Is the "depression epidemic" really as bad as it appears?

The World Health Organisation has stated that by 2020 depression will create the second largest "health burden" in the world after heart disease. This is a prediction made made on the basis of data analysed by Harvard University Faculty of Public Health. At first sight, this appears to match up with our perception of the society we live in and the clients we work with - more stress, greater unhappiness, increased social and family breakdown. But hold on a minute. Is it really that clear cut or does the WHO position hide a more worrying trend which a brief history tour should illuminate.

Since the marketing of diazepam (Valium) in 1963 for "anxiety disorders" in 1963, their prescription (along with other prescription of other benzodiazepine anxiolytics reached a peak of 24.5 million prescriptions in the UK 1982. In the late 1970s pharmaceutical companies decided that they wanted to replicate Valium's success with other psychiatric drugs. They knew that despite the drug's success, past experience indicated it would be self limiting and that criticism's of valium's "addictive qualities" were already arising in the literature. As a result, they lobbied the American Psychiatric Association, who were reconsidering diagnostic categorisation for DSM III. As a result the APA radically changed their definition of "depression", with the primary effect being to broaden it substantially in 1980. Valium prescriptions peeked in 1982. However the new definition of depression opened up a new huge market for antidepressants and the arrival of Prozac in 1988 cemented the new broader definition of depression into place. In other words, the broadening of the definition of depression has been largely driven by the need to market new drugs.

In practice, most psychologically distressed clients still present with a mixture of anxiety and depression, as they were in 1970s, except that medication driven diagnosis classifies it as "depression". Secondly, the relative lack of addictive properties of SSRIs has meant that their prescription has escalated beyond that that existed for the benzodiazepines. 31 million were prescribed in 2006. Many have seen this is an acceptable price to pay in order to destigmatise requesting help for psychological problems. The price has been a high one however. The medicalisation of psychological distress and unhappiness for large sections of the community has meant that it has disabled and disempowered such individuals and has often legitimised victim roles. It ultimately makes people less (rather than more) psychologically minded about their problems and averts our gaze from the more fundamental question of why are more of us feeling unhappy and stressed, and feel life lacks meaning. Using a medical diagnosis is inappropriate and unhelpful.

Our seminars on 'Working with Depression: New Thinking & Effective Interventions' give us an opportunity to discuss these and many other issues. I am sure they will be stimulating training days for all of us. However, I welcome any of your thoughts on the topic here.

Best Wishes
Paul Grantham

It's official: 30-50 % of your clients have substance misuse problems!

The UK National Statistics Information Centre has indicated that "30-50% of clients with mental health problems have current drug or alcohol issues". This would suggest that up to every one in two clients we work with on a daily basis, have an additional substance misuse issue.
This has enormous implications:
Firstly is the simple question of do we know who these clients are? How do we find out?
Secondly, we know that this will have implications for the work we do with them. These range most obviously from the impact of the substance(s) on mood through to clients' ability to remember what we say to them.
There are of course numerous other issues ranging from the impact on client motivation through to knowing which to work with first.
I've raised this issue because there is still a great tendency to divorce substance misuse from the other problems clients present with. Even in the field of anger management, where the connection between substance use and the problem is very obvious, this is so. Kassuinove and Taffrate's otherwise excellent "Anger Management: A Complete Treatment Guidebook" has only two and a half pages (out of three hundred) on substance misuse — and those are right at the end before the index! Take a brief look through the indexes of the books you have relating to your field of work. Are they any different?
This separation is also reflected in services. Clients with "substance misuse problems" usually go to a "substance misuse service" (with the possible exception of those working with offenders). But this assumes that substance misuse is the presenting problem and that the client sees themselves as having a difficulty with substances. What do you do if the don't? How do you work out which of your clients use which substances? Do you know the effects of substances on the client? How do you manage the issue within your work? Do you refuse to work with people if they use? Refuse when they are intoxicated? Refuse when they are withdrawing?Ignore the problem altogether?
As always, we are interested in how you approach this whole topic and what your thoughts are on it.

Yours
Paul Grantham

Is selflessness an essential part of being happy?

Positive Therapy (and its academic parent - Positive Psychology) have focused extensively on the question of how individual happiness can be increased. One area of work which has produced interesting results is the role of gratitude. The PRACTICE of gratitude and kindness has important implications for how happy and content people are... and it acts as a strong antidote to negative states such as depression, anger and anxiety.
How exactly do you practice gratitude and kindness?
Martin Seligman's early work on gratitude suggested writing a 300 word statement to someone who had done something good for you (but whom you had never thanked) and to go round to their house and read it to them!
Robert Emmons therapeutic interventions have asked clients to write about five things for which they were thankful, every week for 10 weeks.
Sonja Lyubomirsky meanwhile found that asking clients to perform five acts of "kindness" a day significantly improved their mood.
There are of course motivational issues around with this work which would have to be addressed with our clients. However it does appear to raise a number of important issues:
It suggests client improvement can occur NOT by addressing their problems but instead by enhancing qualities and emotions that are incompatible with those problems;
It suggests that to be truly happy it is essential that you practice some form of selflessness;
It suggests that "going through the motions" of kindness and gratitude produces useful results even if one does not initially have these feelings.
We welcome any of your thoughts on the topic.