Seasonal Affective Disorder

It’s that time of year – the clocks have gone back, it’s cold, and already getting dark on our commute home. Whilst many people moan about this time of year, for some it can trigger symptoms of low mood and depression.

Seasonal Affective Disorder is defined as “a type of depression that comes and goes in a seasonal pattern.” (NHS Choices). It’s typically worse from December to February, getting better in spring and summer. For SAD to be diagnosed, there has to be clear evidence of worsening symptoms during winter, which can’t be explained by other circumstances (DSM-IV). In addition, there needs to be evidence for part or full remission during the summer months. Symptoms of SAD are similar to those of depression: low motivation and self-esteem, sleep problems, changes in appetite, withdrawing from social interactions and persistent negative thoughts.

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Estimates of the prevalence of SAD range from 0 – 9.4% of the population, depending on who is being studied (Magnusson, 2000). One study compared rates of SAD at 4 different latitudes in the USA and found that is was most common in the northern latitudes (Rosen et al, 1990), which would be expected as SAD can be triggered by lower levels of natural light. This study also found higher rates of SAD in females than males (this finding is in line with overall levels of depression between men and women). It is thought to be caused by the lack of sunlight in winter months disrupting our circadian rhythm, which can be described as our internal body clock. This can affect the serotonin system in the brain, which is responsible in part for mood regulation.

There are various different treatment options for SAD, including light therapy, cognitive behavioural therapy, or antidepressants (Lurie et al, 2006). I’ve spoken about CBT before on this blog (see here for more information), so today I’ll just focus on light therapy and antidepressants as treatments for SAD.

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Light therapy involves sitting by a specialised lamp, which emits a specified wavelength and brightness of light (at least 2500 lux). It is thought to work by encouraging the brain to produce serotonin – a neurotransmitter which is linked to feeling happy. Sitting by a lamp for 30 minutes to an hour each morning is the recommended ‘dose’ of light (NHS.uk). One meta-analysis has shown that light therapy is as effective as drug therapy in treating SAD (Golden et al, 2005).

Some antidepressants also work by increasing our serotonin levels. Known as SSRIs (selective serotonin reuptake inhibitors), they work by stopping as much serotonin from being reabsorbed at synapses in the brain and therefore leading to an increase in our mood. For antidepressants to be optimally effective in SAD, the NHS recommend starting to take them before winter and continue until spring.

 

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Orthorexia – a new type of eating disorder?

You might have heard some of the negativity in the press recently about so called ‘clean eating’ and it’s advocates, who promote a lifestyle which involves cutting out any processed food and often entire food groups (gluten/dairy etc). This is not because of any medical reason, but simply just to be as ‘healthy’ as possible. I’m not going to go anymore into the debate around clean eating today (there’s too much to say, and several people have done it already) but I’ve mentioned it here as it has been linked to a rise in a condition known as orthorexia.

Orthorexia nervosa (so called by Steven Bratman, 1996) is characterised by a fixation with healthy food consumption. More than just dieting, sufferers will become obsessed with healthy food, and food will become preoccupying and a source of anxiety. Other problems often caused by this disorder include social isolation due to having to have complete control over their food intake, and some nutrient deficiencies caused by an extremely limited diet.

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image from http://www.thefullhelping.com/neda-week-2014-considering-orthorexia

People with orthorexia (like some who ‘eat clean’) will often cut whole food groups or types of food out of their diet, thinking this will benefit their health. Common foods to be avoided are those which include artificial colours, flavours or preservatives, or foods perceived as containing too much sugar, or salt (Catalina et al., 2005). Orthorexics will also develop strict rules about food, which may also extend to rituals around food preparation (Chaki et al, 2013).

However, despite it’s increasing recognition, orthorexia isn’t listed as an official disorder by the DSM-V diagnostic manual for mental illness. As it is a relatively new disorder, research on orthorexia is lacking compared to other eating disorders such as anorexia or bulimia. There is some debate about whether orthorexia is a subtype of one of these existing eating disorders (Zamora et al, 2005), an eating disorder in it’s own right (Bratman & Knight, 2000), or a type of obsessive-compulsive disorder (e.g. Mathieu, 2005). Alternatively, some researchers view it as a combination of the above e.g. Brytek-Matera (2012) who describes orthorexia as “a disturbed eating habit which is connected with obsessive-compulsive symptoms.”

As researchers are still unclear how to categorise orthorexia, it is unsurprising it hasn’t yet made it in the DSM-V. However, despite it’s absence, Bratman & Knight (2000) have developed some guidelines for diagnosing orthorexia. These include:

  • preparing healthy food overtaking other activities in life, with sufferers spending over 3 hours a day thinking about or preparing food
  • following a very strict and restrictive diet plan
  • a healthy diet becoming linked to self-esteem, and feelings over superiority over others who do not follow such a strict regime
  • the nutritional value of a meal becoming more important than it’s taste or the joy from eating it

Orthorexia can be treated successfully, with a combination of cognitive behaviour therapy and medication such as SSRIs (a type of antidepressant) being shown to be effective in some cases (Mathieu, 2005). This study also suggested that orthorexics responded better to treatment than suffers of other eating disorders, perhaps due to their concerns and increased awareness about their health.

There is no question that more research needs to be done to establish more data on people living with this condition, which will enable preventative measures and effective treatments to be developed.

 

Prevention is better than cure – Youth Mental Health in the UK

In Theresa May’s recent speech to parliament she stated that she wanted to end the stigma of mental illness and improve the state of mental healthcare in the UK. As a researcher into mental health services for children and adolescents, I hear often about the struggle parents have to get an appointment for their child to be seen by a psychologist, or the problems they face when care ends at 16-18, without the smooth transition to adult services enabling continuity of care.
Whilst it is vital that more money is spent on the NHS as a whole (recent talks of ‘crisis’ in A&E departments shows the obvious need for more resources), money which is promised to mental health services cannot be diverted to other areas which are struggling. These areas are definitely important, but they should not be funded to the detriment of youth mental health services.
Research by Young Minds (2014) found that 77% of NHS Trusts who responded had cut or frozen their Child and Adolescent Mental Health Service (CAMHS) funding between 2013 and 2015. Significantly, demand for these services increased over this time. This increase reflects a general trend over the last 20 or so years, for example the number of 15-16 year olds with depression nearly doubled between the 1980s and 2000s, and the number of young people being admitted to hospital for self harm has gone up by a massive 68% in the last 10 years (http://www.youngminds.org.uk/training_services/policy/mental_health_statistics).
Current services do not meet the need for care, with up to one in every four or five teenagers thought to have a mental illness. In a typical school, this would be around 3 in each classroom in the UK. With 75% of mental illness having an onset before the age of 24 (Kessler et al, 2005), it is vital that young people can access the services they need during this critical time in their development.
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As mentioned above, care at CAMHS often ends when a young person is between the ages of 16 and 18. There are separate services for children and adults (CAMHS, versus AMHS) and this can represent a significant disruption of care. Young people have to move to a new adult service, in a new location and form a relationship with new healthcare professionals.  Previous research has found that only 4% of patients experienced an optimal transition (Singh et al 2010). Problems identified included a shortfall in time spent planning for transition, inadequate information transfer, and poor continuity of care. There may not even be an appropriate adult service in the local area which the young person can move to, for example in the case of autism or attention deficit disorder.
I am a researcher on the Milestone Project, an EU funded study currently investigating transition in nine different countries in Europe. My role involves interviewing young people and parents about their experiences of mental health services in the UK, and following them up over a period of time to see what happens to them when they leave CAMHS. The results of this study won’t be ready for some time, however it is clear to me that more needs to be invested into improving access for young people to mental health services.

Behavioural Activation

This week’s post is about a technique used as part of cognitive behavioural therapy for people with depression. As you probably know already, symptoms of depression include low mood, low self-esteem, feelings of anxiety and helplessness, and having low motivation and interest in activities which they previously enjoyed.

Behavioural activation focuses on the ‘B’ of the CBT model, in this case on the last symptom in particular – the withdrawal from usual activities and friends. For example, they may start to avoid social engagement and ignore invites from friends or make excuses as to why they can’t meet up, whereas before they would have been happy to go. Although in the short term this avoidance causes a temporary relief, such as a lowering of anxiety, it simply reinforces feelings of low mood or low self-esteem. This maintenance of the condition is illustrated by this diagram below:

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Therefore, in order to break this cycle, behavioural activation aims to change the unhelpful behaviours which continue the cycle of low mood. It does this by gradually building up activities that the person can do, which is turn will improve their mood, and lead eventually to them getting back to activities they used to enjoy. This progression is important, as the change in mood is needed before larger behavioural changes can occur.

Key features of Behavioural Activation are as follows (taken from Jacobson et al, 2001):

  • Firstly, the model is presented to patients by their clinician, who explain a bit about it and why it works. This is called a treatment ‘rationale’ and it is important for the patient to feel confident that this will work. A good relationship and trust with the therapist is also important.
  • Developing treatment goals through collaboration between the patient and the therapist – these goals are new behaviours rather than moods or emotions.
  • Analysis of causes and maintenance factors of the depression
  • Graded task assignment – e.g. starting with something small such as walking to the corner shop. This is scheduled in between sessions, and a hierarchy is discussed with the therapist.
  • Establishing a routine, in the hope this results in improved mood.

Ultimately, the aim of Behavioural Activation is to help the patient re-engage and find joy in activities which they have been avoiding. This will raise mood, and therefore help someone recover from depression.

Why more money needs to be spent on improving access to mental health treatments

This week in the UK is Mental Health Awareness Week, so today’s post will be a bit different – what are the main issues about treating mental illness in our society, and how can access to therapy be improved?

Firstly: not enough money is being spent to improve access to mental health services in the UK. Fact. This means not everyone who needs access to treatment gets it, which, as well as having a massive impact on society, has an extreme effect on our economy too.

The statistics are striking:  only 25% of people with mental illness are in treatment, compared to almost 100% of people with physical health issues (Layard et al, 2012). And mental illness isn’t rare – the World Health Organisation found that mental illness makes up about 40% of all illness in developed countries. In the UK, 15% of the population of the UK suffer from anxiety or depression, but only 5% of those are in treatment (Depression Report, 2005).

Morbidity among people under age 65
Morbidity among people under age 65

And why are these individuals not receiving treatment? A report carried out by several mental health charities found that 1 in 4 primary care organisations do not offer Cognitive Behavioural Therapy – the treatment recommended by NICE for all anxiety disorders and depression. It is therefore clear that more needs to be done to improve access to therapy in the UK.

However, once a patient has been offered therapy, the problems of lack of funding do not go away. Waiting lists can be as long as several months, by which the problems could have got worse. This is another area where there is a massive disparity between mental and physical health services.

Therefore, it seems obvious that more money should be invested in mental health services within the NHS. This comes at a time where the NHS budget is stretched to the limit, and the government are looking at cutting funds to public services. And here’s the clever bit: improving access in mental health services would pay for itself. 

Let’s look at the economic cost of mental illness in the UK. In 2005, it was estimated that anxiety and depression cost the UK about £17 billion per year. About half of disability benefits are paid to people with mental illness. One study found that less than 25% of people with long term mental illness have a job, compared to about 75% of the rest of the working-age population. Therefore, this results in a massive loss of revenue from taxes, as well as increased expenditure on benefits and sick pay.

Even when people are at work, mental illness can reduce productivity and so cost the company money. A NICE study found that improving management of mental health in the workplace could save 30% of reduced productivity and sick pay costs. If a company has 1,000 employees, this equates to a saving of £250,000 per year.

Mental health also has a significant impact on our physical health, which causes more pressure on the health service. Hutter et al (2010) found that individuals with mental health problems use 60% more physical health services than people who are equally ill but do not have mental health problems. This costs the NHS about £10 billion per year. These figures are striking, and show more money, not less, needs to be invested in mental health services.

The massive economic costs of mental illness are clear, but what about savings from improving access to treatment? Layard et al (2007) found that its costs £630 to treat a patient, but this leads to £4,700 in benefits to society in the form of more people off disability benefits and back as work, so paying more taxes, and less spent on physical health services and sick days.

Fortunately, things are being done to make mental health treatment more accessible. For example, Improving Access to Psychological Therapies (IAPT), which aims to train more therapists for specialised local services. So far, this initiative has treated about 756,000 patients a year, with 45% recovering completely, 60% showing a reduction in symptoms, and 5% being well enough to come off sick pay and benefits and return to work.

This just shows the positive impact of expanding mental health services in the UK, and making treatment available for those who need it. At a time when the country is undergoing a change in government, these issues need to be remembered and prioritised. Even with cuts, and less money available, these statistics show that more money, not less, needs to be spent on mental health services in the UK.

PTSD

Post – traumatic stress disorder, or PTSD is a type of anxiety disorder which is characterised by:

  • reexperiencing the trauma (intrusive thoughts)
  • avoidance and numbing
  • increased arousal

It has a lifetime prevalence of about 8%, and is more likely to occur in women than men.

It differs from other anxiety disorders as it is anxiety about something which has happened in the past, whereas other ADs are about something which could happen in the future.

PTSD

This has been explained by the Cognitive Theory of PTSD (Ehlers & Clark, 2000), which states that the sufferer views the traumatic event in a way which produces a sense of serious current threat – they believe they are still in danger.

This is caused by 2 processes:

  • appraisal of the trauma
  • the nature of the traumatic memory and its link to other autobiographical memories.

They could believe they are still in danger as they could interpret the world as being a very dangerous place, or thinking that it was something about them in person that caused the traumatic event to happen.

These processes generate situational fear and avoidance, and therefore maintain fear and anxiety.

The 2nd process which contributes to anxiety is that the memory of the trauma is often poorly elaborated – it is muddled up and not integrated with other past memories. Foa & Riggs (1993) found that sufferers of PTSD can have difficulty intentionally remembering the traumatic event, but have regular involuntary ‘flashbacks’ which are very vivid and emotional. These memories are experienced as being in the present, so act as a source of current threat.

Cognitive therapy for PTSD therefore aims to change the individual’s appraisal of the trauma, so they don’t think the threat is current, as well an integrating the memory into other past experiences. It also encourages sufferers not to try and repress the intrusive memories, as this can actually have the opposite effect and make them think about it more. Finally, it aims to reduce safety behaviours such as avoiding reminders of the trauma e.g. not travelling by car after being in a car accident.

Cognitive Behavioural Therapy is the NICE recommended therapy for PTSD and has been shown to be more successful than other therapies such as drugs or counselling.

 

Thank you for reading!

Panic Disorder

Panic disorder is a type of anxiety disorder which is characterised by recurring panic attacks. A panic attack is a brief period of intense discomfort and anxiety, and can cause symptoms like breathlessness and palpitations. During a panic attack, the individual will typically have thoughts such as ‘I’m going mad’ or ‘I’m having a heart attack’ and as a result, can avoid situations which they believe cause the attacks, such as exercising or going to crowded place.

It is relatively common with a lifetime prevalence of about 3.5%.

But what actually causes the panic attacks? It has been argued by some researchers (e.g Clark, 1996) that people with panic disorder interpret normal internal physiological changes, such as heart beat slowing down or getting faster, as a sign that something is seriously wrong with them. These individuals are biased to interpret signals as negative, which increases anxiety and leads to panic – something clearly shown by the flow chart below:

panic-disorder-symptoms

An experiment by Rapee et al (1986) shows how a negative bias causes panic. Participants with panic disorder were asked to breathe in a substance of 50% oxygen and 50% carbon dioxide. Half of the participants were given a thorough explanation of the process and any side effects, while the other half were not given this information. They found that the group which were given the information panicked less and had fewer catastrophic thoughts than the group who were not given the information. This therefore provides evidence to suggest that it is the negative interpretation which causes anxiety and panic – if the side effects were attributed to the procedure then this does not occur.

But why is panic disorder so persistent? If the sufferer thinks they are going to have a heart attack every time they have a panic attack, but this doesn’t happen, why don’t they realise that it is extremely unlikely that the event will actually occur?
The answer to this is that the individual engages in ‘safety behaviours’ which prevent them from learning that the situation is not harmful. For example, if they think they are going to have a heart attack, they will sit down and be very still. When the heart attack doesn’t happen, they think that its because of the fact they sat down, not the fact that they were never going to have one anyway – to them it is a ‘near miss’.

Knowing that safety behaviours contribute to the disorder, one of the main steps in treatment is removing them. This allows people to realise that they are not in a harmful situation, and allows for the therapist to help them restructure their negative thoughts into ones that are more realistic.