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An insider's guide to depression

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7319.1011 (Published 27 October 2001) Cite this as: BMJ 2001;323:1011

Depression can be lifted quickly

Dear Editor,

The moving personal article, "An insider’s guide to depression, by
general practitioner Kay McKall (BMJ, October 27), shows there is still a
desperate need for good quality information about what depression is and
how best to treat it. Alas, I fear Dr McKall may have needlessly suffered
too long.

For many years, experienced psychotherapist colleagues and I have
been treating people with severe depression quickly and effectively.
Through MindFields College, the largest independent trainer of health and
social service staff, many hundreds of professionals have also learned
these methods for breaking the cycle of depression. For depression is best
thought of as a cycle of behaviour that can be broken by various
interventions.(1)

It has been known for some time that, if REM sleep is prevented,
severe depression lifts. (2) Unfortunately, it returns once the person
resumes normal sleeping and may even worsen, because of extra compensatory
REM sleep. It is also known that ECT can and does lift depression but up
till recently there has been no explanation for this. ECT causes REM sleep
deprivation by producing seizure-like stimulation of the neocortex. Unlike
direct REM sleep deprivation, the lifting of depression lasts even when
normal sleep is resumed because there is no compensatory REM sleep
afterwards.

We now know why reduction in REM sleep leads to a reduction in
depression. During REM sleep and just before it starts there is a massive
firing of the orientation response known as the PGO wave, which, in waking
hours, draws attention to novel stimuli and activates the flight or fight
response, the system which manages the body’s responses to stress.
Hundreds of studies have shown that this mechanism is hyperactivated in
more severely depressed patients.(3) Its activation in sleep is linked
with the function of dreaming and new findings(4) about why we dream
provide the explanation for the link between depression and REM sleep, and
how best to treat it.

The research shows that dreams are caused by emotionally arousing
introspections that haven’t been acted upon when awake. In our dreaming at
night, these introspections are acted out in metaphorical scenarios, which
deactivate the emotional arousal. The effect of dreams, therefore, is to
reduce emotional arousal, thus freeing up brain activity for other
concerns next day. However, the morbid and prolonged introspection, or
self examination, which tends to characterise depressed people leads to
above normal levels of emotional arousal discharge during dreams. In fact,
the pressure for discharge caused by excessive negative introspection is
so great that the first REM period of the night occurs earlier in
depressed people and tends to be more prolonged and show an especially
high rate of discharge. This not only reduces the level of arousal in the
brain but depresses it, leaving the person more likely to lack motivation
next day. (As Kay McKall suggests, depression is less about low mood than
about lack of motivation and interest.)

Depressed people have a very high level of physiological arousal.
Emotional arousal automatically forces the brain into a reactive, black
and white mode of thinking, reducing its ability to think in more subtle,
objective ways. So, after a setback, someone with an essentially
pessimistic outlook will catastrophise their interpretations of life
events and introspect excessively about these interpretations, putting
excessive pressure on the dreaming process. This distorts the REM sleep
system, causing too much autonomic arousal discharge and leading in turn
to physical exhaustion (the orientation response exhausts itself and the
individual also experiences less recuperative slow wave sleep) and
subsequent clinical depression. The cycle repeats itself day after day,
night after night.

All therapies that are effective at lifting depression break this
cycle. Most antidepressants reduce or normalise REM sleep. However, the
most long lasting benefit is likely to result from psychological
interventions that alleviate the negative introspections and focus the
client on solving problems and engaging with life again, particularly if
the intervention teaches the person how to do this for themselves.
Research has shown that such interventions are more effective than
antidepressants in reducing further episodes of depression(5) while
therapies that encourage introspection may make depression worse.(6)

The guidelines for lifting depression which the European Therapy
Studies Institute (ETSI) recommends are as follows:

- Because depressed people are highly aroused, it is necessary to
calm them down, using any relaxation skills that are appropriate –
breathing retraining, massage, guided imagery or relaxing hypnotic
language – before it is possible to work with them cognitively or in any
way at all

– Therapists must help depressed people stop their emotional
introspecting. Explaining what is happening physiologically is often
sufficient to start this process

– Patients must be helped to use their imagination to see how things
could be different. This means using guided imagery in a positive way to
help them remind themselves of the pleasures and satisfactions they have
had in the past and could have again. This is a vital component in the
treatment because rehearsal – whether negative or positive – reinforces.
(This is why psychodynamic and person centred approaches can be damaging,
as they encourage the rehearsing of misery.)

As Dr McKall points out, people when depressed lose both their sense
of perspective and their sense of humour. That is why it is so important
to use every means possible to jolt them out of their depressed tunnel
vision.

We all have basic emotional needs, such as the need for love,
security, meaning and connection, and we also have a number of innate
resources to help us meet those needs, such as memory, imagination,
problem solving abilities, self awareness and a range of complementary
thinking styles to employ in different situations. At ETSI we term these
the ‘human givens’. It is when emotional needs are not met or our
resources are used incorrectly that mental distress occurs. Good therapy
is about helping people identify and meet their emotional needs. It is
about reframing, challenging, inspiring, creating hope and imparting
skills – and patients such as Dr McKall shouldn’t need to have to tell
that to the medical profession.

If anyone would like to know more about the ‘human givens’ approach
to depression, please contact ETSI on 01323 811440 or go to www.the-
therapist.ltd.uk/Books/Depression

Your sincerely

Ivan Tyrrell

European Therapy Studies Institute

(1) Griffin J and Tyrrell I. Breaking the cycle of depression. East
Sussex: Human Givens Publishing, 2000.

(2) Voge G W. The Function of Sleep. Drucker-Collins et al (eds),
pp233–250. New York: Academic Press, 1979.

(3) Nemeroff C B. The neurobiology of depression. Scientific
American, 1998; 278: 6: 28–35.

(4) Griffin, J. The Origin of Dreams, Sussex: The Therapist Ltd,
1997.

(5) Depression and Primary Care .Vol 1 Detection and diagnosis: vol 2
Treatment aspects. United States Public Health Service Agency, 1996.

(6) Danton W, Antonuccio D, DeNelsky, G. (1995). Depression:
psychotherapy is the best medicine. Professional Psychology Research and
Practice, 1995; 26: 574.

Competing interests: No competing interests

01 November 2001
Ivan Tyrrell
Psychotherapist/lecturer/trainer
MindFields College