Last partial update: July 2016 - Please read disclaimer before proceeding.

 

Being alert to the possibility of depression to ensure diagnosis comes first

The most important issue in treating depression is recognising it in the first place. Diagnosis of depression is covered in the previous section of this ‘depression topic’. This is especially the case with adolescents and males. People who fit the above criteria should not disregard their feelings and need to seek help! If a friend or relative is the sufferer, discuss it with them and encourage them to seek medical help. All GPs see many depressed patients and most are well skilled at treating this condition. They really can help, but only when they know there is a problem. Tell them!

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How can I help a depressed friend or family member?

Harm to others

It is important to note that the new baby and other children in the family may at times be at risk when the mother has antenatal depression or PND. Harm to other children can occur by neglect or by physical / mental abuse and either parent / partner may be involved. If this is occurring or if there is a risk that it will occur, a medical practitioner or appropriate child protection authorities need to be notified. Harm to the unborn foetus is also more likely where depression occurs with the pregnancy. This includes harm from alcohol / other drug misuse by the mother or by a mother’s general disinterest in her own personal health / care.

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Treatment options

The majority of patients can be successfully treated with medication and/or psychotherapy (usually cognitive behavioural therapy). Both are equally effective in treating mild to moderate depression. It is important that the treatment chosen is one that the sufferer feels comfortable with and will thus comply with. More severe depression requires treatment with medication, especially where the patient is at risk of self harm or is too distressed to take heed of the counselling advice that is being offered. Increased physical activity should also be an important part of treatment in most people.

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1. Psychotherapy

Psychotherapy is discussed in detail below.

2. Medications

All medications seem equally effective, but different medications are beneficial for different people. As it is not possible to tell beforehand which medications are likely to succeed, some trial and error may be necessary to find the most effective medication. If the initial drug does not work at all within a week or two, it is worthwhile trying several others before giving up on medication. However, medication often works quickly, with benefits being seen in a couple of weeks. Antidepressant medication can also be effective in the treatment of anxiety in many some cases. People who are prescribed an anti-depressant medication need to let their doctor know about other medications they are using, including non-prescription drugs such as St John’s Wort (a herbal remedy often used for depression), as these may adversely interact with the medication being prescribed. It is also important to avoid alcohol consumption and the use of illicit drugs when taking anti-depressants.


SSRIs (Selective Serotonin reuptake inhibitors)

This group of drugs is the most common type of antidepressant medication prescribed in Australia today and is the first choice treatment for most cases of depression requiring medication. (The main exceptions are people with a history resistance to this medication and people with chronic pain.) These medications are highly effective in treating the symptoms of depression and are also good for treating panic attacks, anxiety / nervousness and obsessive compulsive symptoms. They are safe in the event of overdosage and have relatively few side effects, the main ones being nausea, agitation, sleep disturbance, sexual dysfunction, headaches and occasionally dizziness due to low blood pressure. They should not be stopped suddenly as this initiates an unpleasant withdrawal syndrome. This group of medications includes fluoxetine (Prozac, Erocap, Lovan, Zactin, Auscap), sertraline (Zoloft), citalopram (Cipramil, Ciazil, Talohexal), paroxetine (Aropax, Paxtine) and fluvoxamine (Luvox, Faverin).

The information about safe use in pregnancy is limited, with Fluoxetine having the largest body of safety data. (It is, however, excreted into breast milk more than some other SSRIs.) Paroxetine is not a 'first line' choice in pregnancy.

Untreated, depression usually lasts for six months or more. For this reason, treatment usually needs to be maintained for a period of about twelve months. If this is not the first episode of significant depression being treated, then treatment will probably need to go on for longer; usually up to two years. Some people who have numerous (three or more) episodes of severe depression may need to consider the option of lifetime treatment. Antidepressant medication can also be effective in the treatment of anxiety in some cases.

Unfortunately many people cease their medication well before this time, with only about 40 per cent of people continuing on medication for six months. This increases greatly the risk of relapse. This problem is partly due to inadequate discussion regarding medications when they were commenced. (Calls to the National Prescribing Service’s Medicines Line regarding problems with antidepressant medications are very common.) 

The most important part of treating depression is that there is consistent long-term follow-up by the treating practitioner. People requiring treatment with drugs or psychotherapy need treatment for at least a year and those suffering more severe or recurrent symptoms will need follow-up for up to three years or longer.

St John’s wort

This herbal remedy has been used for depression for many years. While there is considerable debate about it benefit, some studies have shown it may be helpful in treating mild cases of depression. It is certainly not recommended for the treatment of more severe cases of depression. It interacts with most other antidepressant medications and should not be used when taking such medication (e.g. monoamine oxidase inhibitors and selective serotonin reuptake inhibitor (SSRIs). It is usually well tolerated, although side effects include rash, itch, nausea, headaches, dry mouth, dizziness and fatigue.

3. Promoting activity

Promoting activity is also an important part of overcoming (and prevent the recurrence of) depression. A common feature of depression is reduced motivation to do all activities and this often translates into reduced physical and social activity. The resumption or continuation of normal activities keeps the person in their normal routine and in contact with their friends and physical activity helps overcome mental and muscular tension and in doing so reduces depressed feelings. A good way to start is to write a list of the things being done each day. (Ask a relative or friend to assist with creating the plan.)

Start with the normal activities, like showering etc, and then add in some physical activity in the mornings and late afternoon. Try to do this activity with other people, as it will increase social contact and make it harder to miss a scheduled activity. Activities should include at least one thing that is enjoyed each day; ‘pleasant event scheduling!!!’ Depressed people have often ceased doing these activities and reintroducing these activities will increase life enjoyment. There should be one activity that gives you a sense of achievement. People should also try to make a habit of accepting all the invitations they receive from friends and family, even though they may not feel like it, as people who become socially isolated have greater difficulty overcoming their depression.

4. Improving sleep

Improving sleep can have a significant impact of improving depression and may also help prevent its onset in some people. Sleep deprivation is certainly a major factor in post-natal depression and in depression occurring in women with young children. Fathers, grandparents etc can be a great help in lightening the load of young mothers and thus help prevent depression occurring. (See section on sleep problems.)

5. Reducing life stresses / improving living conditions

Finally, it is also important to remember that stressful living conditions are an important factor in many cases of depression and that many of these can be improved. Examples include providing financial support, help in the caring and treatment of sick / disabled dependants of the depressed person, identification of physical and / or emotional abuse within a relationship, help with alcohol / other dug abuse either by the depressed person or another family member etc etc. It’s a long list and means that, in addition to therapists, the successful treatment of depression often requires the help many other services, including government welfare services, local area health services, and community-based services such as lifeline, meals-on-wheels, St Vincent de Paul, the Salvation Army, the Smith Family and local church groups to mention but a few. A GP is often an ideal person to assist in accessing and coordinating these various services.

5. Overcoming other substance abuse

Substance abuse is common in people with depression and needs to be addressed as part of the treatment of depression. Alcohol-use problems are the most common, followed by cannabis use. Both are drugs which cause depression of the central nervous system which exacerbates depressive symptoms. As well as their detrimental affect on the depressed person, these substances can cause problems by interacting with prescribed anti-depressant medication.

6. Relax and reduce anxiety through meditation / yoga

Some people find ‘stress-reduction’ techniques such as yoga and meditation can help reduce depressive symptoms. Music is also very helpful

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Some helpful questions to ask when you’re having a bad day
  • What has worked best before to help me through a bad day?
  • What can I do to look after myself better physically on a bad day?
  • Who can I contact to help me?
  • What can I do to manage my thoughts and feelings better?
  • What do I need to avoid?

 

Psychotherapy for anxiety and depression

In the past, psychotherapy for depression and anxiety focused on trying to identify the underlying causes for problems that people faced in their everyday lives. These causes are often deep seated and often commenced in the person’s distant past. The psychoanalysis therapy used to uncover these causes and reverse their effects was very time consuming (and therefore expensive) and required great patience from both patient and therapist.

These techniques have been largely replaced by cognitive behavioural therapy / structured problem solving and, to a lesser extent, interpersonal psychotherapy. The emphasis in these therapies is on changing present thinking irrespective of its cause. These therapies work equally well for treating depression and anxiety.

e-MentalHealth Therpay - A new way of delivering psychotherapy for depression

Historically psychotherapy has been delivered by face-to-face contact between the clinician and the patient. While this is still by far the most common method of delivering therapy, numerous, very effective e-Mental Health options have been / are being developed. They have the advantage of being cheaper for patients and of being avilable in areas where mental health resources are relatively scarce, a common problem in Australia. They are available in two general forms:

It is important to realise that there are many programs available on the net and that program quality will vary. Indeed, some may not be helpful at all. Also, different programs will suit different people. Thus, it essential to ask your GP for advice when selecting a program. Also, as people using these programs obviously have mental health issues, they need regular ongoing review both during the course of therapy and afterwards to see how they are faring as almost all mental health problems tend to be recurring in nature / fluctuate significantly in severity.

e-mental health treatment programs available online

Numerous highly regarded and well-resourced Australian organisations have produced excellent e-mental health treatment programs. These include:

General mental health educational resources

There are also many mental health educational resources available online

General mental health educational resources for young people

These websites present online CBT and positive psychology strategies designed to reduce distress and build resilience in a youth-friendly format.

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Cognitive Behavioural Therapy (CBT) - Changing the way we think.

Acknowledgement: Much of the information in this section on CBT is based on my study of material written by Sydney-based psychologist Sarah Edelman. I believe her book Change your thinking  should be read by everyone. I have certainly given it to my daughters.

Psychological therapy that aims to favourably change the way we perceive and react to problems is called Cognitive Behavioural Therapy (CBT) and over the past 20 yeas it has become the main form of psychological therapy used to treat many important mental health problems, especially anxiety and depression. This is because it is easy to use, takes relatively little time and, most importantly, it works.

Luckily, CBT is just as useful in solving the everyday problems of all people (not just those with anxiety and depression) and it is a method of coping that everyone should consider incorporating into their lives. (See section on using CBT for everyday problems.)

CBT does not rely on looking into the past to try to identify abnormal or harmful past experiences that might be the cause of the problem in thinking. (While past experiences certainly do affect the way we think, there is no proof that identifying such causes actually helps improve current maladaptive thinking or helps reduce depression and anxiety symptoms.)

Rather, the emphasis in CBT is on changing present thinking irrespective of its cause.

People wishing to use CBT techniques need to receive education about its proper use. People with mental health problems such as anxiety and depression need to get professional help, usually from a psychologist or doctor, regarding how to use CBT as their problems are difficult to treat and an outsider's view is often very beneficial. Obviously doing some study before seeing a therapist will be a great help. ('Change your thinking' by Sarah Edelman (ABC books) is an appropriate starting point.)

All psychologists are well trained in CBT, as are many GPs. (As there is a shortage of trained psychologists / psychiatrists in some regions, especially in the country, GPs often find themselves as a community’s primary CBT resource. The fact that they often have a long-standing and trusting relationship with the depressed person and know their social circumstances well means that they are usually very well placed to fulfill this role. Such relationships have been shown to be very beneficial in treating patients with depression.)

Under the supervision of a trained practitioner, all the techniques mentioned below have been shown to help in the majority of depressed or anxious people. However, success depends on the patient gradually taking over the major role as they practice their newly learned techniques in real life situations. The therapist’s role is to act as a guide while their patient learns to become his or her own therapist. As with almost all the lifestyle changes suggested in this book, motivation is the key to success and the person must be ready to start therapy.

The material below only gives an introduction to the topic and is not meant to be a substitute for treatment by a therapist.

How do people with depression and anxiety think about situations and respond to situations?

Unhelpful thinking is responsible for most depression and anxiety. Most people with depression and/or anxiety have inappropriate negative thoughts that automatically come into their heads many times each day. They are termed 'automatic negative thoughts' and they silently shape the unhelpful responses to the daily problems that are the lot of depressed and anxious people. They may occur in association with a specific problem, such as a specific anxiety causing situation, or with most activities the person does, as is often the case in depressed people. They develop over many years and become as second nature as tooth cleaning. Overcoming these negative thoughts is the basis of CBT and is discussed in more detail shortly.

In anxious people, many habits are based around avoiding things that we have feared for a long time. These fears are usually inappropriate and result from incorrect beliefs about a situation. Over the years these habits become second nature. These are often deeply held beliefs and are particularly common in anxious people. Most of the time these habits revolve around the following:

Many people are unaware that they are using these techniques because they have just become part of who they are and they actually act to reinforce the underlying belief so that the belief becomes deeply held. (Deeply held beliefs are especially common in anxious people. People who are afraid of flying really do think they are going to crash!!)

While these behaviours make people feel more secure in the short term, in the end they do not help them address their inappropriate fear and can be a very disrupting influence on their life e.g. excessive alcohol use. Ultimately they tend to lead to depression. (this is why anxiety and depression often co-exist and why treatments that work for one tend to work for the other.)

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Methods of implementing CBT

CBT is implemented in two broad ways.

A. Thinking strategies.

These rely on learning to recognise thoughts and beliefs that make us feel bad and substituting more helpful ones that cause us less upset. There are three parts to this process. 

B.  Behavioural strategies.

The way we behave in response to a problem can either reinforce or challenge our underlying beliefs about a problem. For example, the avoidance behaviour that often accompanies a fear of public speaking reinforces the belief that this is a difficult task. On the other hand, undertaking behaviours that challenge unhelpful beliefs about a problem can be used as a technique assist in undoing these beliefs. Repeating such behaviours (usually  with specific goals in mind) can gradually reduce the problem. For example, making a short speech about a well known topic in a non-threatening environment can show that the task is not so difficult.

This type of behavioural strategy is particularly useful in people who have very rigid beliefs, which is common in anxious people. In these people cognitive therapy (thinking about the problem) is not enough to make them change their belief. They need to see their belief tested (and disproved) in the real world.

Just as behaviours can be used as a technique to change the way we think about a specific problem, it makes sense that the way we act can change the way we feel generally in everyday life. For example, doing positive things such as exercising or finishing a job or just contacting a friend can make us feel good generally and our improved overall mood may make us less likely to automatically adopt a negative attitude when a problem arises. Such general ‘activity scheduling’ is often used when a person’s response to a situation has led to reduced activity generally and is often used in depressed people who commonly stop doing pleasurable activities.

These two techniques are discussed in more detail below.

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A. CBT thinking (cognitive) strategies

The appropriateness of thinking and feeling in response to a particular situation can be assessed in three ways; the nature of the response itself (e.g. sadness verses annoyance), the intensity with which the feelings and thoughts are experienced, and their duration.

CBT asks us to confront and question the beliefs that have caused the thoughts, feelings and responses that regularly disrupt our lives. Are there more helpful beliefs that I could adopt that would prevent me thinking, feeling and acting like this? This is the most important process in CBT.

With practice many people become very good at using CBT to help solve their daily dilemmas.

It is very important to realise that CBT is not the same as positive thinking. Rather, CBT involves assessing how realistic and helpful a particular thinking pattern is for that individual (i.e. how appropriate it is) compared to other alternative ways of thinking. Being positive and just assuming that everything will be fine when it is obvious to all around that the opposite is the case is not helpful.

How do we know we are thinking inappropriately? Automatic negative thoughts.

Each individual in each society is different and should have the right to believe in what they choose, so long as it does not adversely affect others. Likewise, all problems have a variety of solutions and the best one will depend on the individual and the situation at the time.

However, there are some types of beliefs that are generally not helpful in promoting thinking, feelings and responses that are beneficial. As a group these tend to be negative type thinking patterns and are termed ‘ automatic negative thoughts’. Here are some common ones.

It is important to learn these so that they can be easily more recognised. A ‘thought diary’ is often helpful at cataloguing such negative thoughts and brings to the person’s attention how big a part they play in their thinking.

Challenging beliefs

When people have thoughts about a certain situation that upset them, they should logically assess their underlying beliefs to see if they have any of the above features. If they do, then try to see if a more appropriate belief can be substituted. It is necessary to do this in writing (or on a computer) as there are several stages to this process and it is easy to forget ideas that are not written down. Written down thoughts can also be added to and referred back to. The best way to write down thoughts is via a thought-monitoring form and a hypothetical problem is worked through in the form below. 

People who have anxiety and depression will not just have one situation that is causing them problems. Rather they will have patterns of negative thoughts that recur in most of the situations they face each day. However, analysing one problem at a time is simpler than trying to confront all issues at once and, as the thought patterns are often similar, solving one or two problems in this manner will usually help with the rest.

Thought-monitoring form

 

Problem: Failure to achieve weight loss

Sue is a thirty year old woman who has tried unsuccessfully to lose weight on numerous occasions over the past 10 years. She is happily married and in full time employment. Her thought-monitoring form might appear as follows.

 

Situation

I am overweight and unhappy about this. I would like to lose weight to improve my health and appearance and have tried several times but I just can not do it.

Thoughts / beliefs / feelings

 

How do I perceive the situation / event? What do I feel the outcome will be?

 

 

I feel guilty and dislike myself for not being able to control my eating behaviours.

I feel depressed about the situation at times.

I feel I am not as good / competent as people with a healthy weight because I can not reduce my weight.

I feel frustrated by my continued failure.

I will never be able to lose weigh. It is just too hard and I have been unsuccessful before.

I am an inadequate person because I can’t control the way I eat.

Weight loss should be easy as it is just a matter of eating less and exercising more.

Most competent, successful people can control their weight. People who can not control their weight are inadequate.

I must be a normal weight to feel good about myself and be healthy.

 

 

What evidence is there to support my perception?

I have tried on several occasions to lose weight but have failed.

Is there other evidence that does not support my perception?

Lots of my friends are overweight and can not lose it. Perhaps it is harder than I think.

I am successful at other things, such as my job. I have never planned a weight loss program or sought help. That is what I would do with a problem at work and it works.

Lots of seemingly competent people on the TV news are overweight.

Most of the time I enjoy my life. If I can not lose weight it will not be the end of the world.

Thinking errors

 

Am I using faulty thinking?

Shoulds

Awfulising

Black-and-white thinking

Overgeneralising

Personalising      

Filtering

Jumping to negative conclusions

Mind reading

Labelling

Predicting catastrophe

Comparing

Black and white thinking: I must get to a normal weight to benefit from weight loss. I must keep to my healthy eating plan all the time.

Awfulising:  I will not be happy unless I can lose weight.

Predicting catastrophy: I am always going to fail.

Shoulds: I should be able to keep to my healthy eating and exercise plan all the time and lose weight.

Comparing: Others can lose weight, why can’t I?

Over-generalising: I have failed at losing weight and thus I am a failure at everything.

Disputing perceptions.

 

Is there a more balanced way of thinking about this situation?

 

Changing habits is hard I have been eating and exercising the same way since I left school and am used to this lifestyle. It is going to be hard to change. Even Sally who is the most highly motivated person I know said she found it difficult to find the extra time and energy she needed to lose weigh and keep it off.

 

Lots of people are overweight, even successful people. Perhaps it is harder than I have thought: I know from magazines, radio and TV how most Australia adults are overweight and I see many achieving, successful people who are overweight; just look at some of our politicians. I suppose that some might just not care. However, I bet there are others who would like to lose weight but just don’t know how to do it or do not have the extra energy that losing weight requires. I am not alone in this.

 

Perhaps if I plan a weight loss program and get help I might succeed While I have tried many times to lose weight, I have never thought about it properly. Perhaps if I gave it some proper thought and looked at the long term, like my friend Sally did, I would have better results. She lost lots of weight a few years ago and has kept it off.

 

I have lost some weight in the past and that must be better than nothing: I know that for me any weight loss will be beneficial. I know that there are lots of other benefits to eating well and exercising in addition to losing weight, such as reducing cancer and depression. Also, I am physically healthy in lots of other ways, for example I do not smoke or drink too much.

 

I must keep to my healthy eating plan all the time. My doctor in the past has said that it is normal to occasionally ‘weaken’ and diverge from a completely healthy diet. Almost everyone does it. (I know my friends do!!) If I expect to be perfect all the time I will just get disappointed.

 

I should be able to control my eating and exercising all the time. I have been eating and exercising the same way since I left school and am used to this lifestyle. It is going to be hard to change. Even Sally who is the most highly motivated person I know said she found it difficult to find the extra time and energy she needed to lose weigh and keep it off.

 

Departing from my plan will cause me to fail. I know that, individually, slipups are not a disaster are not a disaster and will not cause me to put on weight. The main thing is that I can learn from them and not repeat them in the future.

 

I can be happy even if I fail to lose weight. I know lots of people who lead fulfilling and happy lives while remaining overweight. Factors such as looking after relationships and success at doing meaningful work are far more important when it comes to happiness.  Maintaining a healthy weight is only minor part of what makes me happy.

Positive actions

I am going to try again but this time with some more proper planning.

 

I talked to my friend Sally who has lost lots of weight and she said that I needed a plan that included:

  • Seeking help regarding dietary advice and advice regarding my problem eating behaviours
  • Planning realistic goals. She said that she is still a bit overweight for her height but that she has managed to achieve her goal which was to lose 10 per cent of her original weight. And she has kept it off for three years.
  • Focusing on long term monitoring of my weight

 

She also said that the two things that helped her most were getting her husband Greg involved in her weight loss program as well (they walk together every morning) and seeing her dietitian regularly, especially when she started off. She still sees her twice a year.

 

I am going to talk to my doctor about seeing a dietitian.

 

I am going to ask my husband David to start playing tennis with me like we used to.

 

I am going to stop expecting myself to be perfect. It only ends up making me disappointed with my self when I am not and this has often been the reason I have given up in the past. I will treat my occasional deviations from my optimum diet and exercise plan as normal, especially when I am stressed. Perhaps a goal I could adopt would be to reduce the number of ‘dietary deviations’ I have as I continue with my eating / exercise changes rather than expecting none from the start. I will try to learn from mistakes that occur so that I can anticipate and avoid them in the future.

 

Likewise, I will try to avoid all or nothing thinking about food. I know there are no bad foods, just foods I should consume less often. I am going to really try to avoid feeling guilty.

 

I have lots to be happy about and I will try to focus on positive things in my life. This will stop me being inappropriately worried / disappointed when I occasionally stray from my diet.

 

I will try to make sure that I adopt other healthy lifestyle options to minimize the impact of obesity on my life. I already do not smoke and I will try to exercising more, eat more healthy foods (especially fruit and vegetables) and less salt, and perhaps I could cut down the alcohol a bit when I have a night out with friends. I should also be a bit more regular in having check ups. My doctor said my blood pressure was a bit up last time I went.

 

There will obviously be occasions when using such a form will not be possible or the problem too minor to warrant such effort. In these cases, beliefs about the problem faced can be mentally disputed by such statements and questions as the following.

This process gets easier once experience is gained at CBT.

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B. CBT behavioural strategies

The second method of implementing CBT is through making people actually change their behaviour out in the real world to see whether their beliefs are justified. As stated above, this technique is a very useful additional therapy in people who have very rigid beliefs (often anxious people), as in these people cognitive therapy (thinking about the problem) is not enough to make them change their belief. They need to see their belief tested (and disproved) in the real world. It is very useful in people with catastrophic thinking who believe that the worst case scenario will always eventuate.

The technique involves designing a practical experiment in the person's real life that will challenge their belief and this usually means that the person has to temporarily abandon their safety or avoidance behaviours; they have to 'leave their comfort zone'. This can be difficult, especially for people with significant anxiety. For this reason, the initial challenge should be a gentle one, with subsequent experiments becoming more challenging as it becomes increasingly obvious that their belief is unjustified.

The experiment challenging the belief needs to be designed so that a definite outcome can be tested; if this id done, then that will or will not happen. For example, 'If I do not go back to recheck that I locked the front door once I leave the home, then the house will get broken into.' or 'If I don't do hourly checks that my new baby is OK while she is sleeping, then she will die in her sleep.'  General outcomes such as 'I will get worried' are not specific enough to be of use in behavioural experiments. However, it is usually possible to make such general outcomes more specific by asking questions such as, 'If I get worried, what will happen to me?'

Unreasonable beliefs are often based in truth and it is the response that is inappropriate. For example, houses are sometimes broken into. Thus, in testing, very occasionally the unreasonable behaviour is proved justified; the home might be broken into. If this happens, it is important to point out that it was not the behaviour that caused the incident; the house was not robbed because I did not go back and check the door.

It is best to write done these experiments; an example follows in the box below.

Behavioural experiment plan

 

 

Before experiment

  • Belief: My daughter will be injured or abducted if I let her come home on the bus by herself from school.
  • Alternative belief: My daughter is old enough to catch the bus with her friends from school.
  • Experiment:  I will let her catch the bus home for a week.
  • Specific prediction:  She will be injured or abducted.

After experiment

  • Results of experiment:  She arrived home safely each day and enjoyed being with her friends on the bus.
  • Conclusion: Worrying about my daughter travelling home by bus was unnecessary and unhelpful.

 
 

Graded exposure

This technique is used in people with anxiety who have adopted avoidance behaviours due to their anxieties; for example, avoiding crowded places. It involves repeated exposure to an increasingly confronting situations until the fear has been overcome. It is useful for people who have panic disorders, agoraphobia, specific phobias, post-traumatic stress disorder and obsessive compulsive disorder.

The person grades (out of ten) a variety of related situations according to their ability to provoke anxiety. The person then exposes themselves to the least anxiety provoking situation. Once this is mastered, the next situation is challenged and so on up the list until the problem has been overcome.

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Structured Problem Solving: Another problem solving technique

Structured Problem Solving is a method designed to work logically through a person's problems. It is particularly useful for people who feel overwhelmed by life’s problems and is a useful therapy for all manner of psychological problems, especially anxiety and depression, and general life problems (e.g. relationship, financial, employment, medical, drug and alcohol problems etc). It is often used in conjunction with CBT when a person's thoughts are very rigid and not easily challenged.

The Structured Problem Solving approach to problem resolution follows this general format.

  1. Firstly, with the help of the therapist, the person is asked to write a list of the problems that are worrying or distressing them and the problem(s) that is causing the most stress is then identified.
  2. The person then works out what possible options are available to deal with the problem (brainstorming) and these are listed as possible solutions. The advantages and disadvantages of each possible solution are then also listed, taking into account the resources the person has, such as friends, other people to talk to, finances, health etc. Doing this actually helps the person identify what has caused feelings about a problem and the supports and personal strengths available to him / her for resolving the problem. It can also show how the person coped with similar problems in the past. Occasionally there are problems finding a solution. These commonly fall into the following groups:
    • Where chosen solutions are unrealistic, the therapist can ask the patient questions that help identify the reasons for this.
    • Some solutions will be too vague and require the therapist to ask the patient to incororate more detail in the solution.
    • More complicated problems where possible solutions are difficult to identify can be handled by dividing up the problem into a series of smaller problems.
  3. Having done this, the best solution is selected and a list of the steps needed to carry out this option is made. This includes setting out an acceptable time frame for their implementation.
  4. Having carried out this solution, a reassessment is made at a subsequent consultation. If it hasn’t worked out, the process can be done again (with the benefit of hindsight) and another solution tried out. Initially this process needs to be done in conjunction with a counselor. However, the person can soon learn this way of problem solving and they can then use it to help with future difficulties. This increases the person’s feeling of control over their life.

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Interpersonal psychotherapy (IPT)

Counselling is almost always needed to help with psychological problems / relationship problems. A form of therapy being increasingly used to help psychological problems is interpersonal counselling.

Relationships with family and friends are an integral part of day-to-day life and problems with these relationships account for many of the psychological problems people face. They lead to disruption of the social networks that are very important in providing support and encouragement during challenging and stressful times. This lack of support can lead to more serious problems such as depression.

The emphasis of IPT is on bringing about change through focusing on improving current relationships or changing expectations about them. IPT focuses on careful assessment of the patient’s relationships, examining the way communication occurs within the relationship, including indirect communication, and attempting to identify conflicts, differing expectations and transitions (i.e. changing dynamics) in these relationships. The main aim is to improve relationships through better communication and these improved relationships will assist the person in coping with other current life stresses, such as job loss or bereavement.

To assist with therapy, interpersonal counselling attempts to separate the reasons for the relationship problems into four categories. These are grief / loss, interpersonal (role) disputes, role transitions and interpersonal deficits (relationship inadequacies). Often several problems exist at once and problems can fall into more than one category. For example, death of a spouse will cause both grief and role changes.

Grief: Grief can be any loss experienced by a person, such as death, job loss or injury. While grief is a normal part of experiencing loss, excessive grief is inappropriate and will affect a person’s ability to communicate with partners and friends. Rebuilding damaged existing relationships and establishing new ones, often through establishing new interests, helps in overcoming the grieving process.

Interpersonal disputes:  Interpersonal disputes develop when people communicate poorly or have unrealistic expectations of their relationship. Therapy requires assessment of whether the disputes are capable of resolution. If they are, then compromise needs to be the aim. Reassessing expectations and improving communication and problem solving skills are integral parts of this process. Many of these issues are covered in this book’s section on relationships. Unsalvageable relationships need help so that a peaceful dissolution that minimises further psychological stress can occur.

Role transitions: Role transitions occur when changing life circumstances cause changes in the functions the person has to perform and these changes in function will change the way the person relates to others present in the ‘changed environment’. For example, divorce will drastically change a person’s family roles. Therapy needs to promote adaptation through emphasising the positive aspects of new roles and negative aspects of old ones and encouraging the person to develop new skills that will enable them to replace old roles with new ones.

Interpersonal deficits: Some people have characters that make it difficult for them to establish and maintain lasting quality relationships. These characteristics are often founded in poor past relationship experiences. People then impose characteristics of past relationships onto new ones. These expectations are often incorrect. They distort the person’s view of the new relationship and limit the relationship’s potential. The issues involved are often complex and require more specialized counselling before interpersonal therapy can be of benefit.

Interpersonal therapy usually only requires a short course of therapy, about six to ten sessions. (It can also be used for longer periods.) A short course of therapy encourages the person to make relationship changes quickly. The initial session of about an hour assesses current relationship problems and how these are affecting the person’s coping ability. More serious problems, such as significant depression, that need other treatment modes are also identified. The following shorter consultations attempt to probe the person’s perception of the problem, identify possible effective solutions, slowly implement these solutions, and review progress. This is similar to the approach taken in cognitive behavioural therapy, but in CBT the treatment focuses on the person’s underlying thoughts rather than their relationship dynamics.

Improving social performance

Some people are lacking in the social skills needed to maintain and improve relationships. Education regarding improving both non-verbal and verbal communication can be very helpful in these people.

Click here for detailed information on where to seek out quality counselling

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Depression relapse

Unfortunately depression is often a chronic condition with 50 per cent of people experiencing more than one episode. However, the likelihood and frequency of recurrences can be reduced by the following.

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Further information on mental illness

Mental health resources

Mental Health Branch of the Department of Health and Aged Care  www.mentalhealth.gov.au
This site provides information about crisis supports and contacts, general mental health information, mental health information brochures / publications about specific topics such as depression, anxiety, information about suicide prevention etc.
Ph 1800 066 247

Beyond Blue: The National Depression Initiative https://www.youthbeyondblue.com/?&gclid=CICs69Tvgc4CFQiVvQodF-0MFA

ybblue (Beyond Blue’s youth program)  www.ybblue.com.au
Beyond Blue’s youth program (Self harm at ybblue (https://www.youthbeyondblue.com/understand-what's-going-on/self-harm-and-self-injury

Black dog institute www.blackdoginstitute.org.au
Provides information for clinicians and patient education.

Moodgym   www.moodgym.anu.edu.au
An interactive program of CBT, more aimed at depression, developed by the Centre for Mental Health Research at the Australian National University.)

Reachout www.reachout.com.au
A resource for young people with depression.

Lifeline www.lifeline.org.au  Ph 13 1114
Lifeline provides an immediate counseling service for all people)

Kids Help Line www.kidshelp.com.au
A national 24 hour counseling service for children and young people)
Ph 1800 551 800

CRUfAD, The Clinical Research Unit for Anxiety and Depression www.crufad.com 
CRUfAD is a group of researchers and clinicians concerned with anxiety and depression. It is a joint facility of St Vincent's Hospital Ltd and the University of New South Wales in Sydney, Australia. The self-help section of the web site has useful information about both anxiety and depression for the general public.

Anxiety Panic Hub www.panicattacks.com.au
A consumer web site with a focus on meditation / mindfulness.

Mindmatters  http://www.mindmatters.edu.au
A program that introduces mental health education to secondary schools.

A helpful Australian Government web site:
Children of Parents with a Mental Illness ('COPMI') (An Australian Government web site.)
http://www.copmi.net.au/

 

Further reading on mental health topics

Rowe L, Bennett D and Tong B. I just want you to be happy. Preventing and tackling teenage depression, Allen and Unwin 2009.

Rapee, R., Spence, S., Cobham, V. and Wignall, A. Helping your anxious child. A step by step guide for parents. New Harbinger, 2000.

Macquarie University Child and Adolescent Anxiety Unit
This unit runs 12 week courses for anxious children in the 6 to 12 year age group.
www.psy.mq.edu.au/muaru.

Rapee, R.M. (2001). Overcoming shyness and social phobia: A step by step guide. Sydney: Lifestyle Press.
Deals with social phobias and shyness

Wells, A. (1997) Cognitive therapy of anxiety disorders; a practice manual and conceptual guide. Chichester. John Wiley and Sons, 1997.
  
Beating the blues by Susan Tanner and Jillian Ball. Published by Susan Tanner and Jillian Ball. Distributed by Tower books.
A good book for issues dealing with the treatment of depression.

Don’t panic. Overcoming anxieties, phobias and tensions by Andrew Page. Published by Liberty One Media.
Deals with panic disorders, phobias and anxiety.

Aisbett, B. Living with it; a suvivor’s guide to panic attacks. Pymble, NSW. HarperCollinsPublishers, 1993.

Aisbett, B.Taming the black dog. Pymble, NSW. HarperCollinsPublishers, 2000.

Calrk, S. After suicide: help for the bereaved. Melbourne. Hill of Content Publishing Company Pty Ltd, 1995.

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