Depression

Depression-5-Christian-Jonathan-Haverkampf-common-mental-health-conditions

Depression

Christian Jonathan Haverkampf, M.D.

Depression is one of the most common medical conditions, which can interfere significantly with a person’s quality of life, relationships and ability to work. Several effective treatments are available, including psychotherapy and medication. This article contains a brief overview of both areas, while focusing on psychotherapy, particularly Communication-Focused Therapy® (CFT), as developed by the author.

Keywords: depression, treatment, psychotherapy, psychiatry

Contents

Introduction. 5

Adaptation. 6

Genetics. 6

Psychotherapy. 7

The World is Not Enough. 8

Negative Thoughts about Oneself 8

Medication. 9

Major Depression vs Reactive Depression. 10

Stress. 10

Depression and Health. 10

Age. 11

Differential Diagnosis. 11

Computer-Based Treatments. 12

Communication. 13

Inside-Outside Reflection. 14

Connectedness. 14

Social Connectedness. 15

Social Identification. 15

Depression Treatments and Connectedness. 16

Adolescents and Young Adults. 16

Technology and Connectedness. 17

Autonomy and Connectedness. 17

Connectedness and the Elderly. 18

Connectedness and Groups. 18

Causes of Depression. 18

The Monoamine Hypothesis. 18

Communication Factors. 19

Symptoms. 20

Physical Symptoms. 21

Treatment. 21

Medication. 21

Psychotherapy. 22

Separating Thoughts from Emotions. 22

Body Work. 23

Communication-Focused Therapy®. 23

Change. 24

Analysing Communication Patterns. 25

The Process. 26

Communication Patterns and Structures. 27

Transfer. 28

Meaning. 29

From Meaning to Meaningfulness. 29

Motivation. 31

Interacting with the World. 32

Powerlessness. 32

Insight into Communication. 33

Building the Sense of Self 34

Resonance. 35

Relevance. 35

Communication Exchange. 36

Experimentation. 37

Observing. 37

Integration. 38

Values, Needs and Aspirations. 38

Internal Communication. 39

Meaningful Messages as the Instrument of Change. 39

Broader Experience. 40

References. 41

Introduction

Depression affects a good size of the population. Although it is relatively common and the impact of the individual quality of life can be enormous, there is still a stigma attached to it. A common belief is that it is not treatable, which is in the vast majority of cases untrue. Another misconception is that it lowers a person’s intelligence or changes one’s personality, which is equally untrue. While someone suffers from depression, the ability to focus and concentrate may be reduced, it does not lower a person’s cognitive abilities when the person recovers from the depression. However, the most serious misconception must be the one that there are no effective treatments. In truth, there are many effective treatments available, but their effectiveness often depends on matching the correct treatment modality to the right patient.

The proportion of the global population living with depression is estimated to be 322 million people—4.4% of the world’s population—according to a new report, “Depression and Other Common Mental Disorders: Global Health Estimates,” released by the World Health Organization. The report also includes data on anxiety disorders, which affect more than 260 million people—3.6% of the global population. The prevalence of these common mental disorders is increasing, particularly in low- and middle-income countries, with many people experiencing both depression and anxiety disorders simultaneously. Depression is, in short, the leading cause of disability in the world (Friedrich, 2017).

Depression is also one of the most common comorbidities of many chronic medical diseases including cancer and cardiovascular, metabolic, inflammatory and neurological disorders. (Gold et al., 2020)

Some possible pathophysiological mechanisms of depression include altered neurotransmission, HPA axis abnormalities involved in chronic stress, inflammation, reduced neuroplasticity, and network dysfunction. All of these proposed mechanisms are integrally related and interact bidirectionally. In addition, psychological factors have been shown to have a direct effect on neurodevelopment, causing a biological predisposition to depression, while biological factors can lead to psychological pathology as well. The authors suggest that while it is possible that there are several different endophenotypes of depression with distinct pathophysiological mechanisms, it may be helpful to think of depression as one united syndrome, in which these mechanisms interact as nodes in a matrix. Depressive disorders are considered in the context of the RDoC paradigm, identifying the pathological mechanisms at every translational level, with a focus on how these mechanisms interact. Finally, future directions of research are identified. (Dean & Keshavan, 2017)

To accommodate, they learn to censor themselves, to devalue their experience, to repress anger, to be silent. Examining moral themes in depressed women’s narratives, Jack demonstrates how internalized cultural expectations about feminine goodness affect women’s behavior in relationships and precipitate the plunge into depression. In a brilliant synthesis, Jack draws on myth and fairy tale for metaphors to further our understanding of women’s depression. (Jack, 1991)

Depressive disorders are frequently associated with significant and pervasive impairments in social functioning, often substantially worse than those experienced by patients with other chronic medical conditions. The enormous personal, social, and economic impact of depression, due in no small part to the associated impairments in social functioning, is often underappreciated. Both pharmacologic and psychotherapeutic approaches can improve social impairments, although there is a lack of extended, randomized controlled trials in this area using consistent assessment criteria. (Hirschfeld et al., 2000)

Adaptation

Many functions have been suggested for low mood or depression, including communicating a need for help, signalling yielding in a hierarchy conflict, fostering disengagement from commitments to unreachable goals, and regulating patterns of investment. A more comprehensive evolutionary explanation may emerge from attempts to identify how the characteristics of low mood increase an organism’s ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort. In such situations, pessimism and lack of motivation may give a fitness advantage by inhibiting certain actions, especially futile or dangerous challenges to dominant figures, actions in the absence of a crucial resource or a viable plan, efforts that would damage the body, and actions that would disrupt a currently unsatisfactory major life enterprise when it might recover, or the alternative is likely to be even worse. These hypotheses are consistent with considerable evidence and suggest specific tests. (Nesse, 2000)

Genetics

Data are from 2,302 adolescent sibling pairs (mean age = 16 years) who were part of the National Longitudinal Study of Adolescent Health. Although genetic factors appeared to be important overall, model-fitting analyses revealed that the best-fitting model was a model that allowed for different parameters for male and female adolescents. Genetic contributions to variation in all 3 variables were greater among female adolescents than male adolescents, especially for depressed mood. Genetic factors also contributed to the correlations between family and school environment and adolescent depressed mood, although, again, these factors were stronger for female than for male adolescents. (Jacobson & Rowe, 1999)

Psychotherapy

There are many kinds of psychotherapy, but they all derive from the concept of the ‘talking cure’ developed by Freud and Breuer. Over time, various brands have been developed, but the interaction between the patient and therapist, insight, reflection, and learning are still the basic building blocks of psychotherapy or counselling.[1]

Depression very often does not come ‘out of the blue’, and it is important to understand the factors that contribute to it. While some people have a greater predisposition for depression than others, psychological factors usually play a significant role. The three main schools of therapy are cognitive-behavioural, interpersonal, and psychodynamic therapies. Major differences are that the first one focuses more on learning and the last one more on insight and understanding, but many practitioners combine elements of each of them. I have developed a communication-focused approach, that works with both insight and learning, which is described in more detail below.

Depression comes with negative thoughts and feelings, where one influences the other. It can begin with difficulties and interpersonal problems, such as in a relationship or at the workplace. The more one doubts oneself, s self-critical or blames oneself, the more the spiral of depression reaches down. Communication patterns often change, both on the inside and the outside. Internally, ruminations, negative feelings, despair, hopelessness, and doubts can lead to increasing questioning of oneself to the point where one feels a physical pain or pressure. In severe cases of depression, the communication reaches a point where internal communication, feelings and thoughts flatten out. Depression does not necessarily mean that one feels sad all the time. In the more severe cases, it means that one feels less to the extent that one cannot cry anymore and feels a physical pain of emptiness. Thoughts about ending everything, as in self-harm, can occur quite frequently. They need to be taken seriously, and one should look for immediate help, which can also include a hospitalisation where a more intensive treatment and a secure environment are possible.

The outside communication reflects the internal communication to a large extent. And often it has become impossible on the inside to take a step back from the ruminations and circulating negative thoughts and watch what is happening from the outside. This step back would, however, be very important. Most often people then try even harder to run with their head against the invisible wall. The brain’s job is to think and to solve problems in the world by thinking through them. In a rumination the brain tries to ‘think its way out’. However, this usually just makes it worse. To get the view from the outside of what is happening and to find new strategies through changes in perspective are important steps in therapy.

Psychotherapy should address various factors, such as current stressors, unresolved conflicts, also internal emotional ones, past experiences, and patterns of relating with oneself and the world around. Identifying own needs, values, and aspirations in helpful in finding a life ath that is more aligned with what satisfies and makes happy.

Psychotherapy should be tailored to the individual needs of the patient. The main task of the therapist is understanding. All psychotherapeutic techniques are really a support towards this goal. As every patient is different, one begins in some ways from scratch. Being empathetic, mindful and aware of the other are crucial towards understanding the dynamics, needs, and suffering a patient is experiencing. Understanding can be accomplished in many different ways. Some focus more on the narrative, some on the interaction and communication patterns, others more on behavior patterns, or on past experiences. But all this is just to help the therapist understand in a way, that tools for healing can be applied/

The World is Not Enough

Often in depression there is the sense that nothing is very helpful anymore. One feels alone with a situation where there does not seem to be a way out. One experiences feelings that are unpleasant, as mentioned to the extent of being painful. The internal communication revolves around questions that can lead deeper and deeper into depression. As our mind is programmed to solve problems, it pursues the questions as far as it can. However, if the questions are the wrong ones, this will not lead to a resolution.

Negative Thoughts about Oneself

Depression and risk for depression are characterized by the operation of negative biases, and often by a lack of positive biases, in self-referential processing, interpretation, attention, and memory, as well as the use of maladaptive cognitive emotion regulation strategies. (LeMoult & Gotlib, 2019) Depression is in that sense different from fear or anxiety in that one has negative thoughts about important attributes about oneself, such as personality, resources, strengths and weaknesses. At the same time, it is important to realize that this is I not directly about the innermost core sense of self. It is more about the facilities one has than about the feeling of self. Thus, one approach of the therapy is to connect with oneself on the level of the felling of self, which is below the surface of personality and skills (Haverkampf, 2010b). Straight forward mindfulness exercises in combination with any therapeutic approaches that also pay attention to communication can accomplish this. As the self is one’s perceptions of the internal flows of information (Haverkampf, 2010a, 2018a), the ability to take back a step and observing, while connecting with oneself is a key skill.

Medication

There is little doubt that medication is effective in depression. Increasingly, we also understand why it works, and how. The challenge can sometimes be to select the right antidepressant for a specific patient, but the miss rate usually declines with experience of the therapist. Generally, the side effects are low or non-existent and over a couple of weeks to a few months there is in about seventy percent of cases a marked improved in mood, motivation, focus and the energy to engage in activities. Sleep, appetite and other parameters can improve as well, depending on the medication selected. If a drug does not show an effect, or only an unsatisfactory one, after some time, it is often a good idea to switch the antidepressant, which frequently works.

When it comes to medication, it is important to understand that an antidepressant has usually other effects aside from its effect on mood. This also needs to be fitted to the patient. As mentioned, when psychotherapy was discussed, a depression is not the same for everyone. There are different types and flavours of it, which are unfortunately not capture adequately by the diagnostic systems we have. So, there can be a patient with severe mood lows and paralysis in life with a history of depression in the family, while another patient experiences anxiety and panic attacks with depression in the background after a relationship breakup, and a third one who does not feel that low, but who has severely disturbed sleep, libido and appetite in waves. In all those cases one would diagnose depression, but the treatment could be very different, both on the psychotherapy and the medication side. Understanding the patient, the individual history, the fear, needs, symptoms, aspirations, and more, is important not only to select and plan a course of psychotherapy, but also as regards the medication.

Good communicating is the foundation of good medicating. It not only indispensable in building compliance, but also in selecting the right medication. Too often the profile of a drug does not fit the patient. For example, a patient with insomnia may benefit more from an antidepressant that also has a sleep-inducing effect or another patient with anxiety may find it easier to gradually and slowly titrate up a softer serotonergic antidepressant. Potential or current pregnancy leads to its own unique considerations. Although randomised controlled trials on pregnant women are ethically impossible, we have a lot of data on women who took various antidepressants in pregnancy.

Even with medication one should not lose sight of the overall situation the patient is in, the patient’s past and desired future. The medication needs to fit in. For a patient to whom an active sexual life is a major factor in the level of quality of life, a medication that is very likely to impact libido negatively may be an inferior choice if there are other good alternatives.

Major Depression vs Reactive Depression

A depression, if it is not primarily a reaction to a life event, is called in psychiatry a major depressive disorder (MDD). It is a condition characterized by at least two weeks of low mood that is present across most situations. (APA, 2013) It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and psychological pain without a clear cause. There may also be false beliefs and – in the more severe cases – acoustic or visual hallucinations. Major depression needs to be differentiated from sadness. Depression often actually means the subjective absence of feelings, such as sadness. Patients often cannot feel themselves anymore as before, which can cause additional anxiety.

Another form is the reactive depression, which occurs as part of several conditions, such as post-traumatic stress disorder (PTSD). These forms of depressions are discussed within the articles on these conditions. The following will focus on the depression, which is not primarily a part of these conditions, the major depression.

Some people have periods of depression separated by years in which they feel normal while others nearly always have symptoms present. The first line of treatment is a combination of psychotherapy and medication. Some common antidepressants are mentioned below. This combination has allowed most patients to live normal lives and in the clear majority leads to a significantly higher quality of life.

Stress

There is growing interest in moving away from unidirectional models of the stress-depression association, toward recognition of the effects of contexts and personal characteristics on the occurrence of stressors, and on the likelihood of progressive and dynamic relationships between stress and depression over time—including effects of childhood and lifetime stress exposure on later reactivity to stress. (Hammen, 2005)

Depression and Health

Major depression significantly affects a person’s family and personal relationships, work or school life, sleeping and eating habits, and general health. Major depressive disorder can negatively affect a person’s family, work or school life, sleeping or eating habits, and general health. Between 2-7% of adults with major depression die by suicide (Richards & O’Hara, 2014) and up to 60% of people who die by suicide had depression or another mood disorder (Lynch & Duval, 2010). But depression has also been linked with several physical health conditions, such as cardiovascular and autoimmune illnesses. These conditions make up a large share of the costs society incurs when depression remains untreated. Depression causes the second most years lived with disability after low back pain. (Vos et al., 2015)

Age

Depression can strike at any age, and the main tools we have, psychotherapy and medication as well as supportive therapies, mostly apply to all ages. However, the psychological issues for the different age groups can seem quite different. What may be an identity crisis in college aged adults can be a deeper crisis for meaning and purpose in the middle-age. The reason why I used the word ‘seems’ is because the underlying motives are not really age specific. Self-connectedness and connectedness with the world run like a thread through all these different manifestations. The identity crisis in young adults and the search for meaning in the middle-aged mean that one’s own basic parameters, the needs, values, and aspirations and information about the world feel insufficient. These feelings are a need for greater internal and external connectedness. It is important to keep in mind, however, that these two themes are just gross oversimplifications to cast the spotlight at the core theme of connectedness.

As mentioned, depression is common in older adults. (Kok & Reynolds, 2017) Efficacious psychotherapies for late-life depression exist, but are underutilized in part because of their complexity (Alexopoulos, 2019). Although antidepressants may effectively treat depression in older adults, they tend to pose greater risk for adverse events because of multiple medical comorbidities and drug-drug interactions in case of polypharmacy (Kok & Reynolds, 2017). They are also rather ineffective in treating depression of demented patients, but long-term use of antidepressants may reduce the risk of dementia. However, confirmation studies are needed. (Alexopoulos, 2019)

Differential Diagnosis

A diagnosis is only a tool in working out a treatment that offers a greater likelihood of success. It is important to keep this in mind because in medicine frequently a diagnosis seems to be an end in itself, but it should not be. Depression, a lowering of various feeling and cognitive states, is something that has been around for a very long time. However, increases in complexity and demands in the world quite often lead from stress and burnout to symptoms of depression. These demands can come from professional, personal and social areas of life.

There are many conditions, somatic, psychiatric or iatrogenic, which can induce symptoms similar to that of a depression. A host of other possibilities should thus be considered, and, if appropriate, be actively searched for. In most instances the situation is quite clear, especially in an outpatient setting, but even here it is advisable to explore alternative explanations aside from depression. At the same time, about 85% of patients with depression have significant anxiety, and 90% of patients with anxiety disorder have depression. (Tiller, 2013) In some cases, a patient may also suffer separately from a depression and another condition. In other cases, the full symptoms of depression occur as part of the condition, such as in a schizoaffective disorder, which combines both, the symptoms of a psychosis and a depression.

One should also not forget that medication can also induce depression-like symptoms, even though they do not match those of depression fully, such as the emotional flattening observed sometimes in several antipsychotics (Haverkampf, 2013b) In any case, a full list of the somatic and psychiatric medication the patient takes should always be scanned for anything that could lead to the symptoms the patient is experiencing.

Computer-Based Treatments

Psychotherapy aims at changing how patients communicate and process information, and the important tool are information and communication. Helpful and meaningful information can be provided in many forms. Some people who suffer from depression, anxiety, or OCD work successfully with self-help books. This is essentially a one-way communication, and the hope is that the information presented changes a perspective, a way of thinking or acting, reflection and insight, and internal and external communication in general.

There are also internet-based treatment applications. While a book cannot provide feedback, a computer-based system can do so to some extent. However, a patient cannot assume or hope that the computer will offer real understanding similar to that of another human being. While programs that mimic therapists have been around for a long time, as one only needs to think of ‘Eliza’ from the late 1970s, they can hold the illusion only for a limited time. ‘Eliza’ was a very short program, by today’s standards, running on 8-bit computers with small memory even for the time, but it was ingenious. It would take sentence fragments and ask the user ‘How do you feel about …?’or ‘Tell me more about …’ and the like. The effect was really striking, which also illustrates how easy it can be to convey psychological support in real life.

A computer-based system also cannot replicate the many information channels that are usually available in human interactions. Still, internet-based systems have shown to be of some use in the treatment of depression. Josephine and colleagues conducted a systematic review of randomized controlled trials investigating internet- and mobile-based interventions targeting adults with diagnosed depression. They found that these interventions significantly reduced depression symptoms in adults with diagnosed depression at the end of treatment and at follow-up assessments when compared to waitlist conditions. (Josephine et al., 2017)

One should also not forget media that show human connection. The stereotypical image of the lovelorn on a couch self-soothing with ice cream and watching a film is not so far from the truth. Self-soothing is often underrated in working with depressed patients, and the movie temples of Hollywood’s golden age, where people could experience connectedness with themselves or others, have become the on-demand streaming services of today. My home is my cinema, where I can be distracted and feel connectedness. Good movies are those where one can feel connectedness between the characters of some kind, whether in the positive or in the negative. In the milder and more moderate forms of depression the withdrawal from others is usually accompanied with a greater need for connectedness. A greater need for connectedness, coupled with the negative thought and feelings about oneself, such as self-criticism, self-blame, and guilt, actually lead to greater withdrawal. The auto regulation seems to malfunction, which can be corrected through psychotherapy, for example. However, in some cases, a change in scenery, such as travelling abroad, or a provocative book brought about the needed change.

Doing things for oneself that make one feel better is vital in depression, because it helps regain a sense of control over the own feeling states. What makes depression worse is the sense of helplessness and powerlessness in ending the state. Often this is what prolongs or maintains it. Children self-sooth autonomously by, for example, using a finger, or by asking a caretake for help in the form of a hug, a pacifier, or something else that aligns with the present needs. In both cases, internal and external communication is important. In the former, it is the internal reading and processing of signals and the self-soothing activity, in the latter communication with the outside world is added. As both, internal and external communication are linked, they reflect each other.

Communication

Since communication is the main instrument we have for diagnosis and treatment, words play an important role. Sigmund Freud highlighted the importance of ‘mistakes’ people make in everyday language that reveal something about unconscious content, and the deeper meaning of jokes people make. The rich symbolism in myths and sacred texts often relies on the subtle meaning of words and word constellations. Depression does not create content, but it has an impact on content and on how content is processed. The shift in focus towards negative thoughts and feelings could have the function of pushing the individual towards the positive, but this becomes more difficult because of the disconnectedness one experiences internally and externally in depression. Thus, meaningful communication and connectedness can help to bridge the depression by enabling the move to the positive.

Communication is also important in identifying the type of depression. Communication patterns give away the fingerprint of the condition (Haverkampf, 2010c, 2013a). However, content can be helpful as well. The words individuals use in their communication can give us an insight into depression. Eichstaedt and colleagues showed in their study that the content shared by users on Facebook could predict a future occurrence of depression in their medical records. Language predictive of depression included references to typical symptoms, including sadness, loneliness, hostility, rumination, and increased self-reference. (Eichstaedt et al., 2018) As the world is becoming technologically more connected, more information is available on what and how one communicates. This could be used for good

Again, understanding and empathy are important in identifying where the depression affects the internal communication flows. Through its impact on information flows and processing a mental health condition can be identified. Depression has effects on the flow of cognitive information associated with thoughts, information associated with feelings, information associated with sensation, and so on. Psychosis, for example, also has distinct effects, one of which is the failure in separating whether a source of information is inside or outside the person. Connectedness is usually a good thing, but this really requires that we are all smart enough to make the most and best of it. This smartness in turn requires connectedness.

Inside-Outside Reflection

The communication patterns in the outside world and those on the inside are closely linked. So, the disconnectedness a patient with depression is experiencing can be felt on the outside and on the inside. Helping the patient to achieve greater connectedness in the outside world can so also transfer to better connectedness on the inside, while helping the patient to better connect with himself or herself also improves the connections the patient has with others. In Communication-Focused Therapy®, for example, awareness, reflection, insight, feedback, and experimenting with communication follows similar rules for the internal dialogues as well as for the outside dialogues (Haverkampf, 2010b, 2017b)

Connectedness

The feeling of connectedness with others is a powerful antidote to depression, anxiety and other mental health conditions (Haverkampf, 2020b). Important is that one feels connected in a meaningful way. One could feel lonely in a crowd of people or even when with family and friends. Meaningful connectedness means that one feels understood by others, that communication really works. The human touch is at its most powerful if one is in the presence of people where worlds can connect. A shared history can make connectedness easier in some cases, but by itself it is not enough. Connectedness between individuals requires interest and the effort to try to understand the other. However, it is effort well spent, as connectedness, both internally and externally, can decrease fear and other feelings, that often are at the foundations of the various conditions mentioned.

Why is connectedness so important? When we are connected, we lessen the effect of time and external circumstances. Connectedness happens in the present moment, and the feeling is about the now rather than the past and the future. Also, the more connected we are, the less will be our fears and anxieties. The fear of death is a fear of disconnect, and by feeling connectedness we reduce the sense of disconnect. Depression and anxiety, though in different ways, are also related to the internal sense of connectedness. This does not necessarily require the actual physical proximity of others, but the feeling of being connected into the world. Various mindfulness techniques and approaches that work with feeling at home in the body and in one’s environment can be helpful because they can increase the sense of connectedness.

Social Connectedness

Connectedness is different from mere social support. In a testing model in 272 college students, indirect paths to self–esteem and depression through the mediating variable of social connectedness were more strongly supported than direct pathways from social support or social competence to psychological outcomes. (Williams & Galliher, 2006) However, in a meta-review of fifty-one studies, the strongest and most consistent findings were significant protective effects of perceived emotional support, perceived instrumental support, and large, diverse social networks. Little evidence was found on whether social connectedness is related to depression, as was also the case for negative interactions. (Santini et al., 2015) A secondary analysis of a waitlist-controlled trial with 29 patients was conducted to evaluate treatment response and process of change in social connectedness within a 10-session positive activity intervention protocol—Amplification of Positivity (AMP)—designed to increase positive affect in individuals seeking treatment for anxiety or depression. The AMP group displayed significantly larger improvements in social connectedness from pre- to post-treatment compared to waitlist; improvements were maintained through 6-month follow-up. Within the AMP group, increases in positive affect and decreases in negative affect both uniquely predicted subsequent increases in connectedness throughout treatment. However, experiencing heightened negative affect throughout treatment attenuated the effect of changes in positive affect on connectedness. Improvements in connectedness predicted subsequent increases in positive affect, but not changes in negative affect. (Taylor et al., 2020) A convenience sample of rural residents in a western Colorado county. Self-reported survey data collection with hierarchical multiple regression analyses. The investigators found that the more socially connected a person felt, the better they perceived themselves as physically and mentally healthy. Additionally, the more socially connected the individual felt the less depressive symptoms they reported. Spiritual perspective was not found to correlate significantly with either self-reported depression or perceived health. (Galloway & Henry, 2014)

Social Identification

Cruwys and colleagues ran two studies. In Study 1 (N=52), participants at risk of depression joined a community recreation group; in Study 2 (N=92) adults with diagnosed depression joined a clinical psychotherapy group. In both the studies, social identification predicted recovery from depression after controlling for initial depression severity, frequency of attendance, and group type. In Study 2, benefits of social identification were larger for depression symptoms than for anxiety symptoms or quality of life. (Cruwys et al., 2014)

Depression Treatments and Connectedness

Trials with psylocybin for treatment-resistant depression also support the link between connectedness and depression. It has been argued that connectedness is key in understanding the effectiveness of psychedelic drugs against depression, and there is preliminary evidence to support this. (Carhart-Harris et al., 2018) In a study with twenty patients enrolled in an open-label trial of psilocybin for treatment-resistant depression, it was reported that medications and some short-term talking therapies tended to reinforce their sense of disconnection and avoidance, whereas treatment with psilocybin encouraged connection and acceptance. (Watts et al., 2017)

Adolescents and Young Adults

Much of the data on the association between depression and connectedness comes from school and college settings. Data from Waves I and II of the National Longitudinal Study of Adolescent Health (Add Health)  indicated that higher school connectedness and getting along with teachers were significantly associated with fewer depressive symptoms. (Joyce & Early, 2014) In a study of students at an international university in Japan, a high prevalence of depression was associated with acculturation stress and social connectedness. (Nguyen et al., 2019) In an American study of 248 students aged between 15 and 20 years old showed that family ritual meaning was positively related to social connectedness and negatively related to depression. Social connectedness was negatively associated with anxiety and depression. Family ritual meaning was found to be negatively linked to both depression and anxiety symptoms via social connectedness. (Malaquias et al., 2015) However, recent literature suggests that school connectedness may be a key determinant of adolescent mental health. The relationship between social connectedness and low mood was reduced by the inclusion of self-esteem  and peer attachment style. Peer attachment style was the largest predictor of low mood. (Millings et al., 2012) In a 2001 population-based sample of 4746 students in public schools, adolescents’ perceptions of low parental caring, difficulty talking to their parents about problems, and valuing their friends’ opinions for serious decisions were found to be significantly associated with compromised behavioral and emotional health. Interventions aimed at improving the parent–child relationship may provide an avenue toward preventing health risk behaviors in youth. (Ackard et al., 2006) In a longitudinal study of 142 youth recruited from an emergency department, who screened positive for elevated levels of bullying victimization, prospectively, family and school connectedness were negatively associated with depression and suicidal ideation. Across time points, community connectedness was negatively associated with suicidal ideation. The three subtypes of interpersonal connectedness among victimized youth (family, school, community) were associated with depression and suicidal ideation. (Arango et al., 2019)

Technology and Connectedness

a systematic review of recent research addressing the associations between adolescents’ sense of social connectedness and Internet technology use. Although Internet technology might provide additional opportunities for adolescents to seek emotional connection with friends and school, this study suggests that real-life social skills are still a necessary foundation for them to use technology in a beneficial way. (Wu et al., 2016) Hwang and colleagues investigated whether social connectedness on a support website protects older adults against depressive symptoms over the course of a year, above and beyond the protective effect of offline social connectedness. 197 adults aged 65 years or older. The more messages older adults read on the web-based forum for the first 6 months of the study, the less depressed they felt at the 1-year follow-up, above and beyond the availability of offline support networks at baseline. This pinpoints the substantial potential of web-based communication to combat depressive symptoms in this vulnerable population. (Hwang et al., 2021) Results from a study by Grieve and colleagues suggested that Facebook use may provide the opportunity to develop and maintain social connectedness in the online environment, and that Facebook connectedness is associated with lower depression and anxiety and greater satisfaction with life. Limitations and future directions are considered. It is concluded that Facebook may act as a separate social medium in which to develop and maintain relationships, providing an alternative social outlet associated with a range of positive psychological outcomes. (Grieve et al., 2013) A multidatabase search was performed. Papers published between January 2005 and June 2016 relevant to mental illness (depression and anxiety only) were extracted and reviewed. Results: Positive interactions, social support, and social connectedness on social networking sites (SNSs) were consistently related to lower levels of depression and anxiety, whereas negative interaction and social comparisons on SNSs were related to higher levels of depression and anxiety. SNS use related to less loneliness and greater self-esteem and life satisfaction. Findings were mixed for frequency of SNS use and number of SNS friends. Different patterns in the way individuals with depression and individuals with social anxiety engage with SNSs are beginning to emerge. (Seabrook et al., 2016)

Autonomy and Connectedness

The relationship between autonomy–connectedness, and depression and anxiety was investigated in 94 primary mental health care patients and 95 psychology students. All participants completed the Autonomy–Connectedness Scale–30 (ACS‐30), the Beck Depression Inventory (BDI), and the Symptom Checklist–90 (SCL‐90). Results indicated that the primary mental health care group compared with the control group scored lower in Self‐Awareness and Capacity for Managing New Situations, and higher in Sensitivity to Others. Women compared with men had higher levels of self‐reported Sensitivity to Others. Regression analyses showed that both (low) Self‐Awareness and (high) Sensitivity to Others predicted depression, as well as anxiety; also, (low) educational level had predictive value. These results indicate that low autonomy–connectedness might be a risk factor for depression and anxiety. (Bekker & Belt, 2006)

Connectedness and the Elderly

Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health. The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across 8 centers. About three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression. (Grover et al., 2018)

Connectedness and Groups

In a further study, Kaniuka and colleagues examined depression and anxiety as mediators of the linkage between perceived stigma and suicidal behaviour, and the moderating role of LGBTQ community connectedness. Among their sample of 496 LGBTQ persons, psychopathology mediated the association between perceived stigma and suicidal behaviour. Connectedness moderated the relation between perceived stigma and depression, and between perceived stigma and suicidal behaviour in the anxiety model. (Kaniuka et al., 2019)

Causes of Depression

Its impact on functioning and well-being has been compared to that of other chronic medical conditions such as diabetes. The biopsychosocial model proposes that biological, psychological, and social factors all play a role in causing depression. The cause is believed to be a combination of genetic, environmental, and psychological factors. (APA, 2013) Risk factors include a family history of the condition, major life changes, certain medications, chronic health problems, and substance abuse. (APA, 2013) About 40% of the risk appears to be related to genetic variations.

Lifetime rates are higher in the developed world compared to the developing world. Maybe a heightened stress level in a more complex living and working environment contributes to that, but it may also be a lower rate of diagnosing this condition in the developing world.

The Monoamine Hypothesis

The monoamine hypothesis has been partially questioned, but it is still the leading, and also most coherent, hypothesis there is in providing a biological explanation for depression, as well as some anxiety disorders. Over time, its emphasis on particular neurotransmitters has shifted to a limited extent, while the focus on the neurotransmitter serotonin has endured. The monoamines are serotonin, norepinephrine, and dopamine. The antidepressants act on the neurotransmitter levels or on the receptors.

Serotonin is hypothesized to regulate other neurotransmitter systems; decreased serotonin activity may allow these systems to act differently and become less stable. According to this hypothesis, depression arises when low serotonin levels promote low levels of norepinephrine, another monoamine neurotransmitter. Some antidepressants enhance the levels of norepinephrine directly, whereas others raise the levels of dopamine, a third monoamine neurotransmitter. These observations gave rise to the monoamine hypothesis of depression.

In its contemporary formulation, the monoamine hypothesis postulates that a deficiency of certain neurotransmitters is responsible for the corresponding features of depression. The main effect is, however, believed to be due to changes in the receptor densities on the cell membrane rather than the changes in the neurotransmitter levels. This also explains why antidepressants can take a few weeks to work. This may be the time needed by the cell to change the receptor density and patterns in the cell membrane through recycling and protein synthesis.

Communication Factors

Humans are constantly in a web of relations with other people. External communication from birth and even before influences how information is processed in the brain and how an individual communicates and interacts with others. The individual learns certain communication strategies and patterns that are shaped over time in response to the environment, internal communication and the biology underlying the neuronal network.

As children we pick up communication patterns from our parents or other important people in our lives which can then be internalized and also influence how we communicate with ourselves internally. And this process continues throughout or life, practically with every interaction we have with others. Our awareness of the flows of internal information then give rise to the sense of self.

Trauma committed by people can have such a devastating effect on individuals because of the communication it contains. Being exposed to someone who communicates that they negate our worth as a human being, our autonomy and integrity, traumatises and hurts us deeply. There need not be physical scars in a somatic medical sense. Our mind and our body form a union, however, and harm to one also harms the other. The body is the means that we can communicate with ourselves and others, while the mind connects us mentally with others. If that delicate fabric of connectedness between ourselves and others is torn or ruptured, we lose some of the safety and security it gives us. Trauma can be healed when we understand that its nature is in the communication that cause it. Awareness, insight, adapting communication patterns and learning new ones, as well as feedback are helpful in overcoming trauma (Haverkampf, 2016, 2020a) as they are in recuperating from depression.

Symptoms

A person having a major depressive episode usually exhibits a very low mood, which pervades all aspects of life, and anhedonia, the inability to experience pleasure in activities that were formerly enjoyed. Depressed people may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self-hatred.

Changes in the communication with oneself and others changes when an individual is depressed. This is a consequence of the symptoms of depression but often works also to deepen and prolong the condition. Loss of interest in things that were once enjoyable, seeing less meaning in activities and events and withdrawal from the world, and to an extent from oneself, are often the result and may worsen the depression, while more communication with oneself and others can help to reverse the depression.

In severe cases, depressed people may have symptoms of psychosis. These symptoms include delusions or, less commonly, hallucinations, usually with negative and unpleasant content. A good indication that a psychotic symptom is maintained by a mood disorder is that the value of the content of any delusions or hallucinations is consistently in the direction of the mood disorders, such as negative content in a depression or alternating positive and negative content in bipolar disorder.

Other symptoms of depression, which are commonly observed, include

  • poor concentration and memory
  • withdrawal from social situations and activities
  • reduced sex drive, irritability,
  • insomnia
  • and thoughts of death or suicide (which requires immediate professional help).

Insomnia is a common symptom. In the typical pattern, a person wakes very early and cannot get back to sleep. Hypersomnia, or oversleeping, can also happen. In an atypical form of depression, it is even possible that a patient experiences primarily insomnia, loss of concentration and poor memory retrieval, without a clear lowering in mood.

Physical Symptoms

The physical symptoms of a depression are often underestimated. A depressed person may report multiple physical symptoms such as

  • fatigue
  • headaches, or
  • digestive problems.

Appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. Family and friends may notice that the person’s behaviour is either agitated or lethargic.

Treatment

The two types of treatment, for which there exists broad empirical and conceptual support, are medication and psychotherapy. Generally, the best approach is to use both together. However, in very severe cases of depression only medication may be feasible, while in cases of mild depression psychotherapy may be sufficient.

Medication

There are various groups of antidepressants, often with regards to their function on neurotransmitters and neuroreceptors. The selective serotonin receptor inhibitors (SSRIs) are the ones most commonly used. They can also help against anxiety and panic attacks, as well as various other symptoms and conditions, such as emotional instability and eating disorder. Examples are escitalopram (Lexapro®) and sertraline (Zoloft®). The serotonin and norepinephrine reuptake inhibitors can also help against anxiety, but may be more activating, which can lead to increased nervousness and anxiety in the beginning. The best way to reduce an increase in anxiety in the first days, which can happen with most antidepressants, is to start the medication at a very low level and increase it in small increments in patients with anxiety, especially if there are also panic attacks.

Psychotherapy

As already mentioned, there are various brands of psychotherapy which are designed to help in the long run. Cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT), as well as Gestalt therapy and others, are also focused at the short-term, while psychodynamic psychotherapy aims at a more permanent resolution of the depression in the long-run. (Haverkampf, 2017a) Communication-focused therapy (CFT), which was developed by the author to more closely work with the mechanism that underlies many forms of psychotherapy, communication. (Haverkampf, 2017f)

Psychotherapy should be targeted at the long-run. Short fixes for depression often do not work, and only in the short run. The reason is that a patient’s interaction patterns with herself and the environment often need to change, which requires some time. Good communication helps against a depression, but it often requires a change in perspective, as well as awareness and reflection, which ensures an enduring effect but requires time.

There is a significant amount of research which shows that the effect of psychotherapy may to a large extent be due to the personality and communication approach of the therapist, and there is a debate to what extent the specific viewpoint of a school of psychotherapy plays an actual role in the outcome of psychotherapy. This is one reason why communication-focused therapy (CFT) puts an emphasis on the communication patterns and dynamics that unfold, and are induced to unfold, in a psychotherapeutic session.

For any form of psychotherapy to work, it has to lead to some form of change. To achieve a lasting adaptive and helpful change, it has to come from the patient himself or herself, because if the change is not in sync with the patient’s basic parameters, any change will over time revert back, either to the state before the therapy or a state that is somewhere half-way between the pre-existing one and the desired state. If change is lasting nevertheless, it is often due to factors outside a manualized and structured therapy. One explanation could be that even a manualized approach contains elements that may help the patient to develop in a direction that correlates with the patient’s basic needs and aspirations on some level.

Separating Thoughts from Emotions

In many schools of psychotherapy there is unfortunately an almost complete separation between thoughts and emotions. However, from a communication perspective they both are signals, containing information. When a thought triggers and emotion, or an emotion leads to certain thoughts, it is in both cases some meaningful information which leads to new sets of information. This is also useful in the therapy, because communication patterns that apply to one kind of information also apply to the other.

The uncrossable dividing line between thoughts and emotions has largely contributed to a situation where we understand neither. We could arbitrarily categorise information, but it still does not bring us closer to understanding the dynamics in which the information, or the categories of information, flow. For example, a question as one of the most powerful communication tools can elicit an emotional signal in a person without a cognitive thought, because it is information which can under certain circumstances be retrieved directly.

Regarding both, emotions and thoughts, as bundles of information does not reduce their individual qualities, but these qualities are part of the information that makes up the thought or emotion. Whether a message is emotional or cognitive cannot be extrinsic to it. However, where a piece of information flows is in a sense intrinsic to it. Thus, the thought of pain and the feeling of pain can be quite similar in information content, but where the information flows in the neural network, and in what way, may be vastly different.

Body Work

Focusing on the mind often neglects the wider dimensions of the body. In a study with a group of women with major depressive disorder, experiences of yoga were that it served as a self-care technique for the stress and ruminative aspects of depression and that it served as a relational technique, facilitating connectedness and shared experiences in a safe environment. (Kinser et al., 2013)

Communication-Focused Therapy®

Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. (Haverkampf, 2010b, 2017b, 2017f, 2018b) The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy needs to lead to change in some form. (Haverkampf, 2010b)

register them as emotions; thus, severely depressed patients are as in-capable of experiencing sadness as of feeling joy. Their feelings are diffuse, are not registered as emotions, and are not properly identified. (Bucci & Freedman, 1981)

Change

Change can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them.

There are various factors that may stand in the way. If fear inhibits the information retrieval from memory this will not fully work. However, this fear is again a signal, information that is transferred from one point to another and triggers certain information processing patterns. If these patterns are not helpful in supporting the larger goals of need fulfilment with respect to the internal and external world, they can lead into such stationary and change inhibiting dynamics as indefinite loops, or vicious cycles, in which a fear signal just leads to another fear signal, rather than inducing change. These dynamics include

  • looping of information
  • disconnects
  • misdirected information

and many others. They are a consequence of inhibited change. To break out of these communication predicaments, changes in communication patterns are needed that compensate, interrupt, reconnect, or act in another positive way.

Michael feels a lump in his throat. His therapist looks at his with an encouraging trace of a benevolent smile. Michael is not helped much by it, he feels under even more pressure. The therapist than finally asks a question, while Michael is about to despair. “Described the lump.” At first Michael does not know what to do with this question. However, he begins describing the lump and develops increasing investigatory spirit in doing so. After he has been talking for a little while, Michael discovers that his narrative has actually shifted to talking about his feelings …

CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

The goal is thus not to simply provide information, to communicate information from one point to another, but to understand the flows of information, to better use communication patterns and to recognise if something is not working. The objective is really to understand flows of information rather than to get caught in a specific content. Since change comes from the detection, decoding and processing of meaning in a message, a patient suffering from depression, and several other mental health conditions, will see a decline in symptoms over the time, the better he or she becomes in spotting meaning.

Many popular forms of psychotherapy, such as Cognitive-behavioural Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, communication constructs like transference and counter-transference have been formulated, which focuses on the outcome of communication processes. CFT in contrast attempts to focus on the process itself.

CFT attempts to analyse how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behaviour of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient.

Analysing Communication Patterns

The first important step in therapy is to create awareness for communication in general. Humans are sending and receiving countless of messages every minute, and most of this runs automatically. However, for messages that can be processed by higher brain functions, whether from internal and external sources, there is the option to make these communication processes conscious. Particularly in interactions with other living organisms, particularly humans, communication patterns have evolved that facilitate the exchange of meaningful information between one brain and another. While most of this communication is outside consciousness, there are processes that let some of it pass the filter and bring it into consciousness. Creating greater awareness means putting the focus on these flows of information by observing the observable. For example, if a patient focuses just on her right hand, for example, while she is talking or on the timber in her voice, this creates awareness for a small aspect of the information in her interaction with another. Becoming aware of a thought that is repeatedly coming back and is followed by a feeling of anxiety may lead to the observance of internal communication flows. While the majority of the information exchange in the human body, particularly on a cellular body, is not accessible to conscious awareness, the aggregate result is.

Paul is at home alone. It is close to midnight, he feels low and cannot sleep. He does not really know why. The day has been good overall, but sporadically a melancholic feeling strikes, as if out of nowhere. He looks at the clock in the living room, as the hands seem to stand still. Everything is still. It has been an intense week, and it is maybe the first time when everything seems to quiet down. In this stillness, he notices something new, a tension he cannot put his finger on. It seems as if from nowhere and he cannot identify it.

Rather than thinking about, he just sits there, experiences, is open and curious. The point of tensions takes on more detail, and he feels he can make out some context, bits of emotions and thoughts, faint signals that are becoming more defined. While he is curious about what they may grow into and become, he enjoys the changes that are taking place before his inner eye …

The Process

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.

Communication Patterns and Structures

Communication patterns are basic units of communication dynamics which make spontaneous communication in everyday situations possible. A certain form of question may be such a communication pattern, which humans use instinctively without further thinking about the pattern they are using. Some basic communication patterns may be hardwired, but many are also learned. Since they all have to adhere to basic laws of information exchange, the patterns themselves adhere to certain rules. The author has focused more specifically on the origin and nature of communication patterns elsewhere. (Haverkampf, 2018c)

An awareness of communication structures and patterns begins with an inventory of what is there. An analysis reveals the constructivist nature of conversation, how the therapist uses rhetorical devices in an interactive manner to pursue his therapeutic agenda and how the dialogue is a systemic process. However, it goes deeper as the same laws of communication do not only apply in the external world but also in the inner realms of a person. This makes communication less constructivist, but as natural processes that follow universal laws.

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. Communication has certain rules, and in a context communication patterns emerge that help the organism survive, evolve and prosper. A language can be seen as sets of symbols and signals that are used within communication patterns. We all communicate in patterns because they make communication more efficient within a given context, However, people spend little time observing and reflecting on their communication patterns on the inside and in the external world.

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the communication patterns with oneself and the world do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. All these are modifications in external and internal communication patterns because they change which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.

Passive social media use (PSMU)—for example, scrolling through social media news feeds—has been associated with depression symptoms. More time spent on PSMU was associated with higher levels of interest loss, concentration problems, fatigue, and loneliness. (b) Fatigue and loneliness predicted PSMU across time, but PSMU predicted neither depression symptoms nor stress. (Aalbers et al., 2019)

Facebook depression is defined as feeling depressed upon too much exposure to Social networking sites (SNS). Researchers have argued that upward social comparisons made on SNS are the key to the Facebook depression phenomenon. Our literature search yielded 33 articles with a sample of 15,881 for time spent on SNS, 12 articles with a sample of 8041 for SNS checking frequency, and 5 articles with a sample of 1715 and 2298 for the general and the upward social comparison analyses, respectively. In both SNS-usage analyses, greater time spent on SNS and frequency of checking SNS were associated with higher levels of depression with a small effect size. Further, higher levels of depression were associated with greater general social comparisons on SNS with a small to medium effect, and greater upward social comparisons on SNS with a medium effect. Both social comparisons on SNS were more strongly related to depression than was time spent on SNS. (Yoon et al., 2019)

A search of PsycINFO, Medline, Embase, CINAHL and SSCI databases reaped 13 eligible studies, of which 12 were cross-sectional. Findings were classified into four domains of social media: time spent, activity, investment and addiction. All domains correlated with depression, anxiety and psychological distress. However, there are considerable caveats due to methodological limitations of cross-sectional design, sampling and measures. Mechanisms of the putative effects of social media on mental health should be explored further through qualitative enquiry and longitudinal cohort studies. (Keles et al., 2020)

There are growing concerns about the impact of digital technologies on children’s emotional well-being, particularly regarding fear, anxiety, and depression. A growing body of research confirms the relationship between digital media and depression. Although there is evidence that greater electronic media use is associated with depressive symptoms, there is also evidence that the social nature of digital communication may be harnessed in some situations to improve mood and to promote health-enhancing strategies. Much more research is needed to explore these possibilities. (Hoge et al., 2017)

Transfer

Considerations of psychopathology and a greater understanding of child and developmental psychology provide a greater insight into the question how depression may be transferred from mother to child, for example. (Goodman, 2020) From a communication perspective this is easily understandable. The child’s first experiences of the world internally and externally is shaped through the communication with others, mainly the primary caretakers. Depressed parents have been found to interact with their children differently, in ways that affect child development. Depressed mothers have been found in some studies to use less emotion and expressivity in their language with their babies. Non-verbal communication is especially important at an early age, and depressed mothers tend to make less eye contact. Through withdrawal, depression can also lead to a wider social disconnect, which can then affect both, the mother and the child.

Meaning

Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Information that contains meaning has the potential to bring about a change. This means it that it has to contain something that is not entirely predictable. If we were fully certain of that piece of information, it could not lead to change. Thus, any therapy that does not work with meaning and meaningful information must be quite useless and ineffective. Even a highly manualized and structured therapy contains some novel information, which can be relevant and meaningful to the patient. In fact, practically all interactions with other people contain some elements of novelty, relevance and meaning. If communication is all pervasive, chances are high that there will also be some meaningful communication.

By focusing more specifically on the communication process, it is possible to increase the density of helpful change, and thus to make therapy more effective. A positive effect is also that as the patient experiences the relevance and practical workings of the therapeutic process, motivation and optimism about the positive outcomes of therapy increase. These effects come through connectedness, but also increase connectedness in the future.

Meaning is here used in the sense of understanding the information behind information, its symbolic content. For example, even the simple sentence “How are you?” can have a broad range of meanings from “Hi!” to “Are you feeling better?” Our thoughts and feelings affect how we decode meaning. They affect the questions we ask about another’s comment and the context in which we understand it. This applies to our own internal communications, and external ones. Learning communication in different contexts is like learning foreign languages.

Important is also how we interpret our own thoughts, the meaning we give to them and to our feelings. How we interpret our own thoughts, the internal communication in general, influences how we see ourselves. Thus, by changing our internal communication strategies we can also affect how we feel about ourselves. Primarily cognitive and psychodynamic psychotherapies offer many strategies in this area, while the former tends to be more manualized and the latter organically growing out of the psychotherapeutic work.

From Meaning to Meaningfulness

To be able to help patients with depression it is important to understand the road from meaning to meaningfulness. While meaning is relevant content, meaningfulness is a measure of how much relevant content one sees in something. At the same time, meaningfulness can be a feeling, which imputes relevance to something, a relevance, which, as has been described above, contains hope for some change in emotional, cognitive or other state or process. The importance in getting patients to see more meaningfulness has been borne out in many studies. Carstens and colleagues, for example, administered in their study the Sense of Coherence scale and the Beck Depression Inventory to fifty patients diagnosed with major depressive disorder and to fifty control subjects. Significant negative correlations were found between scores on Depression and total scores on the Sense of Coherence scale as well as all three of its subscales (Comprehensibility, Manageability, and Meaningfulness). A significant positive correlation was found between scores on the Sense of Coherence scale and age. Of the three subscales, a low score on Meaningfulness was the best predictor of scores on Depression. (Carstens & Spangenberg, 1997)

How do we achieve the perception of more meaningfulness? That is linked to the ‘demands’ of our basic parameters, our needs, values, and aspirations. Identifying them through information we already have about ourselves from the past, in terms of situations that were fulfilling or unfulfilling, and through observation and reflection on our communication patterns can make it easier for us to find what is meaningful to us. Once things that are meaningful are identified, one not only gravitates more towards those things, but can also seem more of them in present activities and situations.

As an example, consider a social get together, a party, where people stand around and talk to each other.

Last year, Randy felt uncomfortable at Bob’s birthday party, particularly on a day where he does not feel his best. Bob always invites lots of people Randy does not know. He would stand there and do his best to mingle. Was that not the point of it to mingle? But Randy was not entirely sure what he was doing at the party? Yes, sure, he wanted to have a good time, had to have a good time, but it would be over after a couple of hours anyway, and then he would be by himself again.

Since last year, Randy had looked into Communication-Focused Therapy and several other therapeutic approaches, which seemed to help people. He also worked with a therapist. He found out that he likes being with people and is interested in them at a deeper level, rather than just pleasantries. He probably had learned at home not to look into things too deeply. Don’t scratch the surface. But that did not lead to very fulfilling relationships.

This year, Randy is at Bob’s birthday party again. He walked into the main room. He sees a woman looking at a photograph hanging at the wall. Since last year he has discovered his interest in other people’s lives, their perspectives and insights. He walks over to her and talks about the photograph, and asks what she thinks about it? How she feels about it? An hour later they were talking again about things that were important to them. This was a new experience for Randy.

What this everyday occurrence illustrates, that if one zooms in on the meaningful, such as talking with another human being about what they find important, it is less likely to get caught in the meaningless, small talk for the sake of small talk. While small talk fills an important role in building relationships, one needs to see it only as a transition phase, in which the focus should already be on the next phase in relationship building. Far too many people, particularly those with social anxiety or depression, stay in the small talk for its own purpose state. One reason may be, what we already discussed under the topic of connectedness, the longing for connectedness and, at the same time, the apprehensiveness about it. Ways to see more meaningfulness are powerful antidotes to this dilemma.

Meaningfulness is frequently something that is seen within the context of one’s life story, or part of the life story. However, it should not be dependent on the story, because the story in turn depends again on the individual needs, values, and aspirations, the basic parameters of the person. On the other hand, a story is a frame for communication that takes place within it. At the same time, the communication dynamics that develop within a story are meant to get the person closer to the fulfilment of the individual needs, values, and aspirations. Thus, identifying the latter can help to construct a story, in which more meaningfulness can be found. It is in the story where past present and future can come together and support one in the creation of more meaning and more meaningfulness. Stories, as long as they are flexible and align with oneself, can also speed up the decoding process of messages and facilitate communication.

Motivation

Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Motivation often comes when one has already started on a task. This is even more true in depression. Once one is engaged in a task, the depression tends to become less of an issue. The thoughts and feelings we build up before engaging in a task can be coloured significantly by mood and other factors, so that depression can influence the motivation and initiative to begin on a task quite directly. Here it is again to zoom in on what is really important to oneself, and also to see the communication aspects when one engages in a task. Any task is an interaction with the environment and with oneself, and as we already discussed, our communication or interaction patterns with the environment shape the enjoyment and satisfaction we derive from it. One valuable task in therapy is to look at, reflect, and experiment with these patterns.

Interacting with the World

At the core of Communication-Focused Therapy® is interaction. Interacting with the world is an important pillar in moving away from depression. Anything that helps to interact with the world in a meaningful way can help to overcome negative thoughts, feelings, and ruminations, as well as to find energy, initiative and motivation again. But how to get back into the world if one cannot find the energy and initiative to do so, and the world seems bleak?

As already mentioned, an important part in reintegrating in the world is just to do things. Action. However, it is not mindless action we are looking for, but mindful action; the kind that gives one the feeling of progressing rather than regressing. The first steps are often the most difficult steps, and anything that helps us to get moving is usually leading one in the right direction. Important from a Communication-Focused Therapy® perspective is to examine the pattern one usually used to interact with the world and to see where changes can be helpful. One often also needs to develop new ones, either in combination with old ones or by themselves. Through experimentation one can then adjust them so that they fit and are effective in getting one’s needs, values, and aspirations met in the world.

Powerlessness

The feeling of powerlessness is one of the hallmark features of depression, which often leads into a vicious cycle, which further paralyses the patient. This powerlessness often goes hand in hand with a sense of disconnectedness. After all, communication is how we can exert power by changing our environment and ourselves. As depression inhibits meaningful communication, the latter can help overcome the sense of powerlessness.

Particularly problematic can also be the feedback a depressed person receives from others, which can maintain the depression. Coyne tested the hypotheses that (a) normal Ss respond differentially to the behavior of depressed patients, (b) this differential response is due to the fact that the target individuals are depressed, and not that they are patients, and (c) this pattern can be related to the symptomatology of depression. Each of 45 normal female undergraduates conversed on the telephone with either a depressed patient ( n = 15), a nondepressed patient ( n = 15), or a normal control ( n = 15). It was found that following the phone conversation, Ss who had spoken to depressed patients were themselves significantly more depressed, anxious, hostile, and rejecting. Measures of activity, approval responses, hope statements, and genuineness did not distinguish between S groups or between target groups, but important differences were found in the Ss’ perception of the patients. It was proposed that environmental response may play an important role in the maintenance of depressed behavior. Furthermore, special skills may be required of the depressed person to cope with the environment his behavior creates. (Coyne, 1976)

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message (e.g. I am not OK with our weekend plans because I rather stay in the city; I need to communicate this to my partner)
  • Encoding the information in a message (I will say it to him verbally; I want to be clear but cautious because we had a fight yesterday and he is feeling low today)
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information (my partner is unhappy)
  • Processing the information further (is she unhappy with me? I better don’t go there.)

It is obvious from this example that communication has failed, as the feeling “I rather stay in the city” gets converted into “is she unhappy with me?” Some vital information is not transmitted even though both individuals have the capability to communicate anything they want. It is not difficult to imagine that person A could be an anxious person and person B a depressed person. The communication patterns they use may have served some function in the past, as they both seem to be protecting themselves from some negative emotional consequence. However, in the present they do not promote a more optimal outcome, which could take into account both their needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.

Resonance

Resonance is when new information becomes meaningful because of the information the other person possesses, whether consciously or subconsciously. The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. This also means that the therapist, consciously or subconsciously, needs to have a good sense of the patient’s values, interests and aspirations, of what is relevant to the patient, which can also show in the symptoms and the situations in which the symptoms are triggered.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is saying and otherwise communicating, since it reflects the information the patient already has, and which represents the foundation for resonance.

Depression makes the own information, particularly the emotional information less accessible, which can also lower resonance. However, while in most depressed patients resonance may become narrower, it does not cease to exist. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.

Relevance

Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout.

Relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the centre of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.

Experimentation

Experimenting with communication patterns is a central element of Communication-Focused Therapy®, which is shared by therapist and patient. As a therapist, one has to continually find new ways of doing things, mostly quite spontaneously in the situation. This is where creativity is an important skill of the therapist. At the same time, the patient needs to learn to also experiment with different ways of doing things, particularly in communicating and interacting with themselves and the world around them. Depression, anxiety, OCD, fears, psychosis, and many other conditions, lead to a narrowing of the breadth of communication and interaction patterns. The result is often a rigidity in these patterns also within oneself. Thoughts and feeling become more monotone and lead back to themselves in endless cycles. It seems as if there is no way out of them. A reset often can be helped by several techniques that bring the focus to new and potentially meaningful information, such as in mindfulness practices, for example, where one may focus on an object and investigate it mentally at deeper and deeper levels. One positive outcome is to prevent thoughts spirals triggered by irrelevant questions. Also, new information of any kind is like a ray of sunlight shining into the prison cell of depression. One at least has to grapple with the fact that there is a sun out there, which leads toa greater desire for change. Action for change may be much more difficult to accomplish in more severe cases of depression, but new meaningful information can contain a chance for change.

Core benefits of experimentation also include practice of great flexibility, which can break the rigidity in depression and lead to the openness, which lets through more meaningful information from more sources. This increases the perceived connectedness with oneself and the world, which is a powerful antidote against depression, fear and anxiety. Experimentation also helps to instil the connectedness with more life through constant change.

Observing

Observing is a skill that usually leads to many of the other skills. Important is the ability to observe without asking any specific questions. The communication patterns we use today have their origin in our past interaction and experiences on a bed of biology. Observing our own actions and those of others in various situations help to bring us insight into the underlying dynamics we repeat again and again in interactions with others, as well as the patterns we repeat within ourselves. Some of them work and some less so. An important and very basic question is whether they serve the aim of greater connectedness with ourselves and others, whether they help us to identify more closely our own needs, values, and aspirations, and whether they support us in achieving these basic parameters with others. Communication is how things are create, evolve, and are put into practice in the world, and the more one feels one understands and can make one’s communication patterns work for oneself and others, the less helpless, alone, and powerless one feels. Thus, working with them has a direct effect on the feelings that underlie and come with depression.

Observing one’s internal communication patterns has a similar effect on the feelings of depression from the inside.

Integration

As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost from exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017b, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017g, 2017c, 2017e, 2017d, 2017h, 2017i). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are, however, the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy and counselling in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com. He is also a frequent guest on www.askdrjonathan.com.

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[1] Both terms, psychotherapy and counselling, are often used interchangeably. In academia and research ‘psychotherapy’ has been used traditionally more frequently. Many patients, however, find the term ‘counselling’ less stigmatizing and ‘pathological’. I will use the term psychotherapy as a matter of habit and convenience.

Communication-Focused Therapy® (CFT) for Depression

Haverkampf-C.-J.-2020.-Communication-Focused-Therapy®-CFT-for-Depression.-In-CFT-Vol-IV-pp.-320-339

Communication-Focused Therapy® (CFT) for Depression

Christian Jonathan Haverkampf, M.D.

Depression is a mental health condition that affects a large part of the population at least once over their life span, significantly reducing life quality and impairing work and relationships. Psychotherapy and medication are the main treatments for the condition. Communication-Focused Therapy® (CFT) is a therapy developed by the author, focusing on communication processes to treat depression. Improvements in internal and external communication and awareness for a patient’s needs, values and aspirations appear to be effective against several symptoms of depression and increase motivation and compliance for therapy. This article provides an overview of a conceptual framework from a communication perspective and several approaches for treating depression with psychotherapy.

Keywords: depression, communication-focused therapy, CFT, communication, psychotherapy, psychiatry, treatment

Table of Contents

Introduction. 4

Depression. 6

Flattening of Emotions. 6

Negative Interpretations. 7

Communication-Focused Therapy® (CFT®) 9

Communication Patterns. 10

Questions. 11

Timeline. 11

Getting Information. 12

Connecting. 12

Integration. 13

Analyzing Communication Patterns. 13

Emotional Signals. 14

Motivation. 15

Insight into Communication. 15

Building the Sense of Self 17

Meaning. 18

Resonance. 18

Relevance. 19

Communication Exchange. 21

Integration. 21

Values, Needs and Aspirations. 22

Internal Communication. 22

Meaningful Messages as the Instrument of Change. 23

Broader Experience. 23

References. 25

 

Introduction

Depression is a general lowering of emotional experiences, while in the lighter forms, it may just be a reduction of positive emotional experiences. A dialling down of internal and external communication, such as thoughts, feelings and activities, usually accompanies it. Loss of energy, motivation, and initiative, loss of enjoyment and interest in pleasurable activities, and loss of concentration are just some of the possible attributes of depression.

All explanations for depression seem to depend on the framework of the school of thought that produced them. An early answer from ego psychology was that depression is the emotional expression of a state of ego-helplessness and ego-powerlessness to live up to certain strongly maintained narcissistic aspirations. (Bibring, 1953) This explanation is in some ways not so far from what we can observe in depression in every clinical practice, even if we rarely use the terminology anymore. Patients who are depressed indeed mostly feel helpless and powerless, which are practically requirements of the sense of feeling depressed. When we find ourselves in a situation where there seems no escape or where we have to decide quite literally between a rock and a hard place, we are more likely to feel depressed, unless we develop a new alternative and open a door we have not seen before. Unfortunately, depression makes it seem harder to innovate and be creative. One of the techniques of Communication-Focused Therapy® (CFT) is to restore the ability to see a broad range of options and innovate in depression. The path there is through work on communication patterns, as communication is how we all get our needs, values and aspirations satisfied.

Depression usually impairs the emotional communication one has with oneself and with others. (Haverkampf, 2017e) Experimental data has been showing quite consistently that depressive subjects exhibit disrupted emotional processing.  (Delle-Vigne et al., 2014) This emotional disconnect from oneself leads to a less complete sense of self and lower confidence in oneself and the world. (Haverkampf, 2012) The disconnect then leads to significant secondary impairments in everyday life.  It affects the interaction patterns one has with other people and oneself, leading to various relationship and workplace problems, and from here to further depression and anxiety. Thus, a neverending vicious cycle can pull the individual suffering from depression ever further down. Fortunately, in most people, depressive episodes are self-limiting as self-regulatory mechanisms usually kick in once it has reached a level where the quality of life is severely compromised. What then happens is that a shift or change in the internal and external communication happens that pulls the individual out of the depression. This latter process is what Communication-Focused Therapy® aims to bring about in patients where these auto-regulatory processes are absent or maladaptive. (Haverkampf, 2010b)

The symptoms of depression are the result of maladaptive internal and external communication patterns. A disturbance in the flows of meaningful information flows within the nervous system and between the nervous system and the outside world leads to a disconnect, resulting in less perceived meaning in the world and worse decisions because there is less available information. The informational deficit about oneself and the world leads to depression and anxiety, which causes even more withdrawal in a vicious cycle.

The link between communication patterns and mental well-being is an essential insight for its enormous ramifications on understanding and treating depression. However, one needs to view it as a large puzzle, where the pieces all fit in in the end. These puzzle pieces can come from many areas of an individual’s everyday life. In a study on monogamous romantic relationships, for example, mutual constructive communication was associated with decreases in depressive symptoms for males. In contrast, demand-withdraw communication correlated with increases in attachment avoidance and depressive symptoms. (Givertz & Safford, 2011)

An essential step in overcoming depression is becoming curious about how one communicates with oneself and others. Using constructive inquisitive communication patterns can have a healing effect (Haverkampf, 2017i). In therapy, the therapist can encourage observing the communication patterns a client operates and the assumptions made in them about intentions, wishes and needs, values, and other factors that determine the quality, quantity and future of human interactions. Since all psychotherapies to date, use human interaction as the main instrument in the healing process, even if they do not focus on it, most therapies can have a beneficial effect. Unfortunately, the focus is often not on communication patterns, which can, at least from a theoretical perspective, render them less efficient. While it is true that learned behaviour and past experiences influence the severity of the symptoms, they do so via internal and external patterns of communication. In any instance where therapy works, it is a change in information flows and communication behaviours that brings about changes in symptoms and quality of life. (Haverkampf, 2010b, 2017a)

Depression

Depression is a state of low mood and aversion to activity that can affect a person’s thoughts, behaviour, feelings, and sense of well-being. A depressed mood can be a normal temporary reaction to life events such as loss of a loved one, a job loss, but also ‘positive’ ones, such as winning in a lottery or having sudden and spectacular success. All these events represent changes globally, requiring internal modifications to adjust internal and external communication systems to the new reality. A job that is now suddenly more practical requires a different internal dialogue, such as less analysis and more exploration. It may also require different external communication patterns with colleagues rather than work in front of a computer screen. If these changes have only occurred partially or not, the information exchange patterns do not fit the situation. This lack of fit can lead to feelings of being overwhelmed, withdrawal, emptiness and feelings of depression, or in some cases (hypo)manic states.

The sum of the basic patterns of external and internal communication, an individual’s personality, remains relatively stable over time. (Haverkampf, 2010a) This also applies if a mental health condition, such as depression, improves. In a sample of depressed outpatients receiving a 5-week trial of pharmacotherapy, changes in neuroticism and extraversion scores were modestly or not accounted for by changes in depression scores. (Santor et al., 1997) However, how individual communication elements and patterns are used in given situations can be subjected to change, leading to significant changes in personal satisfaction, contentment and happiness.

Flattening of Emotions

Depression leads to a disconnect. A patient is no longer able to access positive emotions to the same extent as before. However, at the same time he or she may also become disconnected to a varying degree from ‘negative’ emotions, such as sadness. In all cases, the individual suffers from missing out on important information about the own person. This then leads to negative feelings, possibly also fears and anxiety, because meaningful information is missing. To some degree it is possible to counteract this with activities that are meaningful to oneself. One may even say that in the best a depression weeds out thoughts and activities that are less meaningful. And in most cases short and especially the reactive depressive episodes are self-limiting. But in the more severe and longer lasting depression the disconnectedness from emotional signals accelerates the downward spiral of decreasing emotional connectedness and increasing ability to correctly send and receive meaningful messages. (Haverkampf, 2010c, 2013)

Reconnecting with emotional signals can be helpful in depression. This should not add to the pressure on the patient ‘to feel better’. In Communication-Focused Therapy®, this is usually done by using the communication patterns in the session or memories of past interactions and experiences in the world to inquire into the feelings that were associated with them. However, the main technique is concerned less with individual emotional episodes, but with enabling a patient to become more aware of and influence communication processes and information, which lead to particular emotional signals. (Haverkampf, 2017a)

Negative Interpretations

Elevated levels of repetitive negative thinking are present across a large range of Axis I disorders and appear to be causally involved in the maintenance of emotional problems. It has also been argued that repetitive negative thinking is characterized by the same process across disorders due to the inherent similarities (Ehring & Watkins, 2008). A depression leads to more negative interpretations of messages from the environment and from within oneself. As one attributes the cause of negative experiences to oneself and engages in self-blame, feelings of guilt, failure and incompetence emerge. At the same time, the own person, others and the world as a whole appear to be less meaningful and less relevant. This loss of meaning can potentially lead to dangerous situations of self-harm or even suicide. To prevent this requires an insightful and caring use of communication between therapist and patient.

It is important to realize that it can be the same information which reaches the patient, but which is associated with more negative emotions and thus more hypotheses of negative consequences. A depressed affect can so lead to an increased selection of information associated with negative emotions, which can then lead to an even more depressed affect. This vicious cycle usually does not pose a problem because positive information becomes more appealing, which pulls the individual out of the negative affective state. In a depression where emotional and other communication is inhibited already, it is more difficult for the autoregulatory mechanisms to work, making a spiralling into an increasingly depressed affect more likely.

Analytical internal communication patterns can be helpful in many areas of life. However, in depression they are often used for the wrong purpose, possibly in the attempt to extricate oneself from the symptoms of depression. In a study by Rimes and Watkins, thirty depressed participants and thirty never-depressed participants were randomly allocated to ‘analytic’ (high analysis) or ‘experiential’ (low analysis) self-focused manipulations. As predicted, in depressed participants, the analytical self-focus condition increased ratings of the self as worthless and incompetent pre- to post-manipulation, whereas the experiential self-focus condition resulted in no significant change in such judgements. (Rimes & Watkins, 2005)

Negative thinking can often be triggered by some internal or external information, frequently an intrusive, which may be easier to shrug off for a non-depressed person. In this instance, it is as if the depressed person tries to preempt any disappoints or possible negative emotions from an adverse outcome, by already realizing them intracranially and fighting them with compensating emotions. However, this only leads to further negative thoughts and downward spiraling ruminations. One solution is to identify thoughts as mere thoughts and not real, another to build a sense of oneself as being able to deal with whatever may be coming one’s way, particularly the own emotions.

Repetitive negative thinking can, on the other hand, be distinguished from other forms of recurrent cognitions, such as obsessions, intrusive memories or functional forms of repeated thinking. (Ehring & Watkins, 2008) This illustrated how certain symptoms of a mental health condition can be grouped along the internal and external communication patterns they are associated with, and that they can be categorized into a moderate number of sets.

Communication-Focused Therapy® (CFT®)

Communication-Focused Therapy® (CFT®) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. Communication processes are at the same time the instruments of change and their target. Any therapy has to lead to change. This can include changes in acceptance levels, new insights, learning processes and more. All these aspects are determined by communication processes and some are communication processes themselves. For the acceptance of a certain situation or emotion, for example, with the aim of reducing conflicting emotions and anxiety, one needs to learn about the situation or emotions and identify them and then put them into context with information from memory and use internal and external communication flows to reflect on them. If fear inhibits the information retrieval from memory this will not fully work. CFT aims, among other things, at reducing the fear of information retained in memory or communicated from others. This requires more meaningful information rather than less which can be communicated more freely as the fears or other inhibiting factors decrease. The freer and more open the communication processes become, the easier it is for autoregulatory processes to counter unhelpful diversions from health affect states. However, this requires insight, reflection and experimentation in therapy.

Many popular forms of psychotherapy, such as Cognitive-behavioral Therapy (CBT), psychodynamic psychotherapy and Interpersonal Psychotherapy (IPT) define a format in which communication patterns take place that can bring about change. However, they do not address and work with the communication processes directly. In psychodynamic psychotherapy, there is the concept of transference and counter-transference which focuses on the result of communication processes. CFT in contrast attempts to focus on the process itself. (Haverkampf, 2017a)

CFT attempts to analyze how information is exchanged, the various channels involved and how meaning is generated. Messages do not have to be contained in words, they can also be transmitted by facial gestures or any behavior of the send. To contain meaning they have to be relevant to the recipient and have the potential to bring about a change in the recipient. Working with and analyzing patterns of internal and external communication helps to make the exchange of meaningful information work more effectively, reducing anxiety, emotional, mood, psychotic and other disorder in the long-run. (Haverkampf, 2018b) This does not mean that medication and other forms of therapy do not have their places in treatment, it does not change that at all. However, CFT provides a theoretical and empirical framework that can enrich these other therapeutic approaches, while also being used on its own.

Communication Patterns

Humans interact on millions of communication channels at one point in time. Cells have their communication channels, and every information coming into the system and leaving it uses communication patterns. The reason why certain patterns have to be used is so that the other person can understand the message. A language can be seen as a form of communication patterns on a more complex level. We all communicate in patterns. However, unlike learning a language, people spend little time observing and reflecting on the other communication patterns they use all the time.

In biology, an emerging picture of interconnected networks has replaced the earlier view of discrete linear pathways that relate extracellular signals to specific genes, raising questions about the specificity of signal-response events (Kholodenko, 2006). In synthetic biology, researchers integrate basic elements and modules to create systems-level circuitry (Purnick & Weiss, 2009). The communication of the cells with each other and with the environment determines how effective they are in, for example, eliminating tumor cells. The important basic material is ‘information’, which is then activated and given influence over other factors through meaning, whether that is meaning in in an intracellular or an interpersonal context. Communication patterns and structures facilitate this process. (Haverkampf, 2018c)

Two cardinal symptoms of depression are ruminations and selecting negative information. Many therapeutic approaches focus on the negative, for example, and try to unlearn them. This may work in the short-term but often fails in the long-term if the internal and external communication patterns do not change. An external pattern may be how one could ask for information that could dispel the negative thoughts or an internal testing of the information. Changes in communication patterns means modifications in which and how information is sent, how it is received and how meaning is extracted from it. All these steps can either be adaptive or maladaptive. Depression comes with maladaptive communication patterns which then cause even more maladaptive communication patterns. The way out is to create awareness for, reflect and experiment with these communication patterns, at first in a therapeutic setting and then in the real world.

Questions

As has been pointed out by the author already elsewhere, questions are powerful communication patterns in effecting change in other communication patterns (Haverkampf, 2017i). In depression, they can mobilize resources and redirect thinking towards a different focus, and they can also help end ruminations and looping thoughts. Over time, the patient should become a personal expert in asking the right questions.

Questions represent a large group of communication patterns with very diverse combinations of communication elements. One needs to fine-tune questions to the present communication dynamics and the aim of the questioning. Using them is to cause a branching off in the communication dynamics, which then brings about change in everyone in the session. One should not forget that a question can also change the one asking it, even if one has used a particular type of question hundreds or thousands of times. Questions are so embedded in the social and interactional everyday life that we mostly are not aware of them more than the microtasks we carry out when driving a car. The author has written elsewhere much more in-depth about the question as a communication pattern that can be a potent therapy tool.

Timeline

Patients with depression often spend a considerable amount of time ruminating about the past. Those who also suffer from anxiety may also ruminate about the future. What frequently gets lost is thinking about the present, even though that is the point-like interval of time which is the only one that is ever real. To avoid the reality of the present can be due to various reasons. The depression can make existence so unbearable that one escapes into a different ‘time zone’, and that it is not real may even be wished for in the hope that this also makes the pain less real.

The use of observations, feedback and questions can help the patient to stay in the patient. Several other communication patterns can also achieve this goal. Whenever a communication pattern leads to greater internal and external connectedness, it helps to anchor the patient more firmly in the now. However, this does not lead to more intense suffering because it is the disconnectedness that usually causes suffering. Patients with severe depression do not feel sadder, but they often feel nothing. Truly experiencing an emotion like sadness, when one feels ready for it and while being connected with others and oneself, can be an essential step in dealing with and overcoming a loss or other saddening event. And nothing can be as connectivity promoting as communication itself.

Getting Information

Questions help the patient in changing communication patterns. Still, they can also produce information, which lowers uncertainty, brings new insight or leads to something new in the world, which is enjoyable and improves the overall mood. Often, patients with depression return to the same thoughts or situations because they do not see alternative actions or ideas, which may be enjoyable and lead to a better mood.  Ruminations result not from too much but too little useful information, yet finding the right information again depends on communication patterns.

When things look at their darkest, and everything around seems empty like a desert, it helps be aware of all the meaningful information that is already easily accessible.  Connecting within oneself and others can lead to insights that help in countering the depressed rumination. A therapist’s task is to help the patient build communication patterns that are more effective towards connecting with oneself and others. Doing so allows a patient to find more meaningful information in places such as the own life experiences, which are a treasure trove of information. If I ask what is important to me and what I value, I just have to look at situations in the past and probe how I felt, what I thought and whether my actions and interactions in these situations benefitted me. One only has to be more open to information that can be helpful, and one aim in therapy is to help patients become better at this without fear.

Connecting

Communication patterns that help the therapist and patient connect in the session can also help the patient connect with others and with themselves. As already pointed out, the internal and external communication is a reflection of the other. The ability to communicate with the outer world also increases the ability to communicate better on the inside. Communication-Focused Therapy® supports patients in becoming more aware of, reflecting on, and experimenting with communication, which leads to the flexibility and openness in communication that is very effective against many forms of depression.

Communication patterns to facilitate connecting may again include questions and other communication patterns that enable the flows of meaningful information. Patterns may be repeating a modified message, providing information about a feeling or thought triggered in response to the patient’s communication, making an observation that offers a new perspective, and so forth. It is more than small talk because the therapeutic communication patterns not only test and build relationships but should also provide greater insight. The latter also includes insight into the communication patterns themselves.

Integration

By talking about the communication between patient and therapist it is possible to help the patient see how communication can be influenced and shaped so as to lead to new insights and to make new connections between pieces of information. This integration of different strands of information flows are important in helping the patient to feel more integrated as a whole. For example, talking about communication can help the patient to associate an image with emotions, which in turn may connect with past memories. This integration, however, requires that it is first possible to talk about these thoughts and feelings, and secondly that it is possible to talk about communication in ways which helps the patient to make associations between the different flows of information.

Analyzing Communication Patterns

The first important step in therapy is to create awareness for the flows of information, and their patterns. (Haverkampf, 2018c) These dynamics happen largely outside of consciousness, but they are not random. Rather, they are a result of biology and the internal and external communication experiences of an individual over time. Complex organisms receive, combine transform and send millions of bits of information in the smallest fraction of a microsecond. To navigate within this sea of information successfully is the primary objective of every organism, humans included. Health conditions in general are a result if these processes no longer work adequately. Mental health conditions often also include a significant impairment in the external communication between a person and the environment.

The human brain is in a particularly good position to work with information, and one objective of therapy should be to help it work better with information, whether this is coming from emotional signals, sensory organs, or retrieved from within the neural network itself. Communication processes and information can be made conscious. We might not be able to identify the information stored in a neuron, which would not anyway, because that information only makes sense within the context of the neural network. However, we can become aware of information stored in the neural network, even if it is a tiny detail or something that does not seem to fit into an existing pattern.

Particularly in interactions with other humans and other living organisms, communication patterns have evolved that facilitate the exchange of meaningful information in an efficient way. They need to be largely automatic, such as a gesture in response or a change of voice, and it may be even more distracting to follow them all, but it is possible to discern and work with some universal patterns. For example, the sequence of a specific type of question and a specific type of answer can be universal, such as the nod of a waiter signaling attention, followed by a guest using the palm of her hand and finger to scribble in mid-air, which indicates that she wants the bill. A complex business negotiation, however, would also use the basic communication element of question and answer and build it into more complex patterns. Spiraling negative thoughts in depression, on the other hand, also use otherwise adaptive communication elements, however, they do so in unhelpful communication patterns. The problem is not the ability to worry and think, but how this is done, the pattern, which is not constructive and unhelpful.

Emotional Signals

The emotional signals contained in a message are important because own emotions one becomes aware of can contain a lot of information. The brain uses a lot of information to form an emotion. To yield an emotion of sadness requires not only the information that a relationship has ended, but also the information about the relationship itself and potentially the relationships before, including information from interactions with one’s parents, and so forth. In a therapeutic setting, all this information can be helpful to adapt strategies, or to design new ones, and help the patient to integrate all this information into his or her life.

The communication between therapist and patient gives clues about thought patterns and beliefs, which affect how messages from others are interpreted and how own messages are assembled and communicated. It also helps to get an idea for how a patient constructs meaning. What someone sees as meaningful and relevant is largely determined by own needs and wants, but also past experiences. When the patient begins to form new communication patterns or adapts old ones, it is helpful to help in identifying patterns that have worked well for him or her in the past. Sometimes new ones have to be constructed from scratch, if a patient has been socially isolated for a while, for example. It is then useful to rely more on the therapeutic interaction as a model to train new communication patterns. In some patients who have suffered from depression for a long time with social isolation this may be necessary, but also important to maintain the patient’s motivation for the therapeutic work.

The importance of awareness is that it gives the patient a greater sense of hope and control when the depression causes hopelessness and despair. The journey patient and therapist take together in exploring and experimenting with communication in itself has a major antidepressant effect. It requires openness and insight which cannot be manualized. Communication has, however, universal rules which can be understood and worked with.

Motivation

Decreased motivation is a central symptom of depression which often makes therapy more difficult. It is no different in a communication focused approach. Experiencing what is possible in therapy can raise motivation significantly, but this requires at least some motivation to begin a therapy and makes it through the early stages. A communication focused approach may have the advantage here that it has material to work with from the time the therapist opens the door and makes eye contact with the patient. Another advantage on the motivational side is that a communication focused approach places emphasis on the interaction between patient and therapist, and thus the relationship, which helps to motivate the patient to wait and see what the therapy has to offer.

Insight into Communication

In many instances, reflecting on one’s communication patterns and strategies with oneself and others in concrete situations leads to insight about them. This is quite practical in nature. Observing communication patterns and trying out new ones is an important part of therapy. Since communication has different components one can focus on its components:

Person A

  • Selecting information for a message
  • Encoding the information in a message
  • Sending the message through a communication channel (using the speech system to say the words)

Person B

  • Receiving the message through a communication channel (using the auditory system)
  • Decoding the message into information
  • Processing the information further

One will observe quite often that a message it not received accurately. For example, one may say “the weather is nice today”, and the other person may interpret this as a signal that one wants to go on a hiking tour. The easiest way, of course, is to ask the other person again if one is in doubt. However, patients with depression or anxiety are less likely to get the full information.

The communication patterns a depressed patient uses may have served some function in the past, as they could have protected from some negative emotional consequence. However, in the present they no longer promote an optimal outcome, one that takes into account both the own needs, values and aspirations. On the other hand, it is also easy to see how awareness, reflection and experimentation with new communication patterns can resolve the problem, reduce the anxiety in A and lift the mood of B. That is what a communication-oriented therapy should do.

Maladaptive communication pattern can lead to the perception of more negative consequences and less meaning in the world. The former can be a filtering and interpretation deficit, the second often follows the first in the form of a disconnect or disengagement from the world. Insight does not have to lead to a change of current communication patterns, but in many cases also the development of new ones. In practice, this may also include considering situations which can facilitate better communication patterns, as the communication patterns one uses also depends on the communication patterns of the people one interacts with. This is also the basic dynamic when an individual is constantly exposed to other people who are stressed, anxious or depressed. Especially in infants and children who are still in the process of acquiring and forming communication patterns, an anxious parent, for example, can pass on some of the maladaptive communication patterns to the child. Depending on any helpful communication patterns already in memory and the effectiveness of autoregulatory processes, the child may adopt less of the maladaptive communication patterns than it might otherwise.

Observing and insight into internal and external communication patterns are both important. An individual suffering from depression is less likely to see messages as relevant and meaningful if the communication patterns that make up the feeling of being oneself have been compromised. The feeling of being oneself is itself the own observation of internal flows of information or communication. There is thus a strong link between internal and external communication patterns, which also explains how individuals can spiral into a vicious cycle of depression where engaging with the world can make the internal sense of dread and depression even greater, and vice versa. For example, a depressed person who pushes himself or herself to be more outgoing in a social situation often feels worse in the end.

Building the Sense of Self

Seeing relevance in a message requires knowing what one needs, wants, as well as one’s values and aspirations. In short, it means knowing some basic parameters about oneself. When the self becomes more meaningful, the motivation and desires to learn or try out something new, including therapy, increase. To give the sense of self texture requires awareness and identification of the own needs, values and aspiration, thereby attaching more subjectively perceived value to it.

The sense of self is awareness of certain communication flows in one’s own body. These information flows can be sensory, emotional or other signals from cognitive processes or from memory. This is the reason why internal and external communication patterns play such an important role for the sense of self because they influence these information flows. If a patient uses an external communication pattern which interferes with social exchanges, the information flow from the outside world in this respect will be reduced which has as effect on the sense of self. Thus, exposure to meaningful communication and improvements in communication can be very effective in treating the symptoms of depression. Negative perceptions of oneself are reduced and the interactions with the environment improve, which in itself has an antidepressant effect. As the moods lift concentration, focus and memory problems tend to decrease because things feel more relevant consciously and subconsciously.

Meaning

Individuals suffering from depression often see less meaning in the things they do. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.

Meaning requires that one can decode a message and extract some novel information form it which can potentially lead to change within oneself, a new thought, state or emotional signal, for example, which can then also lead to a change in the world. Helping patients to reassess and readjust communication patterns can be particularly helpful in therapy because the resulting change in perceiving and thinking usually also leads to a change in perspective (Haverkampf, 2018d), which then in turn also lead to changes in thinking, feeling, acting and interacting.

Resonance

Resonance is when synchronicity or similarity leads to a potentiation of a signal or piece of information. In a therapeutic setting, resonance can be important because it identifies information that may be important or relevant. A depressed patient who has lost a grasp of what is potentially enjoyable and meaningful can rediscover it when resonance is detected. When the therapist becomes aware of resonance in how a patient is communicating about something, it is often helpful to point that out. If there is true resonance, the patient will usually acknowledge it quite quickly. In other cases, the therapist may also identify it as a projection of something that is important to the therapist only. But if the patient sees a resonance, it can be helpful in getting more insight into the own needs, values and aspirations.

Resonance is when new piece of information becomes more meaningful because of the information that is already present (Haverkampf, 2018a). The interaction between therapist and patient is meaningful to the patient if what is happening resonates with the values, basic interests or aspirations of the patient. In therapy, often the technique of the ‘fishhook’ (Haverkampf, 2010b) may be used. One asks the patient to describe life in general, such as the events of the weekend. The more the patient learns to work with resonance, the easier it will be for her to find insight in these everyday events by using an increasing volume of information effectively, including emotional signals, perceptions, cognitive thoughts and more.

In therapy, patient and therapist look for resonance because it is necessary for the communication of meaning, which brings about a change in the patient. Often resonance can only be guessed by either patient or therapist, and it takes some amount of communication to find resonance. A good starting point is listening to what the patient is communicating, since it reflects the information the patient already has, and which represents the foundation for resonance. The question “how was life yesterday?” or “what did you do yesterday?” can be more powerful than a complex intervention, because it can serve as the starting point to greater insight if one is aware of information resonance.

Depression makes old and new information, particularly emotional information, less accessible, which lowers any potential resonance. However, in many patients suffering from mild or moderate forms of depression accessibility may not be greatly reduced. Rather, it is a question of whether a patient can still believe there is ‘something’ below the unpleasant state. Resonance can help to rebuild a connection with interests, needs, values and aspiration, whose pursuit can be enjoyable, below a surface of depressed feelings. Reflecting with a patient on everyday activities can help to find spots of resonance. If the therapist then uses an inquisitive and interested communication pattern to get information on what about this activity is valued, needed or aspired to by the patient, the patient’s internalization of this pattern can help to form more adaptive communication patterns which can help against and prevent a depression.

Relevance

Depression makes everything seem less relevant as it reduces the spectrum of information that is available, including emotional signals. Less available information leads to less resonance, and thus less meaning which is extracted from messages form internal and external sources as well as less openness to new messages. Looking at a tree may, for example, not be as enjoyable anymore. The visual information about the tree still arrives in the brain as it always did, but the information stored in memory about the good feelings associated with a tree is tuned down. The actual tress has not changed, but it has become less relevant to the person.

Less relevance also means less focus, which could support an evolutionary explanation of depression. In times of stress, it can be helpful if one sees less relevance in the situation and withdraws. However, this may not feasible in the world we live in today. One cannot just leave one’s job form one day to the next. Rather, a common response to stress is often to work even harder, which can the lead into burnout. However, the more one thinks about relevance on a smaller level, the easier it becomes to adjust larger constructs, such as ‘one’s job’. As mentioned before, it is the details which help to identify one’s needs, values and aspirations. On the smaller scale, the brain reorients focus to task-relevant stimulus information. Egner and Hirsch showed that, in response to high conflict, cognitive control mechanisms enhance performance by transiently amplifying cortical responses to task-relevant information rather than by inhibiting responses to task-irrelevant information (Egner & Hirsch, 2005). This also shows that the brain focuses on picking out potentially relevant information rather than by suppressing non-relevant one. Of course, what is relevant is subjective to the individual, but it must be based on existing information about the needs of the individual, one’s internal state and the state of the world.

From a broader and more long-term perspective, relevance is a connection one has with things, people and situations. If something is relevant to what one needs, wants, values or aspires to, one is more likely to be open to information associated with it. If one values being in a relationship, for example, one is more likely to be receptive to messages from a partner, if they are seen as relevant to the maintenance of the relationship. Although, one may not have enough information to judge what is relevant, and therefore focus on the wrong messages, or one may not understand a message. All this can be remedied with better communication patterns which lead to better information, and exposure to meaningful communication.

Changing a situation or one’s perception of it requires taking stock of one’s needs, wants, values and aspirations and then to make a change. If one is working in a job which does not seem relevant to oneself, an option, aside from quitting and finding another one, is to assess if a change in the work or one’s perspective of it is possible that could align it more closely with one’s needs and wants. This can be worked out in therapy. But whatever action one takes, just the doing it already helps against depression.

In therapy, rebuilding relevance through new communication patterns which bring a different focus and more useful information changes how the own person and the world are seen. It also puts the focus on better sources of meaningful messages. For example, if a patient gains the insight that he values staying in touch with a particular group of friends because they share his interests, he is more likely not to decline a lunch invitation by someone who is a part of that group. At lunch, this friend may tell him then what the other members of the group have been up to, which may help the patient with his own career choices as he shares their interests. Raising the level of resonance, and thereby the relevance one sees in oneself, others, activities, things and so on, is very effective in the treatment of depression and other mental health conditions because it lets through more and better information to make better decisions and raises the mood as the world as a whole seems more meaningful now.

Communication Exchange

Meaning is built within the communication processes in the therapy. The interaction between two minds can give rise to a dynamic, which carries the flow of meaningful messages and brings the process forward. Motivation for the process is usually maintained if the messages feel relevant and meaningful to the patient in the present. If emotions or thoughts about the past are brought to the center of attention, they are important to the extent that they are still relevant in the present. This relevance depends on the emotions they can induce in the moment.

The exchange of messages can be influenced by both partners to the interaction. The depression can be felt by both, since it interferes with the construction and free flow of messages. As long as the therapist is open and receptive to the patient’s messages and tries to understand the communication dynamics and the patient sees the process as relevant, it can move forward. Since the patient and therapist have different neuronal networks and past communication (life) experiences they can induce change in each other through the communication of meaningful messages.

Integration

As change in the communication pattern occurs, the information flows within the individual also change. Since the self is a reflection on these communication flows, it can bring about a change in how a person experiences the own self. In the long run, the identified meaning is integrated into the self, which, depending on the meaningful information perceived, can make the self itself more meaningful and valuable. One derives meaning from interacting with oneself and with other people, and this is also how people build their sense of self. Thus, while personality stays largely constant, the sense of self can get a boost form exposing oneself to the right communication environment.

Values, Needs and Aspirations

Depression blurs what feels important to a patient, and the fit between values, needs and aspirations and the current life situation is usually reduced. Whether in professional or personal life, getting what one needs, values and aspires to makes happiness, contentment and satisfaction more likely in the long run. If I value helping people, I know what makes me happy and gives me satisfaction. Communication, whether internal or external, is the instrument, that makes individuals aware of these basic parameters and helps them to pursue them.

The basic parameters, values, needs and aspirations, change little over time. One may alternate between being hungry and not being hungry within hours but eating as a basic need does not change and nor does someone who is happy with being a vegetarian. To some extent these basic parameters seem to be built into our biology, and it is not the therapeutic task to change them but to arrange the world around in such a way as to be able to live one’s values, needs and aspirations. Working with and improving communication with oneself and others usually accomplishes that.

Internal Communication

Exploring interests, values, needs and wants requires becoming sensitive to one’s own thoughts, emotions and physical sensation, to be open and receptive to the information coming in from one’s body and mind. It is about feeling what makes one feel good and what does not. At the same time, it has to make sense and should fit together. If specific values and needs appear to be in conflict with each other, a combination of emotions and rational thinking is often helpful. For a depressed patient, this may not be an easy task, but to bring more structure and sense into a seemingly chaotic and disconnected world, can be helpful.

Internal communication can be practiced in therapy. Since there is a correlation between the communication with others and one’s own internal communication, rehearsing and going through communication patterns in therapy, is often helpful to the patient outside of therapy, not only for the interactions with others, but also for the interaction with oneself. Values and needs can be clarified by talking to someone else and engaging in soul searching on one’s own. An important experience in therapy should be that one can clarify one’s needs and values by reflecting and communicating about them.

Meaningful Messages as the Instrument of Change

Communication in its various forms needs to be the target of therapy because it can be fined tuned and a change here can bring lasting change. The author has described this elsewhere (Haverkampf, 2017a, 2018b) Communication-Focused Therapy has been developed by the author for several psychiatric conditions. (Haverkampf, 2017f, 2017b, 2017d, 2017c, 2017g, 2017h). In depression, the desired change is for a broader emotional experience, seeing more relevance in oneself, one’s thoughts, emotions, and in the world as a whole. Adjusting, discarding and forming new communication patterns can lead to a reduction in symptoms that is more permanent than techniques the focus less on communication.

The actual instrument of change are the meaningful messages which, provided they are encoded, sent and decoded, induce the change. As information in a message resonates and is processed with the already existing information, meaning is created which leads to changes in the future.

Broader Experience

If there is more meaning in oneself and the world, it is easier to focus on aspects of oneself and of the world. This expands one’s experience of oneself and of the world around. Seeing more relevance and more sources of novelty and change in the world, increases one’s experience of the world and makes this experience richer. However, it also requires that one engages with the world, which may be difficult due to anxiety cause by fears and other unresolved emotions. However, working with communication early in the therapeutic process often reduces any anxiety quickly as the patient learns to become aware of and experiment with communication and appreciates and gains insight into the predictability of communication.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. You can reach author by email at jonathan@jonathanhaverkampf.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

 

 

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This article is solely a basis for academic discussion, and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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Body Work and Exercise for Anxiety Panic Attacks Depression and OCD

Body-Work-and-Exercise-for-Anxiety-Panic-Attacks-Depression-and-OCD-2-Christian-Jonathan-Haverkampf-life-improvement-series

Body Work and Exercise for Anxiety, Panic Attacks, Depression and OCD

Christian Jonathan Haverkampf, M.D.

Working with the body is often neglected in major schools of psychotherapy, such as psychodynamic psychotherapy and CBT. Depression and anxiety disorders are some of the most prevalent psychiatric disorders with close to one in five of adults exhibiting symptoms. Exercise has been shown to reduce symptoms associated with these disorders, has the potential to increase the effectiveness of psychopharmacology and to reduce depenndance on it in specific cases. The balance seems to be important between too little and excessive exercise.

Keywords: body work, exercise, treatment, anxiety, panic attacks, depression, OCD, obsessive-compulsive disorder, Communication-Focused Therapy, CFT, psychotherapy, psychiatry

Contents

Introduction. 4

Reconnection. 4

Communication. 4

Information Processing. 4

Integrative Therapy. 5

Exercise and Mental Health. 5

Depression and Anxiety. 5

Age. 6

Neurophysiology. 6

Hippocampal Volume. 6

Endocannabinoids. 6

Adrenocorticotropic Hormone (ACTH) 6

Serotonin. 7

Depression. 7

Body Image. 7

Body Image as a Problem.. 7

Obesity. 9

Breast Cancer. 9

Exercise as an Adjunct to Medication. 10

Techniques. 10

Basic Body Awareness Therapy (BBAT) 10

Pilates. 11

Body Psychotherapy (BPT) 11

Tai Chi 11

Yoga. 11

Exercise Dose. 12

Exercise and Anxiety. 12

Anxiety Sensitivity. 13

Body Dysmorphic Disorder: OCD.. 13

Hypochondriasis. 14

Risks. 15

Prevention. 15

Conclusion. 15

References. 17

Introduction

Much of the information the brain processes is received from and through the body. Since anxiety, depression and OCD are disturbances in the communication and processing of information, it makes theoretical and practical sense to involve the body in the therapeutic process.

While studies support the use of exercise as a treatment for depression, healthcare professionals irregularly suggest and rarely prescribe it. In their depression treatment guidelines, the American Psychiatric Association (APA) states that exercise may be of value but does not consider it as a first-line treatment. The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy.

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. Besides case series and small uncontrolled studies, recent well-controlled studies suggest that exercise training may be clinically effective, at least in major depression and panic disorder. (Ströhle, 2009)

Reconnection

Information comes in through the body. Types of body work and exercise which increase the sense of the body appear to be helpful in various psychiatric conditions. It helps to lessen the focus on a particular bodily function or organ and opens the inflow of information from more points in the body. This can help lower the partial disconnect which is usually present in conditions, such as anxiety, depression, panic attacks, OCD and more.

Communication

The body is a communication device, receiving information from the environment and allowing one to send messages, whether verbal or non-verbal. (Haverkampf, 2018) Communication is also the process which brings about change (Haverkampf, 2010a) and takes a preeminent place in communication-focused therapy (CFT) (Haverkampf, 2017a), which has been developed by the author, and plays a role in all psychotherapies.

Information Processing

The body also uses information that is communicated to it. As the nervous system innervates most parts of the body, there is a fast and ubiquitous connectedness throughout the body. While much information is relayed in the central nervous system (CNS) and then send out again, there are relatively autonomous neural networks distributed throughout the body. From a communication viewpoint one needs to look at them as doing something similar to the brain, though on a simpler level. Information is received, processed and new information is sent out again.

Integrative Therapy

The work with the mind and the work with the body in various shapes and form should be seen as two ways to work on communication systems inside the person. The objective is to make communication work better for the patient. This may require a new perspective on how the mind and the body interact, but communication is how things get done inside the body and with the rest of the world.

Exercise and Mental Health

Early large population studies examined the relationship between exercise behavior and mental health . The relation between self-reported physical activity and depressive symptom was analyzed for 1,900 healthy subjects aged 25–77 years in the Epidemiologic Follow-up Study (1982–1984) to the first National Health and Nutrition Examination Survey (NHANES I) and found that physical inactivity may be a risk factor for depressive symptoms.

Weyer found the odds ratio for depression to be significantly higher (OR 3.15) for the physically inactive compared to regular exercisers in a sample of 1,536 individual 15 years of age and older.

Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies. For example, in a nationally representative sample of adults ages 15–54 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders.

Depression and Anxiety

There is a general belief that physical activity and exercise have positive effects on mood and anxiety and a great number of studies describe an association of physical activity and general well-being, mood and anxiety. (Ströhle, 2009) In a study of 19,288 individuals, De Moor found that regular exercise was associated with lower levels of depression, anxiety, and neuroticism.

Cooney and colleagues conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register up to 2013, www.controlled‐trials.com, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform and any potentially eligible trials not already included are listed as ‘awaiting classification.’ Exercise appeared moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only showed a smaller effect in favor of exercise. When compared to psychological or pharmacological therapies, exercise appeared to be no more effective, though this conclusion was based on a few small trials. (Cooney et al., 2013)

Habitual exercise correlates to a heightened level of mental health and wellbeing and reduced feelings of anxiety regardless of the gender of the individual. Relative increases in maximal cardiorespiratory fitness and habitual physical activity appear to be associated with lower depressive symptoms and greater emotional well-being. Ohta noted that 30 minutes or more of walking or cycling while commuting to work might be associated with an increased perception of mental health in men.

Age

The age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents. In contrast, Fox found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity.

While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psychological disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety.

Neurophysiology

Physical activity and exercise have been shown to induce widespread neurobiological adaptations. Imaging studies have demonstrated structural changes associated with early-onset depression in the hippocampus, amygdala, striatum, and frontal cortex; areas that are all extensively interconnected. Most consistently associated with depression are the findings of volume loss in the hippocampal formation. Increased levels of hippocampal brain-derived neurotrophic factor (BDNF) levels are associated with decreased anxiety. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity (Portugal et al., 2013).

Hippocampal Volume

As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume. Brain neurogenesis is increased by antidepressant medications. Ernst and colleagues hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. They outline four possible molecular mechanisms for this increased neurogenesis, all of which both promote hippocampal neurogenesis and increase with exercise: B-endorphins, vascular endothelial growth factor, brain-derived neurotrophic factor, and serotonin.

Endocannabinoids

Other possible mechanisms for exercise’s ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being.

Adrenocorticotropic Hormone (ACTH)

Changes in the hypothalamo-pituitary adrenal axis, including increased adrenocorticotropic hormone (ACTH) and decreased cortisol production, are associated with exercise and thought to be part of the mechanism of its positive effects on mood.

Serotonin

A randmoised prospective study by Wipfli and colleagues showed that the exercise group had lower levels of depression than the stretching‐control group after the intervention. The exercise group also showed a larger percentage decrease in serotonin than the stretching‐control group. This reduction in blood serotonin after exercise is similar to the effects of selective serotonin reuptake inhibitors. Additionally, percent change in serotonin was found to partially mediate the relationship between exercise and depression. (Wipfli, Landers, Nagoshi, & Ringenbach, 2011)

Depression

Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials comparing exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group. Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found. When these three trials were analyzed together, the effect size was not significant.

There is empirical evidence that exercise compares favourably to antidepressant medications as a first-line treatment for mild to moderate depression. Blumenthal and colleagues conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After four months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically significant difference between the groups. The medication group did have a faster response to treatment in the first four weeks, however. However, in a more recent study, the remission rates were also very similar (45-47%), while the rate in the placebo group was moderately, yet not statistically significantly, lower (31%).

Body Image

Exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms. Bodywork is related to body image. Bodywork allows us to become more aware of our bodies. It is not necessarily the aim that one builds muscles or achieves a body ideal, which changes as soon as the new magazine ad replaces the old one. But working on and with anything increases our awareness for it. This also applies to the body. By working with the body, we learn about the body. Out of the interaction with the body we get new meaningful information and vice versa. Our bodies are powerful information processing entities, and the information we put into it can bring about significant changes. Exercising is a form of interacting with the body and having the body interact with the world, which leads to a range of changes.

Body Image as a Problem

With a healthy sense of self and a positive body image to go with it, the psyche and the body can work together well and lead to an experience of happiness and contentment. Unfortunately, body image disturbance is an increasing problem in Western societies and is associated with several adverse mental health outcomes, including anorexia, bulimia, body dysmorphia, and depression. (Pimenta, Sánchez-Villegas, Bes-Rastrollo, Lpez, & Martínez-González, 2009)

Body image is, of course, a subjective perception, something that is built from information from the outside (such as a visual image from a mirror) and the inside (perceived needs, values, aspirations, expectations). Body image thus also depends on what we believe is essential and what we think we need, value and should aspire to. It depends on how we communicate and interact with ourselves and other people. (Haverkampf, 2010a, 2017a)

How one sees one’s body affects how one shapes one’s body in the future. It also influences how one feels about the body and, as a consequence, about oneself. Pimenta and colleagues studied the association between body image disturbance and the incidence of depression in 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for four years on average (the SUN study). The difference between BMI and body size perception was considered as a proxy of body image disturbance. Men who underestimated their body size were much more likely to be overweight and obese, whereas women who overestimated their body size were much more likely to be underweight. (Pimenta et al., 2009) However, the authors found no association between body image disturbance and subsequent depression.

Different population may place different emphases on different body attributes. Body fat may, for example, play a greater role in one population than in another, which is probably influenced to a large extent by socialization and communication with others. A study that looked at muscle dissatisfaction, body fat, and height dissatisfaction as predictors of signs of psychological distress, such as depression, eating restraint, eating concerns, and social sensitivity) in a community sample of 228 gay men found that body fat dissatisfaction was predictive of all four distress signs (controlling for muscle dissatisfaction). Conversely, muscle dissatisfaction was only associated with social sensitivity, while height dissatisfaction failed to significantly predict any of the criterion variables for distress. (Blashill, 2010) Another study found that women were more likely to engage in indoor tanning and perceived greater susceptibility to photoaging than men. Body image and depression were found to be associated with tanning behaviors and attitudes. (Gillen & Markey, 2012) Since preferred skin tone, and the behaviors to achieve it, has changed significantly throughout the ages, from very light in past centuries to suntanned in the 1970s and 1980s, social trends must play a significant role. Identifying how one takes in outside preferences and makes them one’s own is an important step in identifying more closely the own needs, values and aspirations, which has a direct effect on quality of life and mental health (Haverkampf, 2010b, 2017a).

Mood plays a large role in how one perceives one’s body. If one sees things more negatively overall, this can also affect one’s view of the own body. Joiner and colleagues examined the relationship between body dissatisfaction, depression, and bulimia in 119 female participants and found that depressed symptoms, but not whether the individual was bulimic, were associated with body dissatisfaction. (Joiner, Wonderlich, Metalsky, & Schmidt, 1995) It is thus important to keep in mind that aside from the effect of variations of the body on mood, the latter does have a significant effect on how we perceive the former. A significant aspect of how depression reduces the activity radius and the quality of life is through a distorted perception of the body.

Obesity

There is a relatively close link between obesity and depression, although it is unclear what is the cause and what the effect. Depression may cause obesity, for example through changing eating patterns or reduced physical activity. But it is also possible that obesity may cause depression through an even more negatively perceived body image, which is a result from an interaction between the obesity and experienced social norms and interactions. The author has discussed possible etiologic factors from a communication perspective elsewhere (Haverkampf, 2017b). In any case, it is easy to see how a vicious cycle can form at the intersection between the psychological and the physical. Breaking that cycle requires awareness for an individual’s internal and external communication.

That internal or external communication dynamics may play a significant role could explain why being ‘overweight’, but not the extremes of being underweight or severely overweight, is most highly correlated with depression. De Wit and colleagues showed in their study a significant U-shaped trend in the association between BMI and depression. (De Wit, Van Straten, Van Herten, Penninx, & Cuijpers, 2009) Externally, the social context seems to play a role. Xie and colleagues investigated in a prospective study the associations between overweight and depressive symptoms in Asian and Hispanic adolescents. Significant mediation effect was found only in Asian girls and girls with high acculturation. Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms. (Xie et al., 2010)

On the other hand, there is data which shows an independence from social factors and current comorbidities. Zhao and colleagues examined the associations of depression and anxiety with BMI after taking into consideration obesity-related comorbidities and other psychosocial or lifestyle factors. They analyzed the data collected from 177 047 adults in the US. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5), in women who were overweight (BMI:25–<30) or obese (BMI⩾30), and in men who were severely obese (BMI⩾40) than in those with a normal BMI. Compared with men with a normal BMI, severely obese men were significantly more likely to have current depression or lifetime diagnosed depression and anxiety. Underweight men were also significantly more likely to have lifetime diagnosed depression. Overweight or obese women were significantly more likely than women with a normal BMI to have all three psychiatric disorders. (Zhao et al., 2009)

Breast Cancer

A condition that threatens the body’s integrity also tends to have a psychological effect. If the condition represents a serious threat, fear and anxiety are normal reactions to it. In one study with female survivors of breast cancer of all ages, 56% of the participants had scores that would correlate with potential depression (Begovic-Juhant, Chmielewski, Iwuagwu, & Chapman, 2012). The majority of women felt less attractive and less feminine. Low body image, attractiveness, and femininity positively correlated with depression and negatively with overall quality of life. (Begovic-Juhant et al., 2012) However, this may also provide an approach for ameliorating the depression through work on body image and the self-perception of attractiveness and femininity. Much of this could involve work with communication (Haverkampf, 2017a).

The body and the mind are inseparable. If the integrity of one is in danger, that will reflect of the sense of wholeness of the other. Lasry and colleagues investigated the psychological and social adjustment following total and partial mastectomy. Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed a surprising rise in depressive symptoms, which could be related to an underestimated anxiety they experience. (Lasry et al., 1987)

Exercise as an Adjunct to Medication

Exercise has also been shown to improve depressive symptoms when added to medication. There seems to be an added benefit beyond the direct effect of the antidepressant. In one study, exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone. Unlike its benefit as an adjunct to antidepressant medications, exercise in addition to cognitive therapy was found not to be more beneficial than either one by itself. (Ströhle, 2009)

Techniques

Many types of bodywork exist, and several are generally assumed to maintain and improve overall health and raise the quality of life. Important is as already mentioned above, aside from the physical exercise, the greater awareness and the better more meaningful information about the body and how it interacts with the psyche and the outside world. However, there is still far less knowledge of movement-based treatments focusing on body awareness than medication or psychotherapeutic approaches.

While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise may not be as important as having the physical activity reach a sufficient intensity. For example, both running and weightlifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms.

Basic Body Awareness Therapy (BBAT)

Danielsson and Rosberg explored the experiences of basic body awareness therapy (BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinical trial. The participants’ experiences were essentially grasped as a process of

  • (Danielsson & Rosberg, 2015)

Five constituents of this meaning were described (Danielsson & Rosberg, 2015):

The authors conclude that the process of enhanced perceptual openness challenges the numbness experienced in depression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear. (Danielsson & Rosberg, 2015)

Pilates

Mokhtari and colleagues investigated the efficiency of 12-week Pilates exercises on depression and balance associated with falling in thirty elderly participants. The Pilates exercises decreased depression and improved the balance related to falling in participants. (Mokhtari, Nezakatalhossaini, & Esfarjani, 2013)

Body Psychotherapy (BPT)

Body Psychotherapy (BPT) may be an effective treatment option for patients with chronic depression. Rohricht and colleagues studied the effectiveness of BPT in patients with chronic depression. Patients with chronic depressive syndromes and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7). (Rohricht, Papadopoulos, & Priebe, 2013)

Mindfulness-Based Cognitive Therapy (MBCT) pursues the development of a heightened awareness of one’s body, and its effectiveness has been shown in several empirical studies. Research has focused on the interactions between bodily, cognitive, and emotional processes. Michalak and colleagues argue that considering embodied processes might be a useful perspective for research on the etiology of depression and for mechanisms of action in MBCT. (Michalak, Burg, & Heidenreich, 2012)

Tai Chi

Tai Chi has also been explored in its effectiveness against mental health conditions. It has soft movements, slower speeds, and is relatively easy to learn. The posture of high or low and the amount of exercise can be different according to individual physical fitness. It can meet the needs of different ages and physical fitness. Data from a small study with a single-case design suggests that the intervention had the strongest effect on the participant who presented with hyperactivity and heightened anxiety. (Baron & Faubert, 2005)

Yoga

Field and colleagues compared the effects of yoga (physical activity) versus social support (verbal activity) on prenatal and postpartum depression. Ninety-two prenatally depressed women were randomly assigned to a yoga or a social support control group at 22 weeks gestation. The yoga group participated in a 20-min group session (only physical poses) once per week for 12 weeks. The social support group (a leaderless discussion group) met on the same schedule. At the end of the first and last sessions the yoga group reported less depression, anxiety, anger, back and leg pain as compared to the social support group. At the end of the last session the yoga group and the support group did not differ. They both had lower depression, anxiety, and anger scores and improved relationship scores. In addition, cortisol levels decreased for both groups following each session. Estriol and progesterone levels decreased after the last session. At the postpartum follow-up assessment depression and anxiety levels were lower for both groups. (Field, Diego, Delgado, & Medina, 2013)

Exercise Dose

A dose-response effect with exercise in the treatment for depression has been noted. In one study, high-intensity weight training was more effective than low-intensity weight training in treating depression. Low-intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group.

Aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD of mild to moderate severity. Dunn and colleagues studied whether exercise is an efficient treatment for mild to moderate major depressive disorder (MDD), and the dose-response relation of exercise and reduction in depressive symptoms. Participants were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure and frequency or to exercise placebo control. A 17.5-kcal/kg/week dose is consistent with public health recommendations for physical activity. The main effect of energy expenditure in reducing Hamilton Rating Scale for Depression (HRSD17) scores at 12 weeks was significant. Adjusted mean HRSD17 scores at 12 weeks were reduced 47% from baseline for the 17.5-kcal/kg/week dose, compared with 30% for a lower dose and 29% for control. There was no main effect of exercise frequency at 12 weeks. (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005)

Exercise and Anxiety

Compared to the wide range of research on the positive effects of exercise on depression, anxiety disorders have been less frequently studied. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy.

In general, exercise does appear to be effective in reducing symptoms associated with anxiety. Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise.

In treating anxiety, exercise has been shown to alleviate anxious feelings. While useful in treatment, exercise does not seem to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier.

In another study, the effects of a Feldenkrais® Awareness Through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period. Analysis of variance showed that anxiety scores for all groups varied significantly over time and, specifically, that participants reported lower scores at the completion of the fourth intervention. Further, compared to the control group, females in the Feldenkrais® and relaxation groups reported significantly lower anxiety scores on completion as compared to the beginning of the fourth session, and this reduction was maintained one day later. (Kolt & McConville, 2000)

Anxiety Sensitivity

Exercising at 70%–90% of maximum heart rate for 20 minutes three times a week seems to reduce anxiety sensitivity significantly (Carek, Laibstain, & Carek, 2011). Self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program (Carek et al., 2011). In a study by Cox and colleagues, the most substantial reduction in state anxiety occurred 90 minutes following 20 minutes of aerobic exercise at 80% of maximal oxygen uptake (Cox, Thomas, Hinton, & Donahue, 2004).

Body Dysmorphic Disorder: OCD

The relationship between obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD‐spectrum disorder or even a type of OCD. There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. (Lochner & Stein, 2006)

Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with an imagined or slight defect in appearance, with depression as its most frequent comorbid condition. (Nierenberg et al., 2002)

BDD is frequently comorbid with major depression, is associated with an earlier age of onset of depression and longer duration of depressive episodes, and is found more frequently with atypical than non-atypical depression. Nierenberg and colleagues evaluated the rate of BDD in a cohort of consecutive outpatients with typical and atypical major depressive disorder in 350 outpatient participants. Twenty-eight (8.0%) subjects had a lifetime history of BDD and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier age of onset of depression and longer duration of the current episode, but not a greater number of depressive episodes or greater severity of depression. Subjects with and without BDD were similar with respect to age, gender, and marital status. There was a higher rate of lifetime and current BDD in subjects with atypical depression than in those with non-atypical depression. Subjects with BDD also had higher rates of social phobia, any eating disorder, and any somatoform disorder but not OCD. They also had higher rates of avoidant, histrionic, and dependent personality disorders. (Nierenberg et al., 2002)

OCD and BDD do not significantly differ on many variables but did have some clinically important differences. In one study, the comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity.

Lochner and Stein conducted a computerized literature search (MEDLINE: 1964–2005) to collect studies addressing different dimensions on which the OCSDs lie. Their cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms:

  • “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette’s disorder),
  • “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and
  • “Somatic” (including body dysmorphic disorder and hypochondriasis).

It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders. (Lochner & Stein, 2006)

It has been argued that body-focused repetitive behavior disorders (e.g., trichotillomania and skin-picking disorder) should be included within the obsessive-compulsive and related disorders category, as this is how most clinicians see these behaviors, and as this may optimize clinical utility. The descriptions of these disorders should largely mirror those in DSM-5, given the evidence from recent field surveys. (Stein & Bouwer, 1997)

Hypochondriasis

The symptoms of HC overlap to an extent with certain anxiety disorders, such as panic disorder and OCD. The results of a study using discriminant function analysis indicated that whereas individuals with hypochondriasis experience panic attacks, obsessions, and compulsions, these symptoms are markedly less pronounced than among those with panic disorder and OCD. Conversely, overlaps were found in terms of cognitive biases, with hypochondriasis patients demonstrating elevated levels of intolerance of uncertainty, body vigilance, and fear of cardiovascular symptoms. (Deacon & Abramowitz, 2008)

Risks

While the Center for Disease Control and Prevention and the American College of Sports Medicine recommend that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably) all days of the week, physical activity and exercise have risks that need to be considered. The most common risk of physical activity in adults is musculoskeletal injury. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports.

Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease.

Prevention

Reduced incidence rates of depression and (some) anxiety disorders in exercising subjects raise the question whether exercise may be used in the prevention of some mental disorders. A review of studies showed a bidirectional relationship between physical activity, exercise and adolescent mental health (Pascoe & Parker, 2019). The results suggested that physical activity and exercise programs designed to increase the level of activity in young people should be implemented to be attractive and achievable to young people that may have poor psychological health (Pascoe & Parker, 2019). Another study found that participating in diverse leisure activities and longer exercise time decreases older adults’ risk of having depression. Additionally, the results confirmed that depression is positively correlated with chronic diseases (Lee, Yu, Wu, & Pan, 2018). On the other hand, data from the Netherlands Mental Health Survey and Incidence Study did not find evidence for a dose–response relationship between exercise levels and mental health. Among those with mental disorder at baseline, exercise participants were more likely to recover from their illness compared to their counterparts who did not take exercise, but the authors pointed out that it remains uncertain whether this association truly reflects a causal effect of exercise (Ten Have, de Graaf, & Monshouwer, 2011). In a 2010 meta-review, an ssociation between physical activity and mental health in young people was evident, but research designs were described as often weak and effects small to moderate. Evidence showed small but consistent associations between sedentary screen time and poorer mental health (Biddle & Asare, 2011). In another study involving 42 undergraduates, vigorous exercise had mental health benefits beyond moderate physical activity, was associated with less stress, pain, insomnia and depression, more favorable objective sleep patterns, and fewer mental health problems if the individual was exposed to high stress (Gerber et al., 2014).

Conclusion

Depression and anxiety disorders are some of the most prevalent neurological disorders with close to one in five of adults demonstrating symptoms. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. (Phillips et al., 2007) The balance seems to be important. The term ‘exercise addition’ has been coined for another extreme, in which an individual experiences a need to engage in excessive exercise, has the potential to have adverse effects on both physical and mental health (Berczik et al., 2012).


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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Depression and Psychotherapy (6)

Abstract – Depression has become highly treatable and this article explores some ways of treating it with the use of psychotherapy. The approach presented is a communication focused psychotherapy which has been developed and described by the author before. Psychotherapy alone may not be sufficient in more severe cases, where medication is usually added to bring faster relief to the symptoms of depression, which also facilitates the psychotherapeutic treatment.

Keywords: depression, psychotherapy

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Depression and Psychotherapy (6) Christian Jonathan Haverkampf

A Brief Overview of Psychiatric Medication (4)

Abstract – This article gives a brief overview of the main groups of psychiatric medication.

 

Keywords: medication, psychiatry

 

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A Brief Overview of Psychiatric Medication (4) Ch Jonathan Haverkampf

Depression and Medication (3)

Depression is the medical condition with one of the highest prevalence rates, but also one of the costliest ones in terms of human suffering, missed work hours, higher mortality and the higher incidence of physical illnesses. First-line treatment is usually a combination of medication and psychotherapy. In milder cases, psychotherapy alone may be sufficient, while in very severe cases, psychotherapy may not be possible. Antidepressants from a number of functional families are available, with the serotonin reuptake inhibitors (SSRIs) being the mostly used ones, followed by the serotonin and norepinephrine reuptake inhibitors (SNRIs) and antidepressants from other groups. In cases of treatment resistance, an increase in the dose, or if this is not possible a switch to a different group of antidepressants may be necessary. Rarely is a combination therapy needed. Selection of an antidepressant depends on the specific symptoms, such as insomnia or reduced activity, the patient’s current situation, including pregnancy or a requirement for alertness on the job, and many other factors, including past episodes of depression and the medication history.

Keywords: depression, medication, psychiatry

 

 

For the article click here:

Depression and Medication (3) Ch Jonathan Haverkampf

 


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the website www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. No checks have been made. 

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.

Depression and Medication

Depression and Medication (2) 

 

Depression comes in a multitude of flavors. Traditionally a distinction has been made between the reactive or neurotic depression on one end, which has been seen as largely environmentally induced, and the endogenic depression, which was largely seen as driven by biology. We now know that all three factors of biology, psychology and environment interact together in leading to the symptoms of depression.

 

The Circularity of Depression

Due to the plasticity of the brain, which regulates its morphological and chemical balance all the time, environmental influences can affect the circuitry and the functioning of the brain. Since the biology of the brain determines our thoughts and actions, it influences our environment, which again has a feedback on the brain. Thus, all effect depends on communication inside the brain and between the brain and the environment, and vice versa. This plays an immense role in the etiology and the symptoms of depression. It also explains why a combination of medication and psychotherapy in the majority of cases has the best outcome. Medication should be thought of in many cases of depression, except for the lighter reactive versions, while psychotherapy is always indicated if an individual suffers from depression. A condition that relies largely on communication deficits to be maintained, can also be cured through the ‘talking cure’, psychotherapy.

 

The Combination of Psychotherapy and Medication

Depression should in any case be treated with a combination of psychotherapy and medication if it is serious enough. Psychotherapy in most cases takes a few months to work, and medication, while also requiring a few weeks to work, will in many cases get results quicker than psychotherapy alone. In less severe cases, especially when it is a reaction to obvious external factors, psychotherapy alone may do. Medication can especially provide relief before the effect of psychotherapy, which is more geared towards the long-run, takes hold. While medication cannot make life more meaningful per se, it can improve an individual’s mood, which usually leads to more positive thoughts, a more positive outlook on the world, a decrease in ruminations, less anxiety and improved sleep – and appetite if that is desired.

 

Suicidal Ideation

Suicidality needs to be kept in mind in any form of depression and the mainstream opinion has shifted towards addressing these thoughts rather than avoiding talking about them out of fear that it might trigger them. Since the stability of the therapeutic relationship and communication itself are important tools in relieving depression, one should not be too anxious about naming issues that seem relevant.

A concern was that since the activating effect in several antidepressants can occur before the antidepressant affect, the risk for suicide might increase because a patient who still feels depressed becomes more active. However, the clinical experience is that the opportunity to talk about feelings and thoughts openly in a secure relationship reduces the urge towards self-harm.

 

Interests and Values

As I have outlined in another article on depression, facilitating the idea of a future the patient has some control over is often an important step in treating depression. This often means identifying values, interests and aspirations, which can provide greater motivation and a good feeling about the future, should be allowed enough space. There can be sadness about lost opportunities, but this usually subsides in the face of having a clearer direction in life and a greater promise of happiness, if one pursues the things one truly values and aspires to.

 

Medication

Unfortunately, the perfect medication does not exist. But this is also not to be expected since each antidepressant has a unique profile of effects, positive and negative, which can still be influenced largely by the unique biology of the patient. The following antidepressants are the most common ones. Using a single antidepressant (monotherapy) is usually to be preferred over polypharmacy. However, especially in more severe and treatment-resistant cases of depression, combinations may have to be explored, such as combining venlafaxine and mirtazapine (“California rocket fuel”) to yield an especially potent antidepressant and activating combination, which can even improve sleep (at lower to medium doses of mirtazapine).

Selective serotonin reuptake inhibitors (SSRIs)

The selective serotonin reuptake inhibitors (SSRIs) are the most common used antidepressants because of their relative safety and low side-effect profile. Unfortunately, in the beginning the indiscriminate use of the SSRI Prozac® against ‘everything’ from workplace problems to the stress of unhealthy living lead to a backlash in the media, which unfortunately made many patients avoid all medication out of fear to become emotionally flat or experience a change in one’s personality, which has not been shown so far in any convincing way.

There are several other substances, that work as antidepressants, and all have potential side-effects. Often a substance is used which has a ‘desirable’ side-effect and that deals more effectively with the individual constellation of symptoms:

  • Insomnia: Mirtazapine (Remeron® and many generics) is effective in inducing sleep at lower doses (around 15mg), an effect that seems to wear off once one goes up to 45mg. However, the antidepressant effect of 15mg is usually too small. Especially early on ‘hangovers’ in the morning are not uncommon. Among very common side effects are dry mouth, constipation, increased appetite, as well as somnolence, sedation, sleepiness (which may wear off).
  • Lack of activation: Venlafaxine (Effexor®, Effexor XR®, Lanvexin®, Viepax®, Trevilor®) is a noradrenaline and serotonin reuptake inhibitor (NSRI) and often affectively increases activation. However, one should be careful with patients who might harm themselves (or others) because activation often occurs before the antidepressant effect takes hold. Also, if used in cases of anxiety it may increase the anxiety before reducing it.
  • Co-morbidity with anxiety, panic attacks, OCD: the SSRIs are a good first choice. Venlafaxine seems to be helpful with anxiety, but often it increases anxiety early on, and possibly even medium-term.

Tricyclic antidepressants

Tricyclic antidepressants should not be used to treat symptoms that can be treated with the SSRIs or an NSRI, because of the letter’s better safety profile. It is difficult to imagine there still is an application for MAO inhibitors, except in the rare depression that does not respond to treatment. In the latter cases, my experience is that often medication has not been administered long enough or prescribed in the right dose. Quite frequently there has been no or only inadequate psychotherapy. It is worth remembering that psychotherapy is still and will always be the core treatment for what were a century ago referred to the ‘neurotic’ conditions, such as reactive depression, anxiety, OCD and the like. The reason is that the symptomatology can be traced to problems in interactions, communication and human relationships. Generally, there is better empirical evidence for the usefulness of antidepressants in the treatment of depression that is chronic (dysthymia) or severe.

In any case, it can take weeks for the full effect of medication to be noticed. A 2008 review of randomized controlled trials concluded that symptomatic improvement with SSRIs was greatest by the end of the first week of use, but that some improvement continued for at least 6 weeks.

 

Major depressive disorder

The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. The guidelines recommend that antidepressant treatment should be considered for:

  • People with a history of moderate or severe depression,
  • Those with mild depression that has been present for a long period,
  • As a second-line treatment for mild depression that persists after other interventions,
  • As a first-line treatment for moderate or severe depression.

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least 6 months to reduce the risk of relapse, and that SSRIs are typically better tolerated than other antidepressants.

 

Non-Responders

Between 30% and 50% of individuals treated with a given antidepressant do not show a response. In clinical studies, approximately one-third of patients achieve a full remission, one-third experience a response and one-third are non-responders. Partial remission is characterized by the presence of poorly defined residual symptoms. These symptoms typically include depressed mood, psychic anxiety, sleep disturbance, fatigue and diminished interest or pleasure. It is currently unclear which factors predict partial remission. However, residual symptoms are powerful predictors of relapse, with relapse rates 3–6 times higher in patients with residual symptoms than in those who experience full remission.

 

“Trial and error” switching

The American Psychiatric Association 2000 Practice Guideline advises that where no response is achieved following six to eight weeks of treatment with an antidepressant, to switch to an antidepressant in the same class, then to a different class of antidepressant. A 2006 meta-analysis review found wide variation in the findings of prior studies; for patients who had failed to respond to an SSRI antidepressant, between 12% and 86% showed a response to a new drug. However, the more antidepressants an individual had already tried, the less likely they were to benefit from a new antidepressant trial. A later meta-analysis found no difference between switching to a new drug and staying on the old medication; although 34% of treatment resistant patients responded when switched to the new drug, 40% responded without being switched.

 

Combination

A combination strategy involves adding another antidepressant, usually from a different class of antidepressants to have effect on other mechanisms. Although this may be used in clinical practice, there is little evidence for the relative efficacy or adverse effects of this strategy.

 

Augmentation

For a partial response, the American Psychiatric Association guidelines suggest augmentation, or adding a drug from an altogether different class of substances. These include lithium and thyroid augmentation, dopamine agonists, sex steroids, NRIs, glucocorticoid-specific agents, or the newer anticonvulsants.

 

Which medication to use?

The medication used needs to be tailored specifically to the individual and the set of effects that are desired and those which need to be voided. However, there seem to be clear favorites overall, which the following list of antidepressant prescriptions in the US in 2010 shows:

Drug name Commercial name Drug class Total prescriptions
Sertraline Zoloft® SSRI 33,409,838
Citalopram Celexa® SSRI 27,993,635
Fluoxetine Prozac® SSRI 24,473,994
Escitalopram Lexapro® SSRI 23,000,456
Trazodone Desyrel® SARI 18,786,495
Venlafaxine (all formulations) Effexor (IR, ER, XR) ® SNRI 16,110,606
Bupropion (all formulations) Wellbutrin (IR, ER, SR, XL) ® NDRI 15,792,653
Duloxetine Cymbalta® SNRI 14,591,949
Paroxetine Paxil® SSRI 12,979,366
Amitriptyline Elavil® TCA 12,611,254
Venlafaxine XR Effexor XR® SNRI 7,603,949
Bupropion XL Wellbutrin XL® NDRI 7,317,814
Mirtazapine Remeron® TeCA 6,308,288
Venlafaxine ER Effexor XR® SNRI 5,526,132
Bupropion SR Wellbutrin SR® NDRI 4,588,996
Desvenlafaxine Pristiq® SNRI 3,412,354
Nortriptyline Sensoval® TCA 3,210,476
Bupropion ER Wellbutrin XL® NDRI 3,132,327
Venlafaxine Effexor SNRI 2,980,525
Bupropion Wellbutrin IR NDRI 753,516

 

The Need for Psychotherapy

In any case, medication should always be combined with psychotherapy. In the less severe forms of depression and those that seem to have an explanation and are “reactive”, medication often shows to be less effective and psychotherapy eventually leads in many cases to a full remission of the symptoms.

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy (psychoanalytic and CBT)  and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

Depression and Psychotherapy

Depression and Psychotherapy (2)

Depression usually means feeling low and lacking motivation and energy to do anything enjoyable, but sometimes it may predominantly show in disturbed sleep, a lack of appetite and other diffuse bodily symptoms. The latter condition we call an atypical depression. Often individuals remain undiagnosed or misdiagnosed for a long time before someone correctly identifies the underlying problem as a depression. Frequently, depression is associated with anxiety, and in many cases also with OCD, because they involve some of the same neurobiological pathways, and the same medication can have an effect on all three.

How Anxiety Got Rebranded As Depression

New research finds that one in six U.S. adults used a psychiatric drug in 2013, most often as a treatment for depression. Depression diagnoses have skyrocketed over the past 50 years, but, as Allan V. Horwitz wrote in a 2010 paper, that’s not necessarily a result of underlying changes in our mental health.

See the articlet on JSTOR Daily at http://daily.jstor.org/how-anxiety-got-rebranded-as-depression/