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Article 1 – David KatoArticle 2 – David Dove
The following article is based on information kindly supplied by
David Kato PhD, DHP, MIAH, MAPHP, Cert.H, Clinical Hypnotherapist / Psychotherapist.
of the Bristol Hypnotherapy Clinic www.depression-bristol.co.uk and www.depression-therapist.co.uk
DEPRESSION – a Cognitive Behavioural approach
Any person, be they young or old, male or female, can become depressed. Depression is increasing in all age groups, but particularly in the younger teenage group. Females tend to experience depression twice as frequently as males, and depression is estimated to be around 40% more common in children who have grown up with a depressed parent.
There have been many misconceived ideas about depressed people; perhaps that they are weak, or just feel sorry for themselves. Sometimes they are told to ‘snap out of it’ or ‘there are other people worse off than you.’ This is certainly not helpful and often makes the person feel guilty and even worse about their condition.
Depression has many causes, and therefore has many viable avenues of treatment. Clients, whether they are mildly or severely depressed, can find themselves in situations that are painful to them, and they need help to find a way out.
Depression can affect you physically, causing problems such as eating too much or too little; sleep disturbance; a lowered sex drive; decrease of pleasure or interest in things; fatigue and anxiety. Cognitively, depression can affect your ability to think clearly, making it difficult to concentrate. Memory may suffer, and there can be errors in judgement and decision making.
General day to day living has become much more stressful for some people. There have been many changes in society including higher divorce or separation rates and the general break-up of families; job insecurity; or even thinking you are too fat or too thin. There can be pressures on children to do better and better at school, even with the ever increasing array of subjects they have to study.
All these things can lead to despair and frustration, causing feelings of anxiety, helplessness or hopelessness. Of course not everyone who experiences these problems or stresses becomes depressed. However it is thought that approximately 50% of depressed people go untreated because either they don’t know they are depressed, or a consultation with a doctor fails to diagnose their depression.
There may also be underlying medical or psychological disorders which can create depression.
Biochemistry can play an important part, but the role of genetic make-up in causing biochemical imbalances (which can create depression) has not been fully established. No specific depression gene has been found.
We are biological creatures and therefore sensitive to the environment, family and cultural influences. Most people overestimate the biochemistry factor when evidence is far stronger for depression having its origins in the way people think about, and respond to, life experiences.
Imbalances of substances such as serotonin, nor-adrenaline, and dopamine, usually return to normal levels in the body, when there has been a successful interaction with psychotherapy for the treatment of depression. Usually there is no further need to take any medication to correct such an imbalance. This suggests that the imbalance is the body’s physical response to psychological depression, rather than the other way around.
Sociology. There is an established understanding that family environment can have relevance in producing depression. Learnt responses from a depressed parent or other family member can produce negative responses in a child, which can stay with it into later life.
Everyday life is now a faster and more complex, with higher demands being placed on the individual. Jobs are not as secure as they once were. Hours spent watching TV or on the Internet can result in poor socialisation.
Anti-depressant drugs will often suppress underlying problems, only to find when the patient stops taking the drug, they become depressed again. There is a higher relapse rate from medication treatments for depression than from using therapy. Anti-depressant medication cannot teach coping skills, problem solving skills, resolve interpersonal issues, or protect against reoccurrence of depressive episodes.
However, it would be unfair to say that nobody gets relief from medication, and in some instances it is definitely required.
Older medications such as tricyclics (TCA’s) monoamine oxidase inhibitors (MAOI’s) and selective serotonin reuptake inhibitors (SSRI’s) such as Prozac, Paroxetine and Seroxat, all have side effects. Everyone is different, and one drug may not work well for an individual, whereas another one might.
Unfortunately most GPs tend to think that the cause of depression is mainly biological, and therefore there is always a need for drug therapy.
Scientific findings indicate that depression is caused in three general areas; biology, sociology and psychology, and within these three categories there are many variables. Therefore these three factors should be considered in every case.
Cognitive behavioural therapy (CBT) provides new ways of thinking and feeling within a short period of time. This therapy usually takes between 7 – 9 sessions.
Some other therapies can go on for many months and even years which paradoxically can actually hold the client back from progressing. The longer the therapy continues, the more the client is reminded that their problem is something drastic. The client can become more and more reliant on their therapist, whilst nothing much happens in respect to the client coping better or feeling better.
People suffering from depression tend to think or ruminate about the same old problem over and over again; constantly remembering things in the past that hurt them, or feeling guilty about things they have not accomplished, and feeling that they are useless and hopeless. They say ‘Things will never get better for me. I will never be able to have a good relationship/job. I’m no good at anything’ or ‘it’s my fault things went wrong.’ These unrealistic, self-critical, pessimistic evaluations develop low self-esteem and a sense of hopelessness and helplessness.
Cognitive behavioural and interpersonal approaches, within the state of hypnosis, allow the depressed person to think and feel differently, and can provide sophisticated ways of overcoming problems. Finding appropriate problem solving solutions for the client is imperative, and significantly reduces the instance of relapse. These coping skills and mechanisms are resources which we all have within us, and these resources can be identified and brought out, to be utilised for the future. Clinical hypnosis increases the effectiveness of psychotherapy, which enables unique, specific and positive changes to take place in the depressed individual.
The following information has been kindly supplied by David Dove, The Paloma Centre, Banbury. 01295 277686 firstname.lastname@example.org www.thepalomacentre.com
Gender differences in the experience of Depression & its treatment.
“Depression” is a much misunderstood condition and one which in modern times has become devalued through the common application of this term to a wide range of conditions, not all of which are true depressive states. It has become almost a medical fashion-label to be attached to a wide variety of conditions which has consequently led those people with genuine depressive states to be misunderstood and devalued. Additionally, Depression is often seen as a “female” condition and made the butt of jokes about PMT, for example, which, again, tend to devalue the real impact that a genuine depressive state has on the sufferers.
Depression is common to all genders; it is thought that about 15 percent of people will have a significant occurrence of a depressive state at some point in their lives and it is considered to be the fourth most common cause of disability worldwide. The number of people with depression is hard to estimate for many reasons e.g. because many do not seek help or are not formally diagnosed. Some perspective at this point may be useful. Many, if not most of the 4,000 suicides committed each year in England are linked, directly or indirectly, to depression. On average, 15% of people with recurrent depression (repeated attacks) have an increased risk of suicide. Depression can appear at any age and occurs in every “Western” country. There is some debate about whether it is common in or to every culture across the world, although it now seems likely that depression is a universal human condition.
To gain an understanding of the inaccurate perception of Depression being a “female problem” we firstly need to understand broadly what is meant by “Depression”, its symptoms and general occurrence; we can then look at causes of Depression that are common to all genders, explore in what ways the occurrence in men may be under-reported before examining in some detail various causes that are almost entirely specific to women and in themselves go a long way to explain why this inaccurate perception should have gained such credibility in the public perception.
A generalised description of depression might be “A mood disorder that causes a person to feel sad or hopeless for an extended period of time. More than just a bout of “the blues” or temporary feelings of grief or low energy”. Depression can have a significant impact on the enjoyment of life, work and health, and the people the sufferer cares about.
Before considering the difference between the levels of reported depression between men and women it will be helpful to gain a basic understanding of what we mean by the term “Depression” and some of the ways that it occurs and the possible reasons. Depression affects people in many different ways and can cause a wide variety of physical, psychological and social symptoms.
Broadly speaking, Depression may be categorised in the following three ways:
A. By how serious it is:
- mild, in which there is some impact on daily life
- moderate, in which there is significant impact on daily life
- severe, in which activities of daily life are nearly impossible.
B. By physical symptoms: If you have Depression you will probably have one or maybe more physical (‘somatic’) symptoms
e.g. poor appetite, disturbed sleep patterns.
C. By psychotic symptoms: If you have severe depression you may also have psychotic symptoms, such as hallucinations
or delusions. These symptoms don’t affect everyone with depression.
Some specific types of depression such as post-natal and menopausal will be commented on later but in general terms there are some common causes to the majority of depressive states experienced by all genders.
Factors involved in causing depression, may include:
- A history of depression in the family: It is believed that depression can be passed genetically from generation to generation, although the exact way this occurs is not known.
- Grief from the death or loss of a loved one.
- Personal disputes, like conflict with a family member.
- Physical, sexual, or emotional abuse.
- Major events that occur in everyone’s lives, such as moving, graduating, changing jobs, getting married or divorced, retiring, etc.
- Serious illness: depressed feelings are a common reaction to many medical illnesses.
- Certain medications.
- Substance abuse: close to 30% of people with substance abuse problems also experience major depressive states.
- Other personal problems: these may come in the forms of social isolation due to other mental illnesses, or being cast out of a family or social circle. For some people, upsetting or stressful life events such as bereavement, divorce, illness, redundancy and job or money worries can be the cause. This is often known as ‘reactive’ depression – the depression is a reaction to the event. It’s also called exogenous depression (‘originating outside the body’). In other cases, depression doesn’t have an obvious cause. This is sometimes called endogenous (originating within the body).
Because depression can have many causes, it’s sometimes split into three broad groups; psychological, physical and social.
- Psychological — a stressful or upsetting life event causes a persistent low mood, low self-esteem and feelings of hopelessness about the future.
- Physical or chemical – depression is caused by changes in levels of chemicals in the brain. For example, your mood can change as hormone levels go up and down. This is sometimes seen in women and is associated with the menstrual cycle, pregnancy, miscarriage, childbirth, and the menopause, more later.
- Social understanding — doing fewer activities or having fewer interests can both cause depression and happen because of depression.
Quite often, depression can be triggered by more than one of these factors, and they can influence and affect each other in complicated ways. Other frequent causes of depression include drinking excess alcohol and using street drugs such as cannabis and cocaine.
A valid question to ask, given the difference in reported occurrence, would be, is depression in women different than in men, or is it exhibited or reported differently? Because of the difference in numbers of cases depression was once considered to be a “woman’s disease,” linked to hormones and premenstrual syndrome. The lingering stereotype of depression being a female condition may still prevent some men from recognizing its symptoms and seeking appropriate treatment. This may contribute to the disparity in reported numbers, see later.
In reality, depression affects both sexes, disrupting relationships and interfering with work and daily activities. The symptoms of depression are similar for both men and women, but they tend to be expressed differently. The most common symptoms of depression include low self-esteem, suicidal thoughts, loss of interest in usually pleasurable activities, fatigue, changes in appetite, sleep disturbances, apathy and sexual problems, including reduced sex drive.
Male orientated Depression
There are several reasons why the symptoms of depression in men are not commonly recognized:
- Men tend to deny having problems because they are supposed to “be strong.”
- Western culture suggests that expressing emotion is largely a feminine trait. As a result, men who are depressed are more likely to talk about the physical symptoms of their depression, such as feeling tired, rather than those related to emotions.
- Depression can affect sexual desire and performance. Men often are unwilling to admit to problems with their sexuality mistakenly feeling that the problems are related to their manhood, when in fact they are caused by a medical problem such as depression.
- The observable symptoms of male depression are not as well understood as those in women. Men are less likely to show “typical” signs of depression, such as crying, sadness, loss of interest in previously enjoyable activities, or verbally expressing thoughts of suicide. Instead, men are more likely to keep their feelings hidden, but may become more irritable and aggressive.
For these reasons, many men, as well as doctors and other healthcare professionals, fail to recognize the problem as depression. Some mental healthcare professionals suggest that if the symptoms of depression were expanded to include anger, blame, violence and abuse of alcohol, more men might be diagnosed with depression and treated more appropriately.
Depression in men can have devastating consequences. The Centers for Disease Control and Prevention report that men in the U.S. are about four times more likely than women to commit suicide. An amazing 75-80% of all people who commit suicide in the U.S. are men. Though more women attempt suicide, more men are successful at actually ending their lives. This may be due to the fact that men tend to use more lethal methods of committing suicide, for example using a gun rather than taking an overdose. Depression in men can often be traced to cultural expectations. Western male stereotypes still demand that men are supposed to be successful, that they should restrain their emotions and that they must remain in control. These cultural expectations can mask some of the true symptoms of depression, forcing men to express aggression and anger instead and thereby be referred for “anger management” or Counselling rather than treated for the underlying depression.
In addition, men generally seem to have greater difficulty in dealing with the “stigma” of depression. They tend to deal with their symptoms with a macho attitude or by drinking alcohol. This attitude still pervades society generally but particularly within many male-dominated institutions, such as the military and athletics, where men are taught that “toughness” means putting up with physical pain and admitting to emotional distress is taboo. Rather than seek help, which means admitting to what they perceive as a (female) weakness, men are more likely to deal with their depression by drinking heavily or committing suicide thereby totally avoiding possible reportage.
Differences in the experience of Depression.
Some of the other ways in which depression may be experienced differently by men and women are:
- Depression in women may occur earlier, last longer, be more likely to recur, be more likely to be associated with stressful life events, and be more sensitive to seasonal changes.
- Women are more likely to experience guilty feelings and attempt suicide, although they are successful less often than men.
- Depression in women is more likely to be associated with anxiety disorders, especially panic and phobic symptoms, and eating disorders.
- Depressed women are less likely to abuse alcohol and other drugs.
From this it can be seen that men may be experiencing or dealing with depression differently or, because of social stereotyping, be reported and/or diagnosed differently thereby significantly altering the statistics.
It is interesting to compare the male attitude, and resultant lower reportage, with a survey of female attitudes towards depression conducted by Mental Health America on public attitudes and beliefs about clinical depression:
- More than one-half of women believe it is “normal” for a woman to be depressed during menopause and that treatment is not necessary.
- Approximately 10%- 15% of all new mothers get post natal depression which most frequently occurs within the first year after the birth of a child.
- More than one-half of women believe depression is a “normal part of ageing.”
- More than one-half believe it is normal for a mother to feel depressed for at least two weeks after giving birth.
- More than one-half of women cited denial as a barrier to treatment while 41 % of women surveyed cited embarrassment or shame as barriers to treatment.
- In general, over one-half of the women said they think they “know” more about depression than men do.
From this it will be seen that the more “open” attitude towards recognising, accepting and dealing with depression among the female population will influence the statistical reporting of the complaint.
Female Specific Depression.
In addition to the general experience of depression and the difference in the ways that male oriented depression is reported there are significant areas that are unique to women. Rates of depression appear to be similar in girls and boys before adolescence. However, with the onset of puberty, a female’s risk of developing depression increases dramatically, to twice that of males. It is believed that women may be more prone to depression because of changes in hormone levels that occur throughout a woman’s life such as during puberty, pregnancy and menopause, as well as after giving birth, having a hysterectomy, or experiencing a miscarriage. In addition, the hormone fluctuations that occur with each month’s menstrual cycle increase the risk for premenstrual syndrome, or PMS. In addition, for women trying to balance a home, a family and a career, unique stresses are experienced that may lead on to wider health and social problems.
As would be expected, there are also various aspects of everyday life that have been identified as tending to increase the likelihood of depression in women occurring and some of these are:
- Loss of a parent before age 10.
- Physical or sexual abuse as a child.
- History of mood disorders in early reproductive years.
- Family history of mood disorders.
- Use of certain oral contraceptives.
- Use of certain infertility treatments.
- Ongoing psychological and social stress (e.g., loss of job, relationship stress, separation or divorce).
- Loss of social support system or the threat of such a loss
Up to 75% of menstruating women experience premenstrual syndrome (PMS), a disorder characterized by emotional and physical symptoms that fluctuate in intensity from one menstrual cycle to the next. Women in their 20’s or 30’s are those most affected. About 3-5% of menstruating women experience premenstrual dysphoric disorder, or PMDD, a severe form of PMS, marked by highly emotional and physical symptoms that usually become more severe 7 to 10 days before the onset of menstruation. It is now recognised and accepted that these fluctuations in hormone levels are important causes of discomfort and behavioural change in women. While the precise link between PMS, PMDD and depression is still unknown, chemical changes in the brain and fluctuating hormone levels are both thought to be contributing factors.
Of course, the most obvious “unique” experience for women is that of childbirth and, not unnaturally, this brings with it a whole range of complex emotional issues to deal with, particularly for the first birth experience, which if not recognised and dealt with can give rise to depressive states. In one way, pregnancy is often viewed as a period of well-being that protects women against depressive or emotional disorders given the level of care and attention given to her at this time. But depression appears to occur almost as commonly in pregnant women as it does in those who are not pregnant.
The factors which appear to increase the risk of depression during pregnancy are:
- Having a history of depression or PMDD.
- Age at time of pregnancy, the younger the woman, the higher the risk.
- Living alone.
- Having limited social support from family and friends.
- Marital conflict.
- Uncertainty about the pregnancy.
The stresses of pregnancy can cause depression or a recurrence or worsening of depression symptoms and depression during pregnancy can increase the risk for having depression after delivery (post natal depression, see below). The potential impact of depression on a pregnancy is particularly important as it can interfere with a woman’s ability to care for herself during pregnancy. She may be less able to follow medical recommendations, and sleep and eat properly. Depression can also cause a woman to use substances such as tobacco, alcohol, and/or illegal drugs, which could harm the baby and the depressive state may make bonding with the baby difficult.
Having a baby is a life-changing experience. Pregnancy and the first year after the birth are periods that many parents find quite stressful. The birth of a baby is an emotional experience and, for many new mothers, feeling tearful and depressed is also common. However, sometimes longer periods of depression, known as post-natal depression (PND), can occur during the first few weeks and months of the baby’s life.
PND can have a variety of physical and emotional symptoms, and many mothers are unaware that they have the condition. It is therefore important for partners, family, friends and healthcare professionals to recognise the signs of PND as early as possible so that the appropriate treatment can be given. Following childbirth, there are three generally recognised forms of this type of depression:
- So called ‘Baby blues’ is a common type of depression, and it is the least severe. It does not usually last very long, starting from around the third day after birth and lasting until around the tenth day. During this time, the mother may feel tearful and irritable, but no longer-term affect occurs.
- Postnatal depression affects about I in 10 mothers in the UK, and usually develops in the first 4-6 weeks after childbirth. However, in some cases it may take several months to develop. The mother may feel depressed for most of the time, and the feelings remain for an extensive period of time, months.
- Postnatal psychosis is a rare, but severe, form of depression. It develops in about I in 1,000 mothers. Symptoms can include irrational behaviour, confusion, and suicidal thoughts. Women with postnatal psychosis often need specialist psychiatric treatment.
Although postnatal depression is more common in women, men can be affected too. As the birth of a new baby can be a stressful time for both parents, some fathers feel unable to cope, or feel that they are not giving their partner all the support she needs. They can also find it upsetting if the new baby is getting all of their partner’s attention, giving rise to resentment, feelings of loss and depression. PND can put a strain on a relationship. This can cause the break up of some relationships, which is why it is important to recognise the symptoms of PND at an early stage and take steps to get treatment for either or both partners.
Further types of depression that are unique to women are perimenopausal and menopausal depression. The perimenopause is the stage of a woman’s reproductive life that begins 8 to 10 years before menopause itself. During this time the ovaries gradually begin to produce less oestrogen. Perimenopause lasts up until menopause, the point when the ovaries stop releasing eggs. In the last one to two years of perimenopause, the decrease in oestrogen accelerates. At this stage, many women experience menopausal symptoms.
The menopause is a period of time when a woman stops having her monthly period and experiences symptoms related to the lack of oestrogen production. By definition, a woman is in menopause after her periods have stopped for one year. It is a normal part of ageing and marks the end of a woman’s reproductive years. Menopause typically occurs in a woman’s late 40’s to early 50’s. However, women who have their ovaries surgically removed undergo a similar condition known as “sudden” menopause.
The drop in oestrogen levels during perimenopause and menopause triggers physical, as well as emotional changes — such as depression or anxiety and changes in memory. Like any other point in a woman’s life, there is a relationship between hormone levels and physical and emotional symptoms. Some physical changes include irregular or missed periods, heavier or lighter periods, and hot flushes.
All of these “unique to women” conditions have a significant effect on reported cases of depression, the more possible causes the greater likelihood of reportage.
An additional depressive state that is biased towards women but for less well known reasons is Seasonal Affective Disorder (SAD). SAD is a type of depression or mood disorder with a seasonal pattern. The most common form of SAD is also called winter depression or winter blues, because symptoms are worst in the winter months. They tend to start from around September, are worse when the days are shortest (in December, January and February) and improve in the spring. There is also a summer version of seasonal affective disorder, but this is far less common and has different symptoms.
Around I in 50 people in the UK have SAD. It is more common in women than in men and most commonly starts between the ages of 18 and 40. Up to I in 8 people in the UK experience milder symptoms of winter ‘blues’ (sub-syndromal SAD). Studies around the world have shown that SAD becomes more common the further you are away from the equator..
The apparent disparity in numbers suffering depression may be explicable by several factors which contribute to the imbalance. For example, while there are generalised causes of depression which are common to all genders, there are also some significant causes that are specific to the female gender and there are also social factors which may distort the reportage of the condition.
I have been unable to determine to what extent the specific causes skew the generalised results and so will restrict my comments to those areas where they are more obvious. It is clear that the causes unique to women are statistically significant both in terms of the comparative size of the female population and the sheer number of specifics.
Puberty, reproductive, hormonal, genetic and other biological differences (e.g. premenstrual, post natal, infertility, loss of child and menopause).
Social factors affecting only women also play a part as in the example of the mother who is also a business woman trying to be a mother, a wife, a home maker and an executive, all having conflicting pulls on her time and emotions.
Social factors also affect the reporting by men of depressive conditions in terms of their perceived roles and standing in the community as the male archetypical “macho” male who doesn’t cry and suffer from “girly” things like depression. The male experience will also affect the manner in which it is reported and may well be disguised as alcohol related issues or anger management.
For these reasons alone it is not surprising that depression would appear to affect female more than males, but statistics can and do lie. The lesson from this is to always look for the “why” and not accept presenting issues at face value, particularly as a therapist, that which is presented at therapy.
Treatment will be specific to the individual and may be a blend of elements taken from psychotherapy e.g. CBT to address the issues at the Cognitive or logical level while supported by Hypnotherapy to build confidence in dealing with the issues at the more subjective level. Additionally, modern coaching techniques may be utilised to take the client forward towards a constructive, planned, positive future while also using techniques taken from modern Meridian Energy Therapies such as EFT to deal with the negative emotional issues as they arise.
Material has been extracted from many sources, not all directly attributable, but significant research was conducted on the internet and particularly important sources were:
- NHS Web
- The Cleveland Clinic Department of Psychiatry and Psychology.
- The Centers for Disease Control and Prevention
- The National Library for Health
- Department of Health