Management of Depression

(بحث مرسل من صيدلانيه نوران سراج الدين)

What causes depression?

Most people assume that depression is caused by recent social or personal difficulties, but depression is caused by a range of internal and external factors. Research has shown that chronic problems, such as long-term unemployment or living with an abusive relationship, are more likely to cause depression than recent stressful situations.

Genetics play a part in whether you're likely to suffer from depression - you're also likely to share some personality traits with your parents. Types of personality trait that may lead to depression include:

• Lifelong worrier
• Perfectionist
• Sensitive to personal criticism
• Not assertive
• Low self-esteem
• Self-critical and negative
• Shy and socially anxious

There are also some medical triggers to depression. These include:

• Low thyroid function
• Brain injuries and disease, for example, stroke, epilepsy or Parkinson's disease.
• Some forms of cancer
• Some infectious diseases
• Blood vessel diseases of the brain due to diabetes and/or hypertension (high blood pressure)
• Some steroid or hormonal treatments
• Chronic pain
• Quitting smoking
• Drugs and alcohol

The average person has no idea how common depression is. While all of us have our occasional moods, it has been estimated that almost 10% of us will, at one time in our lives or another, experience clinical depression to the point where counseling, psychotherapy or psychiatric intervention is advisable.

Depression exacts a heavy toll on our society in terms of the costs of treatment, lost productivity both at home and on the job, and also in terms of those families and individuals whose lives have been disrupted or literally destroyed because the symptoms or the disorder were not identified or sufficiently managed rapidly enough.

How do I know if I'm depressed?
Probably the best way for you to figure out whether or not you are depressed is for you to talk with a counselor about what leads you to ask the question in the first place. On the other hand, if you are feeling down, most likely you also are feeling somewhat reluctant to make an appointment right away. Here are some things to look for in yourself to help you think about making an appointment. These items are headings from the Beck Depression Inventory, which is a psychological testing instrument that one of the counselors might have you take once you do come into counseling. The test's purpose is to help the counselor determine whether or not you are depressed, and if so, to what extent:

• Feelings of sadness
  Feeling "down" or "blue", especially if you cannot think of any particular reasons for feeling that way.
• Pessimism
  Habitually seeing the glass half-empty rather than half-full, thinking "if something can go wrong, it will," or that "Murphy was an optimist."
• Past failure
  Feeling like you have screwed up in life a lot more than other people.
• Loss of pleasure (anhedonia)
  Losing your sense of play and humor.
• Guilty feelings
  Spending a lot of time feeling "awful" about things you have done in the past that you now regret and that you can't make up for or correct.
• Punishment feelings
  Feeling like you're being punished in life or deserve to be punished in life for what you have done or for who you are.
• Self-dislike
  Constantly being down on yourself; viewing yourself as unacceptable, unlovable and/or contemptible.
• Self-criticalness
  Seeing yourself as at fault for everything that goes on in your life; criticizing yourself for every little thing.
• Suicidal thoughts or wishes
  Thinking you'd like to kill yourself if you could, thinking that "things will be better once I'm dead" or simply having thoughts of how being dead will somehow solve things for you in some way.
• Crying
  Feeling like you're constantly on the verge of tears or finding yourself crying outside of your prediction or control.
• Agitation
  Feeling like you just can't sit still, like you have to be caught up in one project or another constantly, like you will just burst if you weren't doing something all the time.
• Loss of interest
  Feeling like you "just don't care about anything or anybody anymore;" feeling like "whatever happens, happens, it doesn't matter."
• Indecisiveness
  Having trouble making up your mind, either about major items or about "every little thing."
• Worthlessness
  Thinking of yourself as somehow disposable in life; of no consequence to others and as utterly inferior.
• Loss of energy
  Feeling as though you don't have the stamina to do what you want to do in life, or feeling like you don't have "what it takes" to accomplish anything important at all.
• Changes in your sleeping pattern
  Sleeping in one way or another worse than you did in the past, so that going to bed is seen as something unpleasant rather than as something to look forward to.
• Irritability
  Feeling grouchy and in a bad mood a lot of the time and/or with most people. Feeling too angry to tolerate much of anything from acquaintances or friends.
• Changes in your appetite
  Any negative increase or decrease in your usual eating or appetite patterns.
• Having difficulty concentrating
  Finding it difficult to pay attention to anything for any length of time, finding yourself involuntarily daydreaming at inappropriate times, or feeling like a "space cadet" or an "airhead" a lot of the time.
• Tiredness or fatigue
  Feeling "burned out," "fried" or "wasted" throughout the day; feeling like you're "dragging" or as though "somebody drained my batteries" much of the time.

If you are significantly experiencing any of these symptoms, it's important for you to talk with a counselor about what you can do to resolve and manage these symptoms.

Grief is not depression
This is an important distinction to make. In healthy grief, you typically have lost someone or something very important to you, and you are adjusting to the loss. In those instances where we have lost a loved one, such as a parent, a close friend or a spouse, the grief reaction usually goes on for about two years. The first couple of weeks are the hardest, and the first year is punctuated by episodes of "riding an emotional roller coaster" of ups and downs, especially on holidays and special occasions that remind you of the loved one you have lost. It is pretty common in some instances for the grieving person to go through a series of morbid dreams if the person they lost was lost by death.

The second year is often hard, but the ups and downs of the emotional roller coaster are not as steep and the "anniversary reactions" triggered by the holidays are less intense. Usually by the end of two years the average individual has adjusted to the loss of the loved one and life goes on.

Especially in the beginning, it is important to manage one's grief appropriately, because unmanaged grief can easily turn into reactive depression. In some instances, it has been usual for well-meaning but misguided physicians or funeral home directors to suggest tranquilizing medications to "calm down" the grieving person. Frequently in the past the premature or unmanaged prescription of medications has covered up the grief reaction without resolving it, and the individual has become depressed, alcohol or substance abusing, or even suicidal as a result.

MTU students experiencing grief are strongly advised to come into Counseling Services as soon as possible and look at ways of managing their grief appropriately so that a depressive reaction is avoided and grades are maintained.

Seasonal affective disorder (S.A.D.)
A fairly large number of Michigan Tech students suffer annually from seasonal affective disorder, better known as S.A.D. or simply SAD.

It makes sense.

Houghton, the home of Michigan Tech., is located well to the north of most of the country. The sunlight comes down to us at a much lower angle than it comes down to most of the rest of the country, especially in the wintertime. Even though we can have some brilliantly sun shiny days during the depths of winter, much of the time the winter is marked by cloudiness, snow, artificial light and early sunset- late sunrise.

Because it gets so cold in the middle of winter and because the snow gets to be so deep, many students never really get outside except to slog through the blowing snow from one class to another. They spend too much time indoors studying for their classes and it quickly feels as though the walls are starting to close in.

The locals have a word for that. They call it "going shack-happy."

The combination of low natural light levels, severe winter weather and a tight restriction in one's mobility lean susceptible individuals towards that complex condition now known as seasonal affective disorder.

The true origins of S.A.D. are not fully understood, but they are thought to be centered on the triad of low light levels, hormonal vulnerability in certain individuals (the fluctuation of melatonin and seratonin levels in the brain are thought to play a significant role here) and environmental restrictions.

We may not know the full dimensions of seasonal affective disorder, but we can possibly help you out if you think you may suffer from it. Here at Counseling Services we have a "light box" which supplies full-spectrum light therapy. Light therapy has been shown to be extremely helpful in the treatment of seasonal affective disorder. For many students, that's all they need. They sign up to "sit under the light" for a half hour, once, twice or three times a week, and they do not experience the symptoms of SAD that they would were they not sitting under the light. For other students, counseling support may also be necessary, as they look at ways beyond light therapy to adjust to and cope with the emotional changes that come with every onset of wintertime.

If you have questions about SAD or think you may benefit from light therapy or counseling, call up and make an appointment. We'll be happy to talk with you.

The question of suicide...
For most people, suicide is a frightening issue to bring up. Especially for young adults, questions about suicide dovetail right in there with questions about what you want to do with your life, whether life in general or your life in particular has any intrinsic or ultimate meaning, and with questions over your basic worth as a person or your worth to a particular other person in your life

Regardless of anything else going on, if you are experiencing thoughts or feelings of suicide, or if you know of someone who tells you they are having suicidal thoughts, call Counseling Services immediately. These thoughts and feelings can be cleared up with prompt counseling attention.

Depression in Women

Women experience depression about twice as often as men.1 Many hormonal factors may contribute to the increased rate of depression in women-particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.

A recent NIMH study showed that in the case of severe premenstrual syndrome (PMS), women with a preexisting
vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were re-introduced, they again developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.6,7

Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and requires active intervention. Treatment by a sympathetic physician and the family's emotional support for the new mother are prime considerations in aiding her to recover her physical and mental well-being and her ability to care for and enjoy the infant.


Depression in Men

Although men are less likely to suffer from depression than women, three to four million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.

Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.2

Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or work site mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

Depression is not a disease limited to the adult population. Teenagers also suffer depression, which is a treatable illness. Depression in adolescence could best be understood as an illness when the feelings of depression persist and interfere with a child or adolescent's ability to function.

A significant percentage of children and adolescents suffer from depression at any given time. In my practice, I have seen this number growing at a rapid pace over the last few years. Children who are stressed, have experienced loss, or those who have attention-related learning, conduct or anxiety disorders, are at a higher risk for depression. Depression also tends to run in families.

SIGNS OF DEPRESSION IN YOUNG PEOPLE:
If one or more of the following signs of depression persist, parents should seek help for their children:
• Frequent sadness, feeling low or weepy
• Hopelessness
• Decreased interest in previously favorite activities
• Persistent boredom, low energy
• Increased social isolation, poor communication
• Worthlessness, low self-esteem
• Feelings of guilt
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Difficulty with relationships
• Frequent complaints of headaches and stomachaches
• Frequent absences from or poor performance in school
• Poor concentration
• Major change in eating and/or sleeping patterns
• Talk of or efforts to run away from home
• Thoughts or expressions of suicide or self-destructive behavior

A child who often played with friends may now spend more time alone and without interests. Things that the teenager enjoyed now bring little joy. Children and adolescents who are depressed may say they want to die or may talk about suicide. Depressed children and adolescents are at increased risk of suicide. Depressed adolescents may abuse alcohol or other drugs as a way to feel better.

Suicide among young people nationwide has increased dramatically in recent years. Each year in India, thousands of teenagers commit suicide. Shockingly, suicide is one of the leading causes of death for 15 to 24 year olds.

Adolescents experience strong feelings of stress, confusion, self-doubt, pressure to succeed and financial uncertainty, besides other fears while growing up. For some teenagers, parental divorce, starting a new family with stepparents and siblings, or even moving to a new place can be very unsettling, intensifying self-doubt. In a lot of these cases, suicide appears to the teenagers as a 'solution' to the problem they are currently facing.

Many symptoms of suicidal feelings are similar to those of depression. Parents should be aware of the following behavioral and emotional symptoms in adolescents who may attempt to kill themselves:
• Change in eating and sleeping habits
• Withdrawal from friends, family and regular activities
• Violent actions, rebellious behavior, or running away
• Drug and alcohol use
• Unusual neglect of personal appearance
• Marked personality change
• Persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork
• Frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue
• Loss of interest in pleasurable activities
• Not tolerating praise or rewards.

If a child or adolescent says: ''I want to kill myself'' or ''I'm going to commit suicide'', always take the statement seriously and seek evaluation from a child and adolescent psychiatrist or another physician. People often feel uncomfortable talking about death. However, directly asking the child or adolescent whether he or she is depressed or thinking about suicide can be helpful. Rather than 'putting thoughts in the child's head', such a question will provide assurance that somebody cares and will give the young person the chance to talk about problems.

If one or more of these signs occur, parents need to talk to their child about their concerns and seek professional help when the concerns persist. With support from family and professional treatment, children and teenagers who are suicidal can heal and return to a healthier path of development.

Managing depression in children and young people:
Depression and suicidal feelings are treatable mental disorders. The child or adolescent needs to have his or her illness recognized and diagnosed, and appropriate treatment plans developed. When parents are in doubt whether their child has a serious problem, a psychiatric examination can be helpful.

Managing depression in general:
Managing depression usually requires both professional help and a lot of hard work on your part. It usually takes a fair amount of time as well.

For the milder forms of depression, counseling may be all you need professionally to help you work through the grief, reactive depression or dysthymia you've been experiencing. Usually counseling will involve re-examining some of the painful experiences you've lived through, or will involve looking at your present difficult circumstances and determining what you can do to effectively remedy the situation. At first, counseling may simply involve talking about what's going on for an hour a week. Eventually, however, counseling will probably require you to additionally actively change your circumstances in one fashion or another. Moving to the action component of counseling usually is the most difficult, but once you begin, milder forms of depression usually begin to clear up rather readily.

The question of medications...
For the more severe or longer standing forms of depression, psychiatric assistance in the form of medications might also be necessary. It is important to realize that, for the most part, psychiatric medications do not "cure" depression. They help to "manage" it. For non-biologically-based depressions, medications help you *feel* better but do nothing to help you *get* better. In order to get better, you need to actively work in counseling and in your day to day activities to resolve the underlying unresolved problems which fuel the depressed feelings. For biologically-based or "endogenous" depressions, medications probably need to be taken on a life-long basis. Meeting regularly with your psychiatrist or family practice physician, as well as with a counselor, is probably going to be necessary in the same way that a diabetic needs to see his or her doctor on a regular basis in order to maintain a stable insulin level.

Physical activity management for depression

When people become depressed they often have no energy or motivation. As a result, people with depression become less active. People with severe depression may have difficulty with even simple things such as getting up and getting dressed in the morning.

Generally, the less you do the worse you feel. Therefore, it is important to increase your activity level by planning simple daily activities (eg, shopping, driving, gardening, writing letters, simple domestic tasks). Keep an activity diary! Do things with other people, too - they will help to motivate you when you do not feel like doing much.

Activity planning helps you to do things that give you a sense of achievement, and helps to keep you active. Maintaining physical activity and social contact can help to prevent the depression from getting worse. People who become depressed withdraw from their family and close friends. As a result, they usually have less opportunity to feel cared about and to care for others. A cycle of increasing social isolation then sets in. It is very important to continue to join in with family and close friends, and to accept invitations from others, even though you may not feel like it. People who are more socially isolated have an increased risk of developing depression and take longer to recover.

Physical activity doesn't have to mean going for a ten-mile run or doing a vigorous bout of circuit training - just going for a walk around the block or going to get a newspaper from the local shop can count.

How can you become more active?

• The first step is to create an activity plan that lists the activities you are going to do each day.
• Start by writing in your regular activities (showering, breakfast, lunch etc). Then try to fill in the gaps.
• Include at least one pleasant activity each day and one achievement activity.
• Schedule some physical activity for each morning and/ or late afternoon.
• Try to stick to your plan as closely as possible, but do not get upset if you cannot do so. If an activity runs overtime or cannot be completed, skip an activity and move onto the next one at the appointed time.

Ideas for pleasant activities
Adapt these and think up some of your own to suit your own tastes. At first you might not find these activities as pleasurable as once you might have done, but keep at them and you will begin to enjoy them once again.

• Bushwalk
• Surf
• Play golf
• Read a book
• Surf the Internet
• Write a letter
• Play cards
• Call in on a neighbour
• Take the kids to the park or play with them
• Treat yourself with small things: buy a new item of clothing or a bunch of flowers, have a bath or go to the beach and read a book for a while
• Put a CD on
• Cook something new
• Go to the cinema or to a museum
• Wander around a local flea market
• Plan ahead: go Christmas shopping, organise a dinner party, order some tickets to the theatre or to a sporting event or plan a weekend away. Planning ahead means that there's more to look forward to!

Staying well after depression

However your depression is treated, there are certain steps you can take to make sure that the illness does not come back. Once you have experienced an episode of depression, you are more likely to have a recurrence. Treating depression is more like managing diabetes or high blood pressure than treating a cold - it involves regular monitoring rather than a one-off "cure".

If you are taking medication to help you feel better, you must continue to do so for the recommended amount of time. Some general guides for the treatment of depression include:

• First ever depression - continue treatment for at least six to 12 months after recovery
• Two severe depressive episodes - continue treatment for at least two years after recovery
• Three or more severe depressive episodes - consider lifetime treatment.

Treatments depend on your specific problem and you. As well as medication for severe depression, they may include psychological addresses, education about preventing relapse and treatment of problems that are related to the depression, for example, alcoholism or anxiety.

The chance of future depression can be reduced by a few simple measures. These include:

• Continue with medication for as long as your doctor suggests (often six to 12 months).
• Identify those early warning symptoms which might suggest a recurrence - such as difficulty falling asleep, tearfulness, loss of appetite, increasing tiredness, social withdrawal, irritability, and increased anxiety
• Identify specific risk factors for relapse (eg, family stress, alcohol intake, social isolation)
• Engage in relevant psychological treatments (eg, cognitive behavioural therapy, interpersonal therapy)
• Reduce relevant work, family and financial stress
• Learn specific anxiety and stress reduction techniques
• Reduce your drug and alcohol intake
• Maintain your physical health. Eating a healthy, balanced diet and obtaining exercise can help to stabilise moods

Types of help available for depression

If you think you have a propblem with depression, or know someone who has, it is worth weighing up all of the treatment options that are available to you. One in five Australians has some form of mental health problem, and there are plenty of resources to help you feel better.

Family doctor
Your general practitioner is often a good first step in accessing help for a health problem (mental or physical). Some general practitioners may be equipped to manage your mental health themselves, while other general practitioners may refer you on to specialist help such as to a psychologist or psychiatrist. This usually depends upon the general practitioner’s level of understanding of mental health issues and/or the severity of your illness.

Psychiatrists
Psychiatrists are medical professionals who have the capacity to make medical as well as psychological assessments, conduct medical tests and prescribe medication. Typically, psychiatrists use psychological intervention (eg, cognitive behaviour therapy, interpersonal therapy) along with medication.

Psychologists Psychologists are health professionals who provide psychological intervention (psychotherapy) in the treatment of mental illness or psychological distress. Common types of psychotherapy are cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and psychoanalysis. Clinical psychologists are specialists, trained in the administration of CBT and IPT, and these therapies are deemed to be very effective in the treatment of mild to moderate depression and/or anxiety. Psychologists and clinical psychologists can not prescribe medication in Australia.

Public hospitals
Most public hospitals have a mental health unit attached. This means people with mental health problems can be treated by professionals employed by the hospital either as an inpatient or as an outpatient. When a person is experiencing severe depression, it might be necessary for them to spend a period of time in hospital.

Specialist community services
There are a number of services available in the community. You can access them by phoning your local council or you can find them in the White Pages.

Crisis Assessment and Treatment (CAT) teams
Crisis Assessment and Treatment (CAT) teams provide acute psychiatric care in the community to people experiencing a mental health crisis. The person can be assessed and treated in the community and therefore avoid an admission into hospital. It is not always possible to treat a person in the community, for example in cases where the person is potentially a danger either to themselves or to another person. In such cases, the person will be admitted into hospital.

Helpful pointers
The following points might be useful to consider when thinking about speaking to a health professional:

• If you are looking for a suitable doctor ask for a recommendation from your friends or colleagues
• If you do not feel comfortable with a doctor or other health professional, or suspect they are not managing your mental health effectively, choose another. Your local community centre should have a list of the local health professionals.
• When you visit your doctor, it might be helpful to write a list of your symptoms so you don’t forget.

It is important to give your doctor the full picture, so if you feel comfortable, it might be helpful to take a close friend or family member with you. If you have filled out the depression checklist or the anxiety checklist available from the link below, you could take this with you to show your doctor the symptoms you’ve been having.

The active management of depression - Clinical Update

While family physicians play a leading role in caring for patients with major depression, the quality of that care could be greatly improved. A 1997 to 1998 survey of a national sample of adults with depressive or anxiety disorders revealed that 83% of these patients visited a health care provider. (1) Of this total, 84% were treated by primary care clinicians, compared with 16% who were treated by mental health professionals. However, about 90% of those cared for by mental health professionals received treatment that met criteria for adequacy outlined in treatment guidelines, compared with 19% of those cared for by primary care professionals.

A critical role for family physicians is to integrate treatment of depression with that of other conditions, especially in light of the association of depression with a variety of chronic diseases. The Institute of Medicine has concluded that depression is strongly associated with the occurrence of, and death following, myocardial infarctions. (2) In diabetes, depression is associated with a 2% increase in glycosylated hemoglobin levels (3) and can predict occurrence of diabetic complications. Additionally, chronic illnesses may, in themselves, exacerbate depression several fold.

Alternative treatments for depression

Most people with depression try to manage their treatment themselves. Some common strategies like drinking alcohol or smoking cannabis are clearly unhelpful. Other people try alternative therapies or adjusting their life-cycle. Some activities like increased physical activity or attention to sleep patterns are clearly beneficial.

Alternative therapies for combatting depression that are backed by good evidence

·        St John’s Wort (Hypericum, discussed later)      

• Physical exercise
• Self-help books involving cognitive behaviour therapy
• Light therapy (for winter depression)

Alternative therapies for combatting depression that are backed by some evidence

• Acupuncture
• Light therapy (for non-seasonal depression)
• Massage therapy
• Negative air ionisation (for winter depression)
• Relaxation therapy
• SAMe - an amino acid that's found naturally in cells. (discussed later)
• Folate (found in leafy green vegetables)
• Yoga breathing exercises(discussed later)
• Prayer

Alternative therapies for combatting depression that are backed by poor evidence

• Ginseng (discussed later)
• Lemon balm
• Painkillers
• Vervain - a herbal remedy
• Colour therapy
• Chocolate

In the book Nawa Yogini Tantra(1), it states: “Depression is not so much a condition of having no energy, as a kind of psychic constipation blocking our energy flow.”

Anyone who has suffered from depression, as distinct from sometimes feeling miserable, may recognize the truth of this statement. The feelings of excessive tiredness, lifelessness and apathy, often accompanied by intense introversion and inferiority are characteristic of the condition. Truly it is a state of tamas, where the simplest task becomes daunting to a normally competent human being.

If we follow the yogic approach, we will not immediately look for the causes of this depression but, instead, look at the energetic state of the person. It is not so simple, but probably they are thinking too much and not doing sufficient physical exercise – whether that is in the form of physical work, sport, gardening or yogasanas. So, the first approach through yoga is to practise hatha yoga, to regain some balance between the 'ha' and the tha', pingala and ida nadis. We know that the aim of hatha yoga is to balance the flow of energy, prana, in these two nadis, so that neither the physical nor the mental faculty predominates. In the yogic management of depression, this is a central tenet.

Shatkarmas

It is logical (though not always practicable) to begin with the practice of shatkarmas, the cleansing practices, less for their physical effects in removing excess kapha and more for their energetic effects. Start with tongue cleaning, jihva dhauti or jihva shodhan(2),because this is acceptable for most people, seen merely an extension of their routine teeth cleaning. Practised correctly, jihva shodhan produces a gag-reflex, which raises energy immediately. Next I would teach the practice of jala neti(3), nasal cleansing, using a cool saline solution, rather than the normal warm solution. The mild shock to the system of the cool saline has an awakening effect on the brain, and the forced exhalations that follow (which are imperative to proper drying of the nasal chambers) are energizing.

Now it is necessary to consider whether the person experiences anxiety symptoms, in addition to depression. Clinically, the two states often go hand-in-hand; the person alternates between feeling inert and depressed then, for no apparent reason, extremely anxious and possibly manifesting panic attacks. (Allopathic medicine recognizes this syndrome, frequently prescribing combined anxiety-depression drugs.) Energetically, we might regard this condition as swinging between over-activity in ida and pingala nadis.

The next cleansing practice, kunjal kriya (vaman dhauti)(4) should normally be practised only by those who do not experience anxiety symptoms as a part of the depression. It involves the drinking and regurgitation of warm saline solution, which cleanses the stomach at a physical level. However, it is most valuable in the management of depression because it removes the energetic blocks which have formed as we have consistently repressed painful emotions.

In psychotherapeutic circles, it is widely acknowledged that depression is an outcome of repressed anger, and therapies such as Gestalt therapy enable the individual to externalize previously unexpressed anger. Thus, the huge amount of energy which was being utilized to repress the old anger is liberated for joyful living. Kunjal kriya works similarly and, since this practice bypasses cognition, it often is successful for those people who resist (or cannot afford) psychotherapy.

Clearly it is important to introduce these cleansing practices gradually, according to the needs, temperament and ideas of the person.

Asanas

Asanas form a very important part of the management program, especially the dynamic standing postures and the sequence surya namaskara. Strong backward-bending asanas such as bhujangasana, ushtrasana and dhanurasana are ideal because of their direct effect upon the adrenal glands and less directly on the thyroid gland. But, of course, this depends on the fitness and age of the person. Often, those with long-term mental health problems also have bodies that are stiff and otherwise unwell. So, in these cases, we need to begin asana learning with the conditioning practices of pawanmuktasana part 1(5), which will enable the practitioner to progress safely to the more powerful asanas at a later date.

Recently, scientific research has shown that all dynamic physical exercise releases endorphins; chemicals which affect the brain and enhance the mood (producing what is sometimes termed the 'feel good' factor). However, we know that yogasanas also have a much more profound effect on the whole body-mind complex.

Pranayama

Pranayama practices can contribute enormously to a person's sense of well-being by giving them the skills and confidence to control physiological responses to stress. It is important that the individual, as well as mastering the practices, understands which practice is to be used to address each mental state. For this purpose, I adopt the classification used in the book, Prana Pranayama Prana Vidya (6), which is easily comprehensible and memorable.

We begin with nadi shodhana, a balancing pranayama, which may be safely practised by everyone. It is quickly recognized as bringing about a calmer, more peaceful state and it helps people to understand the effects of nostril predominance on mental state. Further discussion of this pranayama may lead the practitioner to an elementary study of swara yoga and to choosing their activities according to which nostril is flowing at a given point in the day.

Ujjayi pranayama (simple form) is taught as the main tranquillizing pranayama. People with depression symptoms may not appear to need tranquillizing, but they often experience agitated states, especially at night. Those who suffer panic attacks and non-specific anxiety quickly come to appreciate the value of this practice, especially as it can be used at any time, in any place, without attracting attention.

Bhastrika and kapalbhati are the vitalizing pranayamas which enable the practitioner to raise their energy levels quickly and at will. For persons suffering from depression, this means that they can face the day instead of succumbing to their inclination to remain in bed. In conjunction with bandhas, these pranayamas are amongst the most effective in managing depression. (And, of course, the person must understand that these two pranayamas may increase agitation and therefore should be used judiciously.)

Psychophysiology

Yoga addresses the psychophysiology of a person; we know that prana pervades all levels of our being, from the annamaya kosha through to the manomaya and vijnanamaya koshas. The feelings of lifelessness and numbness, so characteristic of the depressed state, can be understood not as absence of energy, (which is how many depressed people describe themselves – “I'm always tired; I have no energy”) but as blocked energy or impaired energy flow. In Nawa Yogini Tantra, it states, “Wilhelm Reich pointed out that the checks and balances of the mind's energy were reflected in the body and that repression was expressed in psychophysical knots that he called 'muscle armour' and yogis call granthis. Although originally a defensive device to protect sensitive areas of the mind from further hurt, these knots are a kind of tourniquet, cutting the healthy flow of energy and blocking us off from whole sections of our being. Sensation is numbed and we become increasingly depleted persons.”

Bandhas

The practice of bandhas addresses the granthis. Moola bandha(7) lifts energy and begins the process of bringing repressed experiences into conscious awareness. Uddiyana bandha is effective in reducing the feeling of emptiness, so often experienced by depressed people. It is especially dramatic in managing post-natal depression, where the woman has physically 'lost' a part of herself; she has delivered a baby and now feels (consciously or unconsciously) empty, bereft. Because bandhas can only be satisfactorily practised in the early morning before eating or drinking, this may encourage the person to establish a yogic routine of morning practice. The benefits are immediately perceptible and provide the motivation to continue.

Changing the thought patterns

Motivation is one of the biggest hurdles for depressed persons to overcome; they may know and admit that regular yoga practice will enable them to feel better, but implementing it is often difficult for them. Hence, practices that take little time but produce an unmistakable improvement in mood are an invaluable source of motivation. Gradually, the enhanced mood leads the individual to adopt a more comprehensive yoga program, resulting in all-round improvement in health and well-being – and a cycle has been broken.

Also, when energy is unblocked and the mood is lighter, the habitual thinking processes change. Some schools of contemporary psychology purport that depressed individuals think wrongly; that they cease to perceive their positive attributes and dwell only on their feelings of inadequacy and shortcomings – hence the discrepancy which so often arises between the person's self-image and the perception held by others. How often the depressed person is told by friends and family, “You are a wonderful person, so talented and you achieve so much...,” yet the individual is unable to hear this, because (s)he is locked into thought patterns which exclude these external realities. Ironically, such well-intentioned comments often serve to increase, rather than reduce, feelings of alienation – and the person withdraws further into their private world of circular, self-denigrating thinking.

Relaxation

Relaxation plays an important part in yogic management of depression. It offers the possibility of respite from the incessant flow of negative thoughts. When wholly engaged in a systematic relaxation practice such as yoga nidra(8), the mind rests and is refreshed. The use of a carefully chosen sankalpa (personal resolution) during the practice will help the practitioner to grow in strength and self-esteem. Also, the decision to dedicate 30 minutes daily to this form of self-care is an important step in healing. It results in increased energy and reduced tiredness, and will probably be deemed enjoyable!

Meditation

Once the individual is practising hatha yoga to improve energy levels and achieve a better balance, then it becomes possible to begin looking at the causes of the depression, through the practice of meditation. (Sometimes depressed people want to learn meditation from the beginning, believing that it will solve their problems, but this is unlikely to be helpful because they are still too tamasic to practise meditation properly.)

The meditation practice of antar mouna(9) has proved to be consistently helpful in understanding the causes of depression. In this practice, after the initial phases of body stillness and sense withdrawal, the practitioner observes the activities of the mind. This is different from 'thinking' because, within a quiet meditative state, one adopts the stance of witness...making no judgements about the thoughts which arise spontaneously in the mind, simply watching and familiarizing oneself with the mental content and processes. Later stages of the practice work with thoughts, fears and memories which cause distress to the practitioner, thus eventually disempowering them and liberating the energy which was being used to keep them outside conscious awareness. Thus the depression truly starts to lift, being eliminated from the root.

Another meditative practice that is often beneficial in managing depression is trataka on a candle flame. The light of the flame stimulates the pineal gland. Understimulation of the pineal by light is now recognized in scientific circles as a significant contributor to seasonal affective disorder – SAD, or winter depression. Also, trataka develops willpower in the practitioner and this quality assists the depressed person in establishing regular practice, so necessary for recovery.

Lifestyle

There are many other considerations in helping people to overcome depressed states. Educating them in yogic diet is vital, since meat and eggs (especially) are very tamasic foods and therefore exacerbate depression. Sleep is a major topic – taking sufficient sleep, starting before midnight and rising early, may involve a real (and positive) change for some people. Self-awareness of how much sleep is needed is important; when people are depressed, they tend to sleep excessively, which compounds the problem. Lifestyle issues, such as the colours we wear and surround ourselves with; the vibrations of different types of music; our choice of television viewing; choice of the company we keep, are all major contributory factors in determining how we feel.

Awareness of moon phases and menstrual cycles (especially the inter-relation between the two) can help people to realize that their mood swings are influenced by external forces. Careful diary keeping can help us to predict and accept cyclical mood variations and to organize our activities in order to optimize our sense of satisfaction and well-being.

To summarize, the yogic approach to managing depression is to take the energetic view. By exploring and mastering the myriad ways in which it is possible to alter our energetic state, by understanding ways to manipulate our energies at will, we can reduce depressive states and gather the strength and willpower to embark on the next phase – that of examining and resolving the underlying causes of the depression.

Acupuncture & Depression