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DEFEATING DEPRESSION: Non-medication ways to beat the blues Bill O ’ Hanlon BillOHanlon.com FREE STUFF Then Click SLIDES Visiting Depresso-Land My story Challenging Depression Myths Myths about depression: Cause is known (biochemical and genetic)

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DEFEATING DEPRESSION:Non-medication ways to beat the blues

  • Bill O’Hanlon

  • BillOHanlon.com

  • FREE STUFF

  • Then Click SLIDES


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Visiting Depresso-Land

My story


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Challenging Depression Myths

Myths about depression:

  • Cause is known (biochemical and genetic)

  • Despite the ads one sees on TV, the cause of depression is not known and has not been established as biochemical or genetic

    • “For most common diseases, specific genes are almost never associated with more than a 20-30% chance of getting sick,” explains Bryan Welser, CEO of gene discovery company Perlegen Sciences. (Quoted in Wired, Nov. 2009, p. 121)

    • “The strongest predictor of major depression is still your life experience. There aren’t genes that make you depressed. There are genes that make you vulnerable to depression.” –Kenneth Kendler, M.D., Professor of Psychiatry and Genetics Medical College of Virginia, TIME, March, 2001

  • Antidepressants are the only effective treatment


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What This Presentation Offers

  • The six strategies: New possibilities for effective intervention

  • These are alternate approaches to use with clients/patients with whom your usual approaches have not helped or to supplement your current methods and approaches


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Depression can be devastating

  • Andrew Solomon

    (author of “The NoonDay Demon”)


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#1 Walking Out of Depresso-Land

Mapping depressed times and non-depressed times

  • Investigate times and aspects of non-depression while finding out about depressive experience


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Focus mainly on depression could add to the problem

A recent study shows that extensive discussions of problems and encouragement of ‘‘problem talk,’’ rehashing the details of problems, speculating about problems, and dwelling on negative affect in particular, leads to a significant increase in the stress hormone cortisol, which predicts increased depression and anxiety over time.

Byrd-Craven, J., Geary, D. C., Rose, A. J., & Ponzi, D. (2008). “Co-ruminating increase stress hormone levels in women,” Hormones and Behavior, 53, 489–492.


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Acknowledgment and Possibility

  • Of course, we need to speak about depression to assess and help the person

  • Move back and forth between discussions of depression and non-depressive moments and experiences.

  • This moves the person out of state-dependent memories and biases for brief interludes and makes change easier

  • This not only respectfully acknowledges the person’s painful and discouraging experiences, but gives them a reminder they aren’t and haven’t always been depressed.

  • It can also illuminate and give hints to skills, abilities and connections that can potentially lead out of depression or at least reduce depression levels.


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Letter from Abraham Lincoln to Fanny McCullough after she was distraught over the loss of her father in the Civil War

Dear Fanny

It is with deep grief that I learn of the death of your kind and brave Father; and, especially, that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares. The older have learned to ever expect it. I am anxious to afford some alleviation of your present distress. Perfect relief is not possible, except with time. You can not now realize that you will ever feel better. Is this not so? And yet it is a mistake. You are sure to be happy again. To know this, which is certainly true, will make you some less miserable now. I have had experience enough to know what I say; and you need only believe it to feel better at once.


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Make maps of depresso-land and non-depresso-land

Compare and contrast and build maps of feelings, actions, thoughts, focus of attention, interactions and contexts associated with both depressive experience and non-depressive experience


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Elaine’s maps

Depresso-land

Confident/Competent-land

Gets out of bed by 9 a.m.

Stays in bed until noon

Doesn’t have a job

or quits job

Contacts friends

Plays music

Eats breakfast foods all day

Focuses on good things

she has accomplished in the past

Stays alone; talks only to depressed friend or therapist

Has a job;

Goes to work

Focuses on bad things happening in the future

Spends time with

women friends

Goes to lunch alone


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Discover exceptions, resources and solutions

  • Find out about moments of non-depression

  • Find out about what happens when the depression starts to lift differently than during it

  • Ask why the problem isn’t worse

  • Import strengths and abilities from contexts of competence

  • Investigate resilience and times of bouncing back from setbacks, tragedies, trauma and troubles


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Inclusion

  • Permission

    • To and not to

      • “It’s okay to feel depressed.”

      • “You don’t have to have hope right now.”

  • Inclusion of opposites

    • “You can be hopeless and have hope at the same time.”

  • Exceptions

    • “You feel hopeless except when you don’t.”


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#2 Undoing depression

  • Pattern intervention

  • Discover repeating patterns involved with and associated iwth depressive experience and help the person change those patterns in small or big ways

  • Patterns of doing, viewing and context

  • Highlight any places around depression that the person has moments of choice


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Undoing depression:Case example

Erickson sends a depressed person to the library


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Undoing depression:Identifying patterns

  • Location/places

  • Activities

  • Timing/Duration

  • Sequences

  • People


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#3: Shifting relationship to depression


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Mindfulness

  • Noticing variations in sensations, feelings, thoughts and experiences around depression

  • Noticing without judging

  • Witnessing rather than getting caught up in; being with

  • Get curious

    Teasdale JD, et al. (2000). “Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy,”Journal of Consulting and Clinical Psychology, 68(4):615–623.

    Teasdale JD, et al. (2002) “Metacognitive awareness and prevention of relapse in depression: empirical evidence,”Journal of Consulting and Clinical Psychology, 70(2):275–287.

    Williams, M.; Teasdale, J.; Segal, Z.; and Kabat-Zinn, J. (2007). The Mindful Way Through Depression: Freeing yourself from chronic unhappiness. NY: Guilford.

    Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Lau, M., & Soulsby, J. (2000). “Reducing risk of recurrence of major depression using Mindfulness-based Cognitive Therapy,”Journal of Consulting and Clinical Psychology, 68, 615-23.


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Mindfulness Based Cognitive Therapy (MBCT)

  • MBCT proved as effective as maintenance anti-depressants in preventing a relapse and more effective in enhancing peoples' quality of life. The study also showed MBCT to be as cost-effective as prescription drugs in helping people with a history of depression stay well in the longer-term.

  • Over the 15 months after the trial, 47% of the group following the MBCT course experienced a relapse compared with 60% of those continuing their normal treatment, including anti-depressant drugs. In addition, the group on the MBCT programme reported a higher quality of life, in terms of their overall enjoyment of daily living and physical well-being.

    Kuyken, Willem, et. al. (2008). “Mindfulness-Based Cognitive Therapy to Prevent Relapse in Recurrent Depression,”Journal of Consulting and Clinical Psychology, December; 76,(6): 966-978.


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Mindfulness Based Cognitive Therapy (MBCT)

Other studies:

  • Bedard, M., et. al (2008). “Mindfulness-based cognitive therapy reduces depression symptoms in people with a traumatic brain injury: Results from a pilot study,” European Psychiatry, Volume 23, Supplement 2, April, Page S243.

  • Bondolfi, Guido; et. al (2010) “Depression relapse prophylaxis with Mindfulness-Based Cognitive Therapy: Replication and extension in the Swiss health care system,”Journal of Affective Disorders, 122(3), May:224-231.

  • Barnhofer, T., & Crane, C. (2008). “Mindfulness-based cognitive therapy for depression and suicidality.” In Didonna (Ed.) Clinical Handbook of Mindfulness. New York. Springer.

  • Barnhofer et al. (2009). “Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study,”Behaviour Research and Therapy, May(47)5:366-373.

  • Bertschy, G.B. et. al. (2008), “Mindfulness based cognitive therapy: A randomized controlled study on its efficiency to reduce depressive relapse/recurrence,” Journal of Affective Disorders, Volume 107, Supplement 1, March 2008, Pages S59-S60.


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#4 Challenging isolation

Depression invites people to isolation and disconnection

Connections as essential healing and preventive factors


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Social Isolation is Becoming More Common

Social isolation is up and so are depression rates


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Social Isolation is Becoming More Common

Shared family dinners and family vacations are down over a third in the last 25 years


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Social Isolation is Becoming More Common

Having friends over to the house is down by 45% over the last 25 years


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Social Isolation is Becoming More Common

Participation in clubs and civic organizations is down by over 50% in the last 25 years


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Social Isolation is Becoming More Common

Church attendance is down by about a third since the 1960s


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Social Isolation is Becoming More Common

The average American has only two close friends


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Social Isolation is Becoming More Common

1 in 4 Americans report that they have no one to confide in


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Social Isolation is Becoming More Common

In 1990, more than 1 in 5 households were headed by a single parent; it is now about 1 in 3


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Social Isolation is Becoming More Common

6.27 million people in the U.S. lived alone in 1990 and that is expected to increase to 29 million by 2015


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Depression Invites Isolation

When people are depressed, they often pull away from others or put them off


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Being Connected Helps

People with five or more close friends (excluding family members) are 50 percent more likely to describe themselves as "very happy" than respondents with fewer


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How to translate this into clinical work

  • Encourage clients to keep, nurture and make social connections

  • Consider group treatment


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#5 A Future With Possibilities

  • Connecting to a future with meaning and hope

  • Often in depression, there is a collapse of future-mindedness and hope

  • We can help reconnect the person with future possibilities


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Future Pull

The farmhouse in my future


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Future Pull

  • Problems into preferences

  • Positive expectancy language

  • Letter from one’s future

  • Starting therapy from post-depression perspective


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#6 Restarting brain growth

The neurogenic/neuroatrophy hypothesis and how to use it in treatment


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The New Brain Science

  • Old view: Brain had fixed structure and set number of brain cells, which declined over the aging process and with damage from trauma

  • New view: Brain plasticity and neurogenesis

    • Brain can grow new cells and make new connections throughout life

    • Brain and body experience alters the structure and connections in the brain, strengthening, growing or weakening them and changing structure


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Neurogenic/Neuroatrophy Hypothesis

Stress suppresses neurogenesis in the hippocampus


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Neurogenic/Neuroatrophy Hypothesis

Experiments have also found evidence that the hippocampus shrinks in people who have had long-standing depression

  • Altair, C.A. et al. (2003). “Effects of electroconvulsive seizures and antidepressant drugs on brain-derived neurotrophic factor protein in rat brain,”Biological Psychiatry, 54(7):703-709.

  • Ruso-Neustadt, A.A. et al. (2004). “Hippocampal brain-derived neurotrophic factor expression following treatment with reboxetine, citalopram, and physical exercise,”Neuropsychopharmacology, 29(12):2189-2199.


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Neurogenic/Neuroatrophy Hypothesis

Antidepressants, on the other hand, encourage the birth of new brain cells


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Neurogenic/Neuroatrophy Hypothesis

  • Animals must take antidepressants for two or three weeks before they bump up the birth rate of brain cells, and the cells take maybe another two weeks to start functioning

  • That's consistent with the lag time antidepressants show before they lift mood in people


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Neurogenic/Neuroatrophy Hypothesis

If an antidepressant is given during a period of chronic stress, it prevents the decline in neurogenesis that normally occurs


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The mechanisms for brain cell growth (neurogenesis)

  • IGF-1 (insulin-like growth factor)

  • VEGF (vascular endothial growth factor)

  • BDNF (brain-derived neurotrophic factor) “Miracle Grow for the brain”


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Neurogenesis/Neuroatrophy Hypothesis

  • Postmortem studies have shown that depressed patients had decreased hippocampal and cortical BDNF levels

  • Several studies have shown increased BDNF when people are treated with anti-depressants for some time

  • Altair, C.A. (1999). “Neurotrophins and depression,” Trends in Pharmacological Science, 20(2):59-61.

  • Karege, F. et al. (2002). “Decreased serum brain-dreived neurotrophic factor levels in major depressed patients,”Psychiatry Research, 109(2):143-148.

  • Sen, S. et al. (2008). “Serum brain-derived neurotrophic factor, depression, and anti-depressant medications: meta-analyses and implications,”Biological Psychiatry, 64:527-532.


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Exercise and brain blood vessel growth

In people ages 60-80, those who aerobically exercised 3+ hours a week over the course of 10 years showed:

  • An increase in the number of large blood vessels in the cerebral region of the brain

  • An increase in blood flow in the 3 major cerebral arteries

  • The cerebral area controls consciousness, memory, initiation of activity, emotional response, language and word associations

  • Narrowing and loss of blood vessels may be associated with cognitive decline

  • Rahman, Feraz, et. al (2008). Study presented at Radiological Society of North America; UNC Chapel Hill researchers.


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SMILE(Standard Medical Intervention and Long Term Exercise)

156 adults, diagnosed w/Major Depression

Randomly assigned to 3 treatment groups

1) Exercise treatment

  • Exercise consisted of brisk walking, jogging or stationary bicycle riding 3x/week

  • 10 min. warm-up; 30-min. exercise; 5-minute cool down

    2) Zoloft treatment

    3) Combined treatment

    “Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder,” James A. Blumenthal, PhD et. al,Psychosomatic Medicine, 69:587-596 (2007).


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SMILE(Standard Medical Intervention and Long Term Exercise)

  • At the end of 4 months, 60-70% of the participants were “vastly improved” or “symptom-free” in all 3 conditions

  • On 10-month follow-up:

    • 38% of Zoloft condition subjects had recurrence

    • 31% of the combined condition had recurrence

    • 8% of the exercise only had recurrence (and people who continued to exercise were less likely as a group to have recurrence)

    • Hypothesis: Self-efficacy; brain growth


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SMILE(Standard Medical Intervention and Long Term Exercise)

How much exercise matters:

Every 50 minutes of exercise per week correlated with a 50% drop in depression levels

“Exercise and Pharmacotherapy in the Treatment of Major Depressive Disorder,” James A. Blumenthal, PhD et. al,Psychosomatic Medicine, 69:587-596 (2007).


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Exercise and Mood:Depression research

Two studies found:

  • People who participated in moderately intense aerobics, such as exercising on a treadmill or stationary bicycle - whether it was for three or five days per week - experienced a decline in depressive symptoms by an average of 47% after 12 weeks

  • Those in the low-intensity exercise groups showed a 30% reduction in symptoms

  • Exercise also helped people who were unresponsive to medications

    Trivedi, M.H., Greer, T.L., Grannemann, B.D., Chambliss, H.O., Jordan, A.N, “Exercise as an Augmentation Strategy for Treatment of Major Depression.”Journal of Psychiatric Practice, 12(4):205-13, 2006

    Andrea L. Dunn, Madhukar H. Trivedi, James B. Kampert, Camillia G. Clark and Heather O. Chambliss, “Exercise treatment for depression: Efficacy and dose response,”American Journal of Preventive Medicine, Volume 28, Issue 1, January 2005, Pages 1-8


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Exercise and Mood:Depression research

A Purdue University study found:

Middle-aged runners who had been running 3-5 times/week for 3-10 years were markedly less depressed than a matched comparison group.

D. Lobstein et al., “Depression as a Powerful Discriminator Between Physically Active and Sedentary Middle-Aged Men,” Journal of Psychosomatic Medicine, 27 (1983):69-76.


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ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly) Study

Cognitive/brain training that increased speed of processing in the elderly decreased the likeilhood of developing depression (compared with a control group) by 38% as measured one year out.

Fredric D. Wolinsky et. al. (2009). “The ACTIVE Cognitive Training Interventions and the Onset of and Recovery from Suspected Clinical Depression,”The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 64B(5):577-585


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Exercise improves mood in elderly

Seniors who had never exercised before experienced a mood-lifting effect (less depression and anxiety and better reported quality of life) from regular aerobic exercise (3X/week on alternate days for 6 months)

Antunes, H.K. et. al. (2005). “Depression, anxiety, and quality of life scores in seniors after an endurance exercise program,”Brasileira de Psiquiatria, 27(4):266-271.


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Exercise improves mood in elderly

Exercise worked as well as an antidepressant medication in relieving minor depression in seniors, and had the added effect of improving physical functioning (such as walking more briskly)

Brenes, G.A. et. al. (2007). “Treatment of minor depression in older adults: A pilot study comparing sertraline and exercise,”Aging and Mental Health, 11(1):61-68.


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Exercise and Mood:Depression research

A University of Virginia study found:

  • Exercise had the most profound mood-lifting effect on people who were depressed

  • The effect increased with the amount of exercise

  • The study also found reductions in anger and anxiety through exercise

    R. Brown et. al (1978). “The Prescription of Exercise for Depression,”Physician and Sportsmedicine, 6:34-49.


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Exercise and Moods:Depression research

Beware of “overtraining,” or exercising too much (as in anorexia and other compulsive problems)

The evidence shows that over-exercising (exercising several times a day at training levels that are at or near maximal) is correlated with depressed moods

W. Morgan et. al (1991). “Psychological Monitoring of Overtraining and Staleness,”British Journal of Sports Medicine, 12:146-59.


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How to translate this in clinical work

  • Consider doing “walking sessions”

  • Encourage clients/patients to move as much as they are able


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