rapid breathing joking so we might go after the heart racing and do the breathing and break it we might look and challenge the thoughts yeah 90% of my crash but maybe 5% I won't we might actually look after the behavior and I won't ask about reassurance I'll sit and I think I'll probably panic and pass out but you know what I'm still alive here so that I get a little agency around myself so with CBT we commonly look at the thoughts I'm worthless the future is bleak nothing will change anxiety I'm in danger something terrible has happened I can't cope anger I've been disrespective it's unfair at once Stanford very powerful thoughts we are very powerful but a thought isn't an action a feeling isn't even in action so with CBT over 14 to 16 sessions beginning to break it down beginning to break that cycle works extremely well in a lot of people interestingly I found when I was studying our training it didn't immediately work with people that I was looking after and I felt feel that was because their mood was already so low and their emotions were really so overwhelming that I had to give a language around emotions and that's what led me to move into interpersonal therapy and get trained in that so again you know different strokes for different folks maude negative cognitive triad negative view of one's self and negative view of the past when you're depressed it's only the negative you ever feel then when you're out of the depression you remember and a good day not everything was bad and the future how to break that so CBT can work through self-help you know there's lots of CBT self-help books I give say to people look up I should get royalties for CBT for dummies but it's just that negative you'll begin to say well no I'm thinking about that automatically and you hold it and change it some people like the computerized ones you know the blue beating the blues psycho-educational group CBT for depression and anxiety complex problems CBT that's developed now further to involve some aspects of psychoanalysis schema therapy somebody might go to an in their same day I'm angry and critical I'm sad and helpless I'm a child like I'm aggressive and they're all these ways we learnt or may have learned and this schema therapy can really help no it's a two-year influence but the outcomes are very very powerful for people who previously had been in and out and in and out of hospital for a very long time so there are all these various ways you know a lot of people here I just fly through the next few because I want to do a little bit about music interpersonal therapy it's on attachments where the things start you know and postnatal depression what was that attachments interestingly there studies saying people who do psychiatry that a lot of them who do old age circuitry and one module old age circuitry's have good relationships with a granddad you know and it's kind of what your model and who you want to help others that psychiatrists there is a bigger group of people whose mothers have postnatal depression so you know you model certain things people who've had a loss of a parent before the age of 12 know you brown and Harris's study that know in essence later on you can experience and distress as loss and so you're experiencing loss and interpersonal therapy does really well there because you're looking at the loss and you're modeling your symptoms and seeing how could we look at that differently is there a way we could communicate that differently what could we do to learn how to communicate that differently conflict all of that so we look in a way which enables a solution which is also helpful grief transitions dispute sensitivities that's what it has and it has a very good evidence base for grief transitions disputes less so for sensitivities and sometimes I find for living with sensitivities and and that deeper trauma maybe schema therapy dialectical behavior therapy it would be better time's up I'm through listening now what I am not me here but it's this you could say that but actually what I mean by that is sometimes people with the same conversations for a very long time and what that might mean is actually what we need to do is target a talking therapy that's specific behavioral activation for goals of depression interpersonal for the interpersonal relationships environment CBT for my thoughts and how the influence mood and their time limited so people do get better so which comes first the chicken or the egg the direction of the cause of depression can be difficult it impacts on people around them people might be supportive but negative feelings in interactions they feel frustrated and family and friends may be exhausted so it's okay to go for professional help and seek that and look for an education session with parent with family doesn't mean they don't love but they have a different language you know somebody says I've done everything for you so maybe in their idea if you do everything for somebody they should get better the other person might think I just need you to listen to me it's different languages what that means so there is evidence for psychotherapy but there are side effects in other words I've had people have been redraw Mathai z'd they've suffered so much trauma that I'm teaching and going through we're going through skills and how to manage that so one has to be aware you don't go right back into something if it's not safe and Beck learnt that in he's looking at CBT because he said he was looking back in groups at something but not giving people current tools and people are resilient and people do come through a lot and there is that kind of narrative in there that simple but there's huge benefits as well because of what they would what I would say is that while you can get a leg up and get going again with with medication wraps actually sometimes with CBT or IPT behavioral activation alone in order to stay well and maintain as well you have to as we said know the cause you have to learn perhaps a language around managing and coping and linking with the symptoms and you may have to enact changes that mean the environment is going to be better for your mental health so the nature there's a role for the environment isn't there nearly coming to the end but I'm Shirley Gleason is somebody again if you look at her Shirley Gleason in the south table now she does a number of groups forest walks and so on and interestingly she did her diploma honor and which of those do you like best most people like nature I think the nature is beautiful I feel young lively secretary and she said oh no I much prefer the one on the right means there's something going on somewhere so there you go but anyway for many people nature the Social Work concept of the person in the environment understand the individual and the environment we all know do you know what that environment is toxic for me it could be a workplace it's so usually to do with your core values in some form so we need a fish be to the individual group and the places we live out our lives so that's all systems theories there is an evidence for that and again you know therapeutic landscapes green gyms eco therapy conservation projects therapeutic horticulture community healing gardens and sometimes doing these things it's not just and it can be good because you're social or you're with others but you're not concentrating their problems you're concentrating on the gardening or whatever but it is also that a nun research would say it decreases the ruminations there your the ruminate when you're depressed is round and round and round you can't get out of your head somehow there's something about the forests who's the green something bigger than oneself as one girl said to me just was such a relief to have something bigger than my head around so there is evidence for supporting the role of nature in mental health nor CT by Brotman contact reduces rumination associated with anxiety and depression rumination is so nature experience can block or counteract us reduce the risk of developing mental disorders so now I'm going to move on to as well in last couple of sites one of them is that again I think older people can suffer from depression and people too easily will say oh well actually that's understandable you've lost this and you've lost that you can ask the other but they don't get psychological therapies offered to them they don't get alternative therapy sometimes offered to them cause it's understandable but just as is understandable doesn't mean that it won't respond to treatment now if somebody with Alzheimer's disease they 30% suffer from paranoia depression anxiety and I mean the last thing you want in the middle of this not knowing what's happening around you is to feel that in fact low and so many times we only are looking at behaviors where it's in fact a lot is coming out now on the mood the quality of the mood that the moment is what counts and you want to make each moment account music is powerful there's a lot written and today isn't the day so much for going over it but there's a huge amount on music therapy at the moment were involved in in our area with looking at is drama therapy versus group therapy music on the one-on-one the use of a therapeutic wire for people the care who's not or the the the spouse who's loved one has dementia might be the first time they're doing something together again so Melissa hello cow if I pronounced it sings to a happy Dorothy's an end-stage Alzheimer's disease [Laughter] [Music] [Music] [Music] my [Music] [Music] [Music] [Music] [Music] Dorothee when you look at that you can see she just live in dock didn't she she just came alive she starts to tap she starts to interact she says oh look I had a gentleman with frontotemporal dementia he hadn't spoken in five years and very little he had the side effects of medication of dribbling and I got this young lady who had she was working with a group called music de la santé who were trained in empathy and trained in music and she began to sing a lot a music in music of a kind of song with the lyre from the 14th century France now he was from West Waterford and he just literally started to sing along and he went like that and said that was beautiful thank you he's like a ballet dancer and there was something in his brain that we connect it and he stopped the dribbling and stopped the side fix he wasn't anxious anymore and that we you know it's a power that is a power of another part of the brain which I think we really owe our patients what about the forest streams and won't be long at this one but just as that how do you feel when you're watching that [Applause] [Applause] [Applause] how did you feel watching that bit loud very relaxing and again you know if you're in the middle of that for a couple of hours yeah the sound won't be as loud as that in the middle of bouncing off a wall but actually you know again the power of that and very much to help with the creative arts mindfulness bibliotherapy lots of things art itself as we're saying alternative once I show this before to people it's nine foot high and across and I think it might stir being Claire Morris Museum our our our local community center eight people with schizophrenia and eight people with social problems in the days when you could ask your health board for money for art I got two art therapists from Italy to come lovely and all we remember and it keeps coming through my head is a gentleman who had depression along with his schizophrenia and he couldn't get out of bed he had negative symptoms so a nurse ago and help him dress and that was fine well you're talking about 20 years and he participated this Greek mask he did one of the panels here and you know it was it the togetherness for the week was of the understanding that the Greeks hid their mood behind this mask was it the language that we gave him but all I know was he rang us in the center at the end of the week and he said can succumb to come out with me I want to buy a new set of clothes he came to a session he came to a nice reception we had and I remember his smile it was a spontaneous smile his new suit beside that and he got into art from then on I used art a lot because sometimes the nonverbal gives an expression of things that we didn't even know we were experiencing so again the power of relationship the power of connecting with each other and above all I mean I keep saying it's like is that the is it what is this debate I use whatever works get a good assessment a good treatment package it takes somebody who works with the evidence and because people do get better and hope is vital hope is also that there is something beyond here which is better for me and so many people I know say well look I wouldn't wish it on my worst enemy but what I've got through it is something quite different now and that is the the sense of enjoyment in that cup of tea or knowing your cow or knowing the moment or that I am actually worth it so in that sense I would say thanks for your attention here sorry for keeping you over and I'd be very happy to take some questions as well [Applause] you

Channel: Aware

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Id: zIYCwgJhVcA

Length: 70min 35sec (4235 seconds)

Published: Thu Jan 23 2020