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From Depression to Freedom

by J. M. G. Williams

(February 23, 2006) - Clinical depression affects roughly one in four people at some point in their lives. It is a severe and prolonged state of mind in which normal sadness grows into a painful state of hopelessness, listlessness, lack of motivation, and fatigue. But, however well defined, clinical depression is many things to many people, varying from mild to severe.

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Mild depression can result in brooding on negative aspects of self or others, feeling resentful, irritable or angry much of the time, feeling sorry for oneself, and needing constant reassurance from someone. It can also result in various physical complaints that do not seem to be caused by any physical illness.

As depression worsens, feelings of extreme sadness and hopelessness combine with low self-esteem, guilt, memory loss, and concentration difficulties to bring about a severely painful state of mind. To make things worse, there may be a change in basic bodily functions. The usual daily rhythms seem to go wrong: can’t sleep, or sleep too much, can’t eat, or eat too much. Enthusiasm for what are usually enjoyable activities fades. Sometimes, there is even a feeling that life is not worth living and that one would be better off dead. The most commonly used treatment for major depression is antidepressant medication. It is relatively cheap, and it is easy for family practitioners, who treat the majority of depressed people, to prescribe.

However, when the episode has passed, and medication ceases, depression tends to return, and at least 50 percent of those who experienced an initial episode of depression find that depression comes back, despite appearing to have made a full recovery.

After a second or third episode, the risk of recurrence rises to 80-90 percent. Early onset depression (before 20 years of age) is particularly associated with a significantly higher risk of relapse and recurrence. For those who have been suicidal in the past, any depressed mood is likely to be accompanied by a return of suicidal thinking.

The problem with viewing antidepressants as the main method for preventing recurrence is that many people do not want to stay on medication for indefinite periods, and when the medication stops, the risk of becoming depressed again returns.

Finding new ways of helping people stay well after depression demands an understanding of why depression keeps returning.

During a period of crisis in which someone becomes depressed and suicidal, an association is learned between the various symptoms (low mood, physical pain, suicidal tendencies, and so on).

Based on Jon Kabat Zinn’s Stress Reduction program at the University of Massachusetts Medical Center, Mindfulness-based Cognitive Therapy (MBCT) combines modern cognitive behavioral therapy with meditation practices to help people become more aware of the present moment, including getting in touch with moment-to-moment changes in the mind and body (see www.mbct.co.uk).

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In weekly classes (the atmosphere is that of a class, rather than a therapy group), and by listening to CD’s or tapes at home during the week, participants learn the practice of mindfulness meditation. The classes also include basic education about our moods, and several exercises from cognitive therapy that show the links between thinking and feeling and how participants can best look after themselves when a crisis threatens to overwhelm them.

The MBCT approach helps participants in the classes to see more clearly the patterns of the mind and to learn how to recognize when their mood is starting to sink. It helps break the normal link between negative mood and negative thinking. Participants develop the capacity to allow distressing moods, thoughts, and sensations to come and go, without having to battle with them.

They find that they can stay in touch with the present moment without having to ruminate about the past or worry about the future. Thus, they come to see with greater clarity and conviction how to approach moment-by-moment experience skillfully, taking more pleasure in the good things that often go unnoticed or unappreciated while dealing more effectively with the difficulties encountered, whether real or imagined.

Two controlled clinical trials have demonstrated that MBCT can reduce the likelihood of relapse by about 40-50 percent in people who have suffered three or more previous episodes of depression. As a result of such findings, MBCT has now been included in the British government’s national guidelines for treating recurrent major depression.

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But this implies a redefinition of treatment itself. As our understanding of depression grows and we see that it is a recurring problem, the emphasis is shifting from cure to prevention. Mindfulness-based approaches have already proven that they will play an enormously important role in this.

J. M. G. Williams is Professor of Clinical Psychology and Wellcome Principal Research Fellow at the University of Oxford. His books include “Cry of Pain: Understanding Suicide and Self Harm” and (with Zindel Segal and John Teasdale) “Mindfulness-based Cognitive Therapy for Depression: a new approach to preventing relapse.”

Last updated: 2/06

From Depression to Freedom

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