Depression and Anxiety
Written and researched by Bob Murray, PhD
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Telephone Therapy Can Be Successful for Depression
May 25, 2003
Three months after enrolling in a disease management program offered
by telephone, patients with acute depression were six times more likely
to have their symptoms reduced to a low level than those who received
the standard care of diagnosis and education about their condition.
Primary care doctors participating in the program were also more apt
to use nationally approved guidelines in treating their patients, say
David W Oslin, MD, of the University of Pennsylvania and colleagues
Treatment provided through the phone program included many more opportunities
for feedback and monitoring of patients as they continued with their care--a
strategy that had been tested previously in face-to-face follow-up treatments.
The new findings “suggest that beneficial results are possible when
delivering disease management exclusively by telephone,” Oslin says.
Phone contact between the patients and specially trained nurses was used
to support the primary care doctor in treating acute depression. The nurses
monitored symptoms and treatment outcomes at three-week intervals, reporting
the results back to each patient’s primary care doctor.
Although doctors were more likely to prescribe guideline-recommended
care for their patients in the phone program, the patients themselves
were not any more likely to follow their doctor’s orders than patients
receiving standard care, according to the researchers. “If we can
identify significant patient characteristics that predict non-adherence,
then an intervention or educational program could be directed to these
patients in order to improve their engagement in the management of their
depression,” Oslin says.
“Depression in primary care is a pressing public health problem.
More depressed patients of all ages are seen by primary care clinicians
than by specialty mental health providers,” according to Oslin.
What this study really shows is that as humans are relationship-based
animals it is relationships that are both the prime cause of depression
and its cure. BM
Read more in General Hospital Psychiatry
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Young Gay Men Are Anxious, Depressed and Ignorant of Their HIV Status
April 2, 2003
An alarming number of young gay men appear to be highly anxious and depressed,
expressing high levels of self-hatred and low self-esteem, according to
new research. And whilst they are aware of health warnings, the majority have
had unprotected sex and few know their current HIV/AIDS status, says the
study led by Dr Debra Bekerian of the University of East London's School of Psychology.
The report also suggests that young gays who claim to have been traumatised
in the past, perhaps through loss of a friend, abuse or violence, are
less likely to engage in unsafe sexual practices once they know their
current HIV status.
This suggests that trauma may have a protective effect
on health behaviour. Most of those interviewed for the study, in youth
clubs and groups in the UK, considered current health messages to be
too clinical and irrelevant to
situations in which young gays have sex. They suggested improvements,
including use of the Internet.
The 1980s saw an unprecedented number
of gay men dying of HIV and AIDS-related illnesses, and a subsequent
hard-hitting education campaign from the
Government and health authorities. Response from the gay community was
positive and reports of sexually transmitted infections fell rapidly.
The new study, however,
comes against recent evidence of an increase in reported infections among
young gay males between the ages of 18 and 29, with
occasional high-risk sex also spreading.
Gay males are becoming sexually
active as early as 14 years of age, and may not have the experience or
assertiveness to adopt safer sex, for example by using
a condom, says the report. So there is a fair chance of getting an infection
right from the start.
There is also less general interest in AIDS and HIV than
there was 20 years ago, with little mass media coverage given to the
topic, so that young gays assume these are diseases relevant to an older
generation. Other research also suggests
they feel it is "who you are" and not "what you do" which
decides levels of personal risk.
Said Dr Bekerian: "To the extent that these findings are a representative
sample, they suggest that young gays
are suffering from serious negative affect
and mental health issues and that some formal attention needs to be given
to this problem. "
It is worrying, says the report, that whilst most
gays questioned reported having had unprotected sex at least once,
they appeared complacent about possible effects on their health.
Read more on the Economic and Social Research Council website
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PTSD Common and Serious for Car Accident Victims
December 2, 2002
It is most frequently associated with combat veterans, victims of violent crimes or those caught up in natural disasters, but post-traumatic stress disorder (PTSD) is most prevalent among survivors of serious car accidents.
"PTSD occurs in about 28% of those who have experienced or witnessed a life-threatening event," said Gayle Beck, PhD, professor of psychology at the University at Buffalo and director of the university's Motor Vehicle Accident Clinic. "Serious car accidents are perhaps the most commonly experienced traumatic events in the United States," she said. "They injure 3 million Americans a year and kill 42,000."
PTSD is marked by clear and significant psychological and physical changes. Its symptoms in accident victims, added Beck, can be just as serious and debilitating as they are in combat veterans. "They have nightmares, flashbacks, sleep difficulties, feel jumpy and jittery, experience anxiety, fear of driving and social isolation," she said. "If untreated, about 30% of those affected will develop a chronic form of the disorder that will persist throughout their lives."
Beck said the therapeutic community after many years has finally recognized the frequency and seriousness of post-accident PTSD. "More people are being diagnosed and treated," Beck said, "but as the incidence rates go up, more and more insurance companies balk at paying for conventional treatment. To date, the most common and successful treatment used for all kinds of PTSD is individual therapy conducted by a highly trained professional."
"Insurance companies have been "skinnying up" reimbursements to psychologists and psychiatrists for years," she noted, "and want to limit their enrollees with PTSD to group therapy conducted by other kinds of therapists because it's cheaper for the companies."
Most clients with PTSD that we have seen have suffered from traumatic childhoods. The accident -- or the war or the natural disaster or the rape -- is a retriggering of those early events. In other words there are two stages to PTSD not one. BM
Read more in NewsRx.com
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Unmarried Mothers More Depressed
December 2, 2002
Researchers in the United States have also found that the absence of their natural father during childhood may leave some women prone to depression. The findings are based on a nationwide study of almost 1,000 women between 1979 and 1992.
Dr Ariel Kalil of the University of Chicago and Dr James Kunz of the University of Maryland looked at information collected as part of the US National Longitudinal Survey of Youth.
Women who took part in the survey answered questions that measured depressive symptoms, such as feelings of worthlessness or hopelessness, loneliness, loss of appetite, restless sleep and concentration problems. The survey indicated that women who gave birth outside marriage were most likely to become depressed in their late 20s. This applied to women who gave birth both before and after their 18th birthday.
The survey also suggested those whose natural fathers weren't living in the home, or who lived with their stepfather before the age of 14, were also more likely to become depressed. A high rate of depression was also found among women who had low self-esteem or who had poor verbal and math skills as teenagers.
The researchers suggested that the link between having a child outside marriage and depression could change in the years ahead, not least because fewer people are getting married. They said: "Perhaps as non-marital childbearing becomes more "normative" over time, the relationship between it and later-life depressive symptomatology will change in nature and strength." But they added: "We see this as a pressing issue for future research."
An estimated one in five people suffer depression at some point in their lives.
There is so much research coming out now to show that two-parent "traditional" families are far superior to one-parent families. Our research tends to support the old african proverb "It takes a village to raise a child." In our clinical experience we find that depression is very often the result of family break-up or parental absence. BM
Read more in Child Development
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Smaller Hippocampal Volume Predicts Vulnerability to Psychological Trauma
November 12, 2002
Research published in Nature has, perhaps, finally proved what a number of researchers, including ourselves, have been speculating was true for some time ("some time" in neurology circles is about 6 months). Extreme stress, for example from an abusive childhood, can cause damage to the hippocampus, a part of the brain dealing with memory and the control of emotion. They have also found that people suffering from post-traumatic stress disorder (PTSD) show the same pattern of damage. Their findings indicate that early stressful events lead to a situation in which the hippocampus suffers. This, in turn, leaves a person at risk for the later development of PTSD. They found, by studying the parents of PTSD sufferers and their identical but untraumatized twins, that the smaller hippocampus was not inherited.
Read more in Nature
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Weight-Loss Surgery Patients Have Depression, Anxiety Disorders
November 12, 2002
Most patients seeking radical gastric bypass surgery suffer from some form of mental health problem and should first be evaluated by a mental health worker, according to a study completed by psychologists and surgeons at the Center for Weight Reduction at Montefiore Medical Center.
"There is a high degree of psychopathology in this population, which could influence their ability to make informed consent and/or their reaction to the surgery and subsequent weight loss," said the authors in an article published in the professional journal Obesity Surgery.
The psychological aspect of obesity surgery is a little talked about topic, but is of increasing relevance today as the number of radical surgeries for obesity increases. In the article, the authors cite a significant amount of depression and anxiety disorders among those patients enrolled in the study. Of 115 surgical candidates, the Montefiore researchers discovered that 70 percent have a current or past mental disorder. More specifically, the candidates had "a lifetime prevalence rate of 56 percent" for "depressive disorders" (versus a lifetime prevalence of 17 percent for the general population). A further 17% suffered from anxiety disorders.
"These are significant findings," according to the report. "We tend to measure success in terms of weight loss alone. We have neglected to measure outcome in terms of other medical and psychological complications, satisfaction with surgery, nutritional intake, exercise level, measure of self-esteem, interpersonal functioning and work functioning. More studies are needed to further clarify which psychological factors play a role in these outcome variables."
Read more in Obesity Surgery
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People Who Recover From Major Depression Never Really Cured
November 12, 2002
A new study, published in the November '02 issue of the American Journal of Psychiatry, has identified an apparent "depression trait marker" in the brain that may explain why recovered patients remain vulnerable to another depressive episode. The finding could have important implications for developing more targeted treatments that help patients stay well longer and identifying family members at risk before they have even experienced a major depression.
Co-investigators Drs Mario Liotti and Helen Mayberg conducted the study at the
University of Texas Health Science Center in San Antonio. "We know that depressed patients, even after they've become well, have a tendency to remain highly sensitive to emotional stress," says Dr Mayberg,
Related research has shown that this emotional sensitivity may be a risk factor for depression recurrence. "This phenomenon is seen in recovered patients -- whether they're on maintenance medication or not, there remains a persistent vulnerability for further episodes. Now we've found a clue using brain imaging that may point to a depression trait marker that underlies this vulnerability."
This "depression trait marker" involves two brain regions: the subgenual cingulate and the medial frontal cortex. These brain regions are located in a band that runs deep within the frontal lobes, down the midline. The subgenual cingulate is an area previously identified as critical to the acute experience of intense sadness in healthy volunteers as well as a target of anti-depressant action in depressed patients.
The medial frontal regions have been previously linked to the cognitive aspects of emotional processing involving self-reference, reward and positive reinforcement. In both the recovered depressed patients as well as the acutely depressed patients, these brain areas now show changes in response to intense negative emotional stimuli in a way that is markedly different from that of healthy subjects.
In the study, 25 adults underwent a temporary mood provocation technique -- memory induced sadness. The participants comprised three groups: An experimental group of 10 women who had recovered from a major depression (nine of the 10 were on a maintenance anti-depressant, one was medication- free); An acute depression group of seven women who were actively suffering from a major depression (all, except one, were medication free during the study); and a healthy group of eight women with no personal or family history of depression.
At the same time as they were recalling an extremely sad experience in their life (for example, the death of a loved one), their brains were scanned using positron emission tomography (PET), which consists of computerized multi-colored images showing where maximum activity (blood flow) is occurring.
Mayberg, Liotti and colleagues at the University of Texas had earlier identified a "see-saw"
relationship -- increases in one set of regions with simultaneous decreases in the others -- between the emotional (limbic) and cognitive (cortical) areas of the brain when healthy subjects go from a neutral to an acute sad state. The reverse pattern -- limbic decreases, cortical increases -- was seen as depressed patients were successfully treated with anti-depressants.
In this latest extension of this work, fully recovered depressed patients (who had been well for over a year) and actively depressed patients -- while showing similar changes in many regions seen in healthy subjects -- also show several "significant differences." Unlike never-depressed control subjects, depressed patients fail to show the expected increases in the subgenual cingulate. More interesting, there were additional, unique decreases in activity in the medial frontal cortex seen in the depressed subjects, that did not occur in the control group. These medial frontal decreases in brain activity in the fully recovered patients mimic the more chronic metabolic abnormalities previously described in severely depressed patients who are not responsive to medication.
This discovery, says Drs Mayberg and Liotti, is helping to zero in on the subtleties of depression recovery and the brain regions that remain vulnerable to acute environmental stressors, despite highly effective treatment. "We think of these abnormal change patterns as a snapshot of the initial brain responses to acute stress in depressed patients -- a pattern that appears similar whether patients are currently ill or fully recovered -- suggesting a more general depression trait marker," adds Dr Liotti.
This information may prove critical in helping researchers and clinicians in their quest to find new drug, cognitive and combination therapies for patients that will prevent recurrence of depression. It may also help to identify patients' family members at risk of major depression, so they can be treated before they become sick.
We would say that any therapy must help the client create specific kinds of supportive, lasting relationships to cushion the effect of triggers that might plunge the person back into depression. Medication and cognitive therapy have been shown not to work in the long-term, because they do not affect the underlying problems in various regions of the brain, nor help the sufferer address the causes of the depression. AF
Read more in American Journal of Psychiatry
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Suicides Up When Conservatives in Power
October 22, 2002
Research done by a team led by Professor R Taylor of the University of Sydney has come up with a surprising fact: more people commit suicide when Liberal (conservative) governments are in power at both the State and Federal level than when the Labor Party (social democratic) is in power. They looked at the total number of suicides recorded for the years from Federation in 1901 to 1998 and corelated the data with the political parties in power at the State and Federal level during that time. They found that almost twice as many people took their lives when the Libs were in power. The reasons might have something to do with a sense that the Labor Party would look after them better and that they had more of an economic future under a more socialist leadership.
Read more in the Journal of Epidemiology and Community Health
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The Anxious Generation
October 22, 2002
Two recent meta-analytic studies involving thousands of children and college students show that anxiety has increased substantially since the 1950's. In fact, the studies find that anxiety has increased so much that typical schoolchildren during the 1980's reported more anxiety than child psychiatric patients did during the 1950's. The findings appear in the Journal of Personality and Social Psychology.
"The results of the study suggest that cases of depression will continue to increase in the coming decades, as anxiety tends to predispose people to depression," says psychologist and study author Jean M Twenge, PhD, of Case Western Reserve University. She adds that other implications of the findings suggest that alcohol and drug abuse will continue to be an increasing problem too, because anxiety usually precedes the onset of substance abuse.
There are also implications for physical health. "Research has found that anxious people have a higher mortality rate, most likely because anxiety has been linked to higher occurrences of asthma, irritable bowel syndrome, ulcers, inflammatory bowel disease and coronary heart disease," said Dr Twenge.
The type of anxiety looked at in these studies is known as trait anxiety, the relatively stable individual differences in anxiety-proneness, which is different than state anxiety, a temporary emotion experienced due to a particular situation. In the first study, anxiety scores from 170 samples of American college students (representing 40,192 students) were analyzed from research conducted between 1952 to 1993. The second study looked at anxiety scores during the same years in 99 samples of children (representing 12,056 children, ages 9 - 17). Both studies show a significantly large increase in anxiety levels, providing more evidence for what some authors have called "the age of anxiety."
Why the increase in anxiety? In both studies, anxiety levels are associated with low social connectedness and high environmental threat. During the study period, social connectedness decreased because of higher divorce rates, more people living alone and a decline in trust in other people. The author says many of these changes involve greater individualism, but she says there can be a down side to this. "Our greater autonomy may lead to increased challenges and excitement, but it also leads to greater isolation from others, more threats to our bodies and minds, and thus higher levels of anxiety," said Dr Twenge.
Most threats also increased during the study period, including violent crime, worries about nuclear war and fear of diseases such as AIDS. The study also cites increased media coverage as a source of a greater perception of environmental threat since the 1950's. Since the study ended in 1993, some of these environmental threats have declined, including crime rates and worries about nuclear war, which are good signs for stopping or reversing increases in anxiety, according to Dr Twenge.
Terrorism, unemployment and the threat of rogue states, on the other hand, has increased.
What's more, she says, social connectedness has not improved very much since the early 1990's. "Although divorce rates have decreased somewhat, the percentage of people living alone continues to increase, and levels of trust are still declining," said Dr Twenge. "Until people feel both safe and connected to others, anxiety is likely to remain high."
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Job Loss Can Lead to Downward Spiral of Depression and Poor Health
October 22, 2002
With world-wide unemployment increasing, more attention is being focussed on the plight of the unemployed. A new report, published in the Journal of Occupational Health Psychology, states that unemployment can start a vicious cycle of depression, loss of personal control, decreased emotional functioning and poorer physical health.
The authors came to this conclusion from interviewing 756 recently unemployed job seekers. The subjects had been unemployed for less than 13 weeks, were actively looking for a job and were not expecting to retire within the next two years. Their average age was 36 years old. Forty-one percent were male and 59 percent were female. Seventy-five percent were White, 21 percent were African American and three percent were from other ethnic groups. Fifty-two percent of the sample were married or lived with a romantic partner. Their education varied: 9 percent had not completed high school; 32 percent had completed high school; 36 percent had some college education; 11 percent had completed four years of college and 11 percent had completed more than four years of college.
At the beginning of the study, the participants rated their current and anticipated financial strain, answered questionnaires concerning depression, personal control, health and emotional functioning. They also responded to these questions at six months and then again at two years.
The results show that this chain of adversity (job loss-financial strain-depression-personal control-emotional functioning-physical health) appears to continue over two years, suggesting "that even reversible life events such as job loss can have lasting effects on those who experience them." At the end of two years, 71 percent were re-employed, working at least 20 hours or more per week but still reported the negative effects of their job loss.
These findings suggest that increases in depression and loss of personal control with those who lose their jobs can have adverse affects on health and emotional functioning for longer than the initial triggering event of job loss, possibly interfering with finding another job, said Dr. Price. Professionals working with suddenly unemployed people should be aware of this chain of events and be ready to help these individuals improve their mental health so they better their chances of re-employment and interrupt the downward cycle.
This study fits in with what we and other evolutionary psychologists have been saying for some time: that job loss, especially among males, leads to a devastating loss of status coupled with an exclusion from the tribe. This latter would be the worst thing that could happen to our hunter-gatherer ancestors. BM
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About the Author
Dr Bob Murray is a widely published psychologist and expert on emotional health and optimal relationships. Together with his wife and long-term collaborator Alicia Fortinberry, he is founder of the highly successful Uplift Program, and author of Raising an Optimistic Child (McGraw-Hill, 2006) and Creating Optimism (McGraw-Hill, 2004).
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