Antidepressants
Talking therapies and antidepressants
Current government policy aims to make talking therapies more easily available on the NHS. Guidelines for the treatment of depression advise doctors to refer patients with a new diagnosis of mild to moderate depressive symptoms for talking therapies before prescribing antidepressants.
There are a number of effective talking treatments for depression. Counselling is useful in mild depression. Psychotherapy is a more in-depth form of therapy than counselling, which can be used to address a wider range of issues. For mild to moderate depression the GP may suggest Cognitive Behavioural Therapy (CBT). This can help people manage their problems by changing the way they think and behave. The Improving Access to Psychological Therapies (IAPT) programme aims to improve access to talking treatments, which may be offered on a one to one basis, in groups, or through online materials. It may be possible to self-refer through this programme instead of going through the GP.
When it comes to mental health problems I’m very psychologically minded okay I think the research suggests psychological therapy is much more effective than antidepressants and lasts a lot longer so the mainstay of my treatment is going to be psychological. And I consider mental health to be like physical health, you know, in physical health we’re not divided into sick people and healthy people we can all be fitter, you know, we could all it’s a spectrum and the same is true for mental health, you know, even if you’ve never had a mental illness you may not be living a mentally very healthy lifestyle. So there’s, there’s lots of things that we can do to improve our mental fitness and so a lot of my conversation with patients is along that line. So when it comes to certainly mild to moderate depression as distinct from people who have got mental distress or stress in their life. I think there isn’t a lot of evidence to say that antidepressants are effective at all, I’m very concerned that that we haven’t got clear data on antidepressants and some of them we have problems with publications bias that only the positive studies are being published I think the effects aren’t clear so I am hesitant to prescribe antidepressants to those people and would much prefer to try psychological therapies as a first choice.
The people we interviewed had accessed a range of different types of talking therapies, as well as taking antidepressants. Some said their GP had suggested counselling or therapy at the time when they were prescribed an antidepressant. Emily’s doctor ‘was very clear on the fact that he believed, you know, some sort of therapy... the medication shouldn’t be used, shouldn’t be by itself, you need to look at the reasons for it’. People felt strongly that it was important to have this type of help, as well as being prescribed an antidepressant. Many believed that although medication can help relieve symptoms you must ‘get to the root of the problem’ in order to recover, Charlotte echoed this view ‘I don’t have a problem taking antidepressants, but it’s just masking the problem, it’s not actually addressing the underlying problem’.
I’m quite pro I suppose anti-depressant medication alongside the therapy because I do think it gives you a certain level of detachment that firstly I think is necessary to, for me obviously... it was needed for me to be able to really talk about things and secondly it helped me just to carry on whilst I was trying to, just carry on with things I suppose whilst, because the therapy it was awful at first, I mean she was fantastic, and by the end of it I thought and still do, the best thing I ever did but it was so horrible those first few sessions I don’t know if I could have, I don’t think I would have gone back if I didn’t have the medication. You know, whether or not it was in my mind that, that the medication was supporting me in that way, whether or not it was true that it was doing that, I needed that to be able to keep going and get a sort of breakthrough in therapy.
But I do think if I only had the medication and not the therapy I’d probably still be on it now because I think if I hadn’t actually learnt about these coping mechanisms and got to, I wouldn’t say the root of the problem because there was no real individual root but it was more about how I coped with stress and how I coped with sort of unravelling that, I don’t think, I don’t see how medication could have, I could come off medication if I hadn’t dealt with that.
The CPN was the first one and I think, I think the main thing I got from that was to accept that there had been things in my life that had happened and even though I thought they weren't big major issues they'd all sort of come together over the years and built up and built up and it did help towards me feeling bad. I used to feel very , I was a terrible mother, I was awful because everyone else can cope, everyone else loves their children, everyone else misses them and I didn't and I thought that was me and I was wrong and I was bad. So it helped me look at things differently .
And do you think that being on medication that you could think about those things more easily?
Yes, yeah, yeah. We touched on cognitive therapy which I have tried since. At the time it all seemed very, well if you're feeling OK yes that's going to be very good. If you're not feeling OK it's going to be very difficult to challenge your negative thoughts because they're your thoughts, you don't see them as negative thoughts that's just how they are .
It's a distorted reality isn't it but you can't…
Yeah, yeah.
When you're in that position it's very hard to recognise that.
Yeah when you're well you can see how it would work. When you're not well it's, it's quite difficult to put into practise. But I think the medication certainly helped me to be able to talk a bit more and listen a bit more and think and reflect on things that have been said and subsequent therapies definitely.
Often people used the terms ‘counselling’ or ‘therapy’ interchangeably and not everyone knew what approach their counsellor or therapist took. Where talking therapy had been suggested by the GP generally it was either CBT or counselling. Some people had undertaken longer term psychotherapy, although often this was at their own expense, or through workplace schemes, because there is limited availability for this type of therapy through the NHS. Some people with more deep-rooted or serious depression saw a psychologist or other mental health specialists on a regular basis through the community health team, or in hospital. Some saw a therapist or counsellor on a one-to-one basis, but others had attended groups, had telephone consultations, or used internet resources. Andrew (below) was dubious about going to a group for CBT at first, but after a while he found it really helpful.
For the first time I acknowledged with him that I was depressed and he said I should think about going on some treatment for that. But I was starting the Cognitive Behaviour Therapy at the same time so I thought I’ve give that a go. But then I just thought no, you know, I do think that’s going to be helpful but I admitted to myself that actually I’m in a pretty horrid place and I just want to get out of it as quickly as I can so I also went on the treatment. And I should say the Cognitive Behaviour Therapy with Talking Space it was called let’s get it right, was really helpful and really good and I’ve benefitted massively from that but I think in combination with the treatment I have really turned around a lot in the past six months and now I look back and I think what a terrible place I was actually in and how there is life and a good life to be had, you know.
I think that the combination worked for me and I think the CBT was incredibly useful in the practical day to day things which, which help me deal with situations. But the, the tablets have helped the sort of underlying cause that has allowed me to embrace the CBT kind of perhaps better and be more open to it. I have to say when I, when the first, the first thing I went to at CBT was a group meeting so the doctor said you can go along on this course, sign up on this course and I did and the first thing I did was a group meeting and I came out of that really feeling terrible, really thinking this isn’t, this isn’t for me. You know I wasn’t expecting it to be such a large group of people and we were talking about, you know, ways you might, you know, ways you might approach fixing the dishwasher or something practical, and I thought oh my God why am I here these people clearly have no idea how I feel this has got nothing to do with my life, you know, and how can, you know, a group of forty people.
That was a lot.
It was... about 36 people, you know, how can we, how can we kind of deal with it. But it was a relief to see so many people there, you know, with the same sort of symptoms because it didn’t occur to me it could possibly be so common. But anyway I came out thinking that and then I looked at their website and I went for a one to one with the councillor who would see me through it and I spoke to her and I thought just give it a go, you know, just let’s see what’s on offer, nothing ventured nothing gained. And I found talking to her was very useful and having someone again there who would support you through it seemed to me to be a good thing. And I did the first, you do an online system and I think you have eight tutorials and stuff you do during the week.
And the first two I thought oh, you know, I’m still not sure but as I did it because I persevered and I spoke with her, after about week four I just thought I can see where it’s going, you know, this is , it starts here [talking over] but it takes you through. And what I, when it kind of clicked with me after maybe week four I actually got quite excited about it and I wanted to do it and I wanted to do the tutorials.
The other two really key things, several key things that have been useful for me have been things like therapeutic support along the side of the medication so getting some kind of understanding of what’s going on and I certainly found CBT very helpful and it’s I think particularly helpful when you’re not too ill because if you're not too ill you can engage with it and understand it and when you're getting unwell hopefully you can use some of those resources to stop it getting worse in some respect or to kind of keep yourself a little bit from succumbing to it. But the other thing really has been mindfulness; I don’t know whether you want me to say anything about that.
Yes quite a few people have mentioned that they have tried this, I think it’s a kind of new up and coming tool to use.
Well I kind of accessed already mindfulness type meditation through, it’s evolved through Buddhist meditation techniques and I already did... do Buddhist meditation techniques in various forms and some of them incorporate kind of the mindfulness. But obviously they weren’t in a mental health kind of setting or for that purpose. And I was lucky enough to be referred to a mindfulness course and what, and what I really, really found and discovered was that it really, really strengthened my own personal meditation practice and it really, it was a mindfulness based and cognitive based course so it was kind of in relation to people who may have suffered anxiety and depression so it was kind of helps you see connections I think with what goes on in your mind and how you process things but what you can do which is through breathing techniques and, and kind of more formal kind of meditation to kind of disengage from that. For me that’s more effective in many ways than CBT. Because CBT involves thinking again but your thinking is skewed when you’re depressed very, very hard to use your thinking mind. Whereas mindfulness what that teaches you is that when you're focusing with, first of all you disengage what is going on in your head because you are taught to focus on your breath you can focus on other things but it’s generally your breath and it might be a certain part of your body. but there’s always an anchor point so whatever is going on in your mind you’re taught to acknowledge it notice it but as soon as you start going off in the story of it and reviewing it or replaying videos in your head, as soon as you realise it’s happened just gently bring yourself back to the breath and don’t judge yourself.
It helped to meet other people and to go to some of the groups and realise that, you know I wasn’t completely crazy and other people had similar thoughts and feelings and suddenly it was the first time even though I know that other individuals, for example, in my family had suffered, it was the first time that I really heard from other people things that I had thought myself, felt myself and that was actually one of a key, key supportive development to my recovery was just feeling connected again.
Views about the potential benefits or otherwise of talking therapy varied widely. People described positive benefits including: gaining new perspectives; helping them cope with difficult life events; developing a better understanding of themselves; helping them develop new ways of thinking and taking responsibility for their lives. Some said that it was helpful just having an impartial and non-judgemental person taking an interest. Lucy Y said, ‘It’s good to have, you know, that sort of private knowledge of non-judgemental space to talk stuff over. Michael said, ‘I’ve always felt that talking to people is the best therapy for everybody, sharing and talking, honest talking one to, you know, heart to heart talking’. Some people had tried different types of therapy over several years but were resigned to being prone to depression. Even so, some said it had helped them find ways to cope or recognise signs or symptoms and to manage things more easily when they felt themselves ‘slipping’.
People varied in when they thought was the best time to access talking therapies. Some had not felt ready or able to talk openly about things when they first sought help and felt an antidepressant helped them to feel more stable and able to engage with therapy eventually.
Some people we spoke to would like doctors to be more willing to suggest talking therapies before prescribing an antidepressant, but they felt that there were constraints on what they could offer. A common complaint was that the availability of therapeutic services was limited and most people who would have liked to have the option said they had not been able to access services immediately. Some people felt let down by the lack of options. Melanie was prescribed an antidepressant and wanted to have counselling, but was told there was a waiting list ‘I was lucky enough to get the private counselling that’s helped me through. If I had still had to have waited to see the counsellor through the GP surgery I don’t know how I would have felt’. Others also felt it was unacceptable to have to wait a lengthy period for an appointment, and that if you were in crisis it could feel as though nobody cared enough to help you. Some expressed concerns that without someone to talk to, people who were seriously depressed could be at risk of harming themselves.
I think it’s awful, I think I’m ready to do it now, I didn’t think it wouldn’t happen for 18 weeks and well you know that’s, and I’m also aware of the fact that there are people that have worse, worse cases if that makes sense so for me in a selfish way I think it’s rubbish but in another way they wouldn’t be like that if their case load wasn’t so much. But actually I know what’s going on and that actually it’s much more political than it is about people and volume so I know what’s going on because I was involved in it for a while.
But when it’s affecting you maybe that changes how you feel about it?
It’s just that, just, I mean I’m ready to do this kind of now and everything seems to be set up for it to happen now and the drugs are kind of working, you know, and the citalopram seems to be working, I’m in a good relationship that’s just getting to a point where I either fix it or it’s probably not going to happen and I don’t want that to happen. But the actual therapy counselling side of it I can’t have for 18 weeks.
Counselling sessions, or therapy such as CBT was sometimes available through workplace schemes or occupational health departments. Others had paid to have therapy privately, but it can be costly and out of reach for people with lower incomes.
In some instances it had been a counsellor who had suggested the GP should be consulted about whether an antidepressant might help. Flora saw a counsellor through the occupational health department at her workplace. The counsellor was concerned about her when she filled out a depression questionnaire and recommended that she should see her GP. Melanie had some telephone counselling sessions provided by a workplace scheme before she decided to consult her GP.
Not everybody wanted to access talking therapies straight away, or at all. It’s not uncommon for people to feel that they just want to take medication to alleviate the symptoms they are experiencing. Some people hadn’t wanted to talk to anyone about their lives or problems, or felt reluctant to talk to anyone for fear of being judged. Others said they had felt numb and detached and incapable of engaging on a meaningful level with talking therapy. Collette reflected that although she had seen a counsellor she hadn’t felt able to ‘open up’. ‘I play games... dance around subjects I would throw questions back at them instead of answering the questions that they want me to, I don’t always mean to, I don’t always want to I just seem to do it as a, I suppose a self- defence’. Charlotte had been offered an appointment for group counselling but said, ‘I didn’t want to talk about my situation in front of lots of people so I didn’t go’. Victoria commented that although she thought it was something worth looking into, ‘it’s one of those things when everything’s going fine you don’t think about it, you only really think about it when you’re having a bad day’. Lucy Y had been referred for counselling when she was younger but had cancelled the appointments beforehand because she felt too anxious about it. It’s only more recently as she’s become older that she’s felt less overwhelmed and has benefitted from seeing a therapist.
I think counselling is something that I should be doing but it’s one of those things it’s the first step isn’t it of doing it, it is kind of the hardest and I think it’s easier to not go and do that. So you know, I guess, you know, I chose medication this time because I wanted something instant, I wanted a quick fix I guess and I was thinking ‘Oh I’ll just take these pills and I’ll be better,’ but that doesn’t obviously solve the deep rooted issues that I may have or one person may have. So, you know, I’m more of probably advocate of going to counselling, I would tell my friends to go to counselling but doing it myself is a different thing isn’t it so I think I don’t take my own advice necessarily.
I love talking so I would love to go to a counsellor and, you know, chat but I, my life, again my life I make excuses like my life’s so full, you know, I’ve got my full time job I do and I’m an artist, I’m a photographer, I‘ve got this relationship, I’m doing this, I always make excuses that I’m too busy to go and probably do the thing that I should.
But the medications quite convenient to fit in with all of that?
Yes because you’re just, it’s swallowing a pill in the morning isn’t it and it’s, it’s kind of, you know, it’s an instant hit, well not an instant hit but it’s something where you don’t have to go and spend some time seeing someone and thinking are they judging you or, you know, all those things that you may think but they’re not but, you know, yeah so you know I think counselling’s something that I, I personally probably should be looking into.
Some had tried talking therapies in the past and not found it useful, but as they got older or their circumstances changed they said they had felt more willing or able to give it a try. Another type of therapy sometimes suited them better. Tim (below) tried CBT but didn’t take to it, but later tried psychotherapy and said it changed his life. Dina had experienced a breakdown when she was postgraduate student and felt that it was psychotherapy that had ‘saved my life’, ‘Well perhaps the antidepressants worked to start with and, you know, kind of lifted my mood but I think it was, the work that I did in therapy that helped me to be able to finish my studies’. Gerry was clear that although antidepressants had helped with the symptoms of depression that ‘you still think depressed thoughts’ and CBT had helped him to think differently about things.
I remember thinking quite clearly I wasn’t, I’d rather not try the drugs so if you’re offering me these two things I’d try the therapy first please. So that was that and I, over the period of twelve months embarked on a something like a guided self-help course and then a slightly more intensive form of CBT.
On the internet?
No through the local services that were available I think it was the IAP service. So I did a six week course over the summer which was called Guided Self Help and I, you know, I found some use in that, I felt but afterwards I didn’t really, I still was quite, because at this point I’d changed jobs because that workplace was really not very good for me and but nevertheless I was still feeling equally not that great about things. and then I did a second more intensive course of CBT, intensive probably in the sense that it lasted longer, it was more like twelve or fourteen weeks spread over about three or four months and that was, you know, I found it, there was a security in the knowledge that I was going to see somebody and that was good but it wasn’t particularly, I felt like always the person I was seeing had to go and check their notes at the beginning of the session to think who is this guy again and that we would go through things in quite a kind of, quite a deliberate kind of slightly patronising fashion and it felt a little bit like this wasn’t really about me this was about that person going through the stages that they’d been taught to go through for people with depression so I felt like a bit of a cog in a machine basically.
I guess my, from my perspective the thing that’s helped me a huge amount is doing a kind of personal long term in-depth kind of psychotherapy and that’s, that’s helped a hundred times more than anything else that I had.
I guess I can make a distinction between starting to do the Cognitive Behavioural Therapy and how that, that altered how I was thinking, you know, my thought processes I started to understand a lot more about how my brain works. but definitely I attribute the, the physical manifestation of either depression or anxiety that being the, you know, the shortness of breath or the sort of being the involuntary clenching when you became anxious or, that definitely the antidepressants helped take the edge off that. And now I would say I’m coming to the end of my CBT treatment now; I’ve had about 15 sessions of CBT. I just went to see my specialist during the week there, he says that I’m in remission now but I should keep on going on the antidepressants for about, he thinks until about March or April next year so that’s going to be about nine months I’ll have been on antidepressants. Touch wood hopefully, you know, I’ll be oaky by then and I won’t have a reoccurrence of the depression so yes.
So all the while that you’ve been on the antidepressants then you’ve been going through this course of CBT as well.
Yes.
I mean how would you say that those two things combine together?
Really well. The CBT or the antidepressants help, like I say these....physical, these physical feelings like the other thing was when I used to try and go to sleep at night I’d always feel like there was this black shadow like, it was weird like weird to describe you know I felt like I had the weight of the world on my shoulders when I went to bed at night and almost like having, you know big black ghost behind me like really pressing down on my shoulders, these are the sort of physical manifestations I was feeling. But stuff like that was, that’s what I mean by ‘levelling off’ you know, that, that really dissipated and I can contribute that to the antidepressants, I’m pretty sure in my mind. But you still think depressed thoughts and what the CBT’s done is help me stop thinking like that so ....realising when I’m having irrational thoughts how I can, you know, (A) realise that I’m having them but (B) sort of like developing strategies to cope with them really I guess. So there are definitely two... attacks from two different sides you know what I mean. And I would never ever I wouldn’t have wanted to and I’d never recommend anyone just having antidepressants because that’s like anything that’s a, for me they ‘re a medicine, they make you feel, you know, it’s like if you were diagnosed with a heart condition you’d get a triple bypass or something like that but, you know, if you have triple bypass and then like didn’t change your lifestyle and continued to eat fatty foods then you know you’re not, you know, it’s like going on antidepressants ...it’s fine for the condition but you’ve got to go, for me, do like talk therapies or like CBT or, you know, counselling or whatever because that’s what’s going to fully cure you and hopefully, touch wood, keep you healthy in the future and stop it reoccurring.
Sometimes people felt that the reason a particular therapy had been successful was because of the relationship they had developed with the counsellor or therapist. Several said that their therapist was the only person who knew them really well. Max commented that whilst the doctor who prescribes his medication knows about his physical health, it’s the counsellor who ‘knows most about my story’. But some said had found it difficult when their therapy finished. Michael described it as ‘a big loss… like a rejection’ and said he felt really let down when he stopped seeing his therapist. Sonia also felt a strong connection with her therapist and that she had become very attached to her. She also commented on the lack of ‘joined up thinking’ between the therapist who she saw on a private basis, and the mental health team and psychiatrist who were responsible for prescribing her medication and providing care on an ongoing basis. Thomas felt there were conflicts of interests between his psychiatrist and GP, and the therapist he had been seeing, who had different opinions about medication.
So there was a kind of attitude conflict between the different people I was seeing. There was my psychologist, who has never focused on medication until recently. He suggested I take mirtazapine. There was no kind of…. He would see as the psychiatrist job or the GP’s job. The GP and psychologist would see medicine as their job but not the talking therapies. So it was a complete non communication between the people that I was seeing.
And going back when I was seeing the lady at the university counselling service - group therapist again there was this non, no communication. They were just - no you don’t take medication; you talk things through, that’s how you solve problems. And they didn’t talk to the GP or the psychiatrist whose main business to be honest was kind of crisis management and giving out medication. There was no communication between the two.
Several people spoke of the benefits of attending courses or working with therapists who taught mindfulness techniques. Mindfulness is a ‘mind body based training’ that uses meditation techniques. It encourages people to develop strategies that help them to attend to the present moment instead of focusing on the past or worrying about the future. Sharon was sceptical about it when she was referred. ‘I thought it was all tree hugging hippy stuff to be honest when they first told me about it but I went and I engaged and it was really good, really, really helped, really helpful’.
The first session was really odd because we were given an object that we had to look at and it was a raisin.
And I thought; I was looking at other people and they were looking at me and we're thinking, 'What are we doing here? What, how on earth is this going to help?' It was a twelve week course so a couple of hours a week and you had homework to do. Based on Buddhism, meditation and things like that so I thought, 'Oh shit, airy fairy stuff whatever,' but it was very good, it was very good. It helps you focus and take time out and step back and assess situations for what they are and it helps with a lot of things other than depression but I found it very helpful for me especially if I was feeling overwhelmed in a situation and normally I'd have just burst into tears and that's it I can't cope. Just to do a breathing exercise for example that's a couple of minutes, step back, look at the situation and think, 'OK this is what you can do, this is what you can't do, what's the point in, in worrying or is it worth doing something? Should you act or not? Accept the situation for how it is and carry on.' And it enabled me to do that quite a lot and it's something that I've continued to do.
How does it feel doing that kind of thing in a group?
I'm not, I'm not a great one for group work but I thought I'd try and everybody; it was, everything was confidential, you didn't have to share anything you didn't want to share so you didn't even know why other people were there. And you can help each other I think, you always get a few that are more talkative than others but you could share your experiences of doing the practises and you’d quite often find that somebody else felt the same as you did for one or somebody felt something totally different and you sit and talk about it and how you can change your approach or how it could be useful in day to day life. And sharing what we'd been practising at home and what we'd used it for and things so it was OK and we'd; definitely there was some sort of bond there between a few of us. Not that we've seen each other outside but yeah it was OK, it was OK.
Doctors are very good but they're a jack of all trades whereas the mental health nurse specialises in mental health and I think it's very easy for the doctors to just, "Oh well we'll try you on another one," and not to look at what effect it is having, what emotional effects it's having or not dealing with and trying to interlock it with other therapies, that's certainly what the mental health nurse did was put it alongside psychotherapy and the mindfulness and bring them all together and use them altogether and I think that's been the key to not just have therapy or just have anti-depressants but to use it all because I think for me definitely you need the anti-depressants to get you up to a level that you can engage and make use of the tools that they can you provide you.
People who had been in hospital sometimes benefited from therapeutic support as well as antidepressant or other medicines. It could help to be in therapy groups with other people who had similar experiences and to realise that you were not alone. But mixing with others’ with serious mental health problems could also be distressing. Some people were critical about the type or standard of therapeutic provision that had been made available in hospital, or said that they had just been given medication with no therapeutic support.
Talking through in group therapy and hearing other situations that people were having to deal with. Horrible situations that happened in people’s pasts, horrible just, you know, stuff like from the news really. And accepting that they were taking similar sort of, not necessarily the same medication but they were taking similar sorts of medication in order to dampen down all those fears that where rising in them for whatever trigger had risen some of their ancient fears so. I think once I was in a community of people that were prepared to express their problems which I hadn’t, there was no group therapy and talking therapy at the acute hospital I went to.
Even though everybody was casually telling each other what their problems were there was no structure to it and there was no and how do you get out of that hole to it. And at least the private clinic there was, you know, like and here’s how you do, you know they introduced us to CBT, they told us about the methods, you’ve got this fear, how big is this fear, is it real, does it really affect that situation and so you started to like wake up to how you can control those thoughts and things so. I think learning CBT really, really helped because it did stop me and made me analyse. And also being amongst people who were wanting to be protected and wanting to get better actually helped me to get more in that mindset. And I also, it helped me to get my problems into relative respective as well.
(See also ‘Treatment in hospital’, ‘Taking other medicines with antidepressants’ and ‘Being prescribed an antidepressant').
Last reviewed June 2016.
Last updated June 2016.
There are a number of effective talking treatments for depression. Counselling is useful in mild depression. Psychotherapy is a more in-depth form of therapy than counselling, which can be used to address a wider range of issues. For mild to moderate depression the GP may suggest Cognitive Behavioural Therapy (CBT). This can help people manage their problems by changing the way they think and behave. The Improving Access to Psychological Therapies (IAPT) programme aims to improve access to talking treatments, which may be offered on a one to one basis, in groups, or through online materials. It may be possible to self-refer through this programme instead of going through the GP.
Simon is a GP and has depression. He encourages his patients...
Simon is a GP and has depression. He encourages his patients...
Emily might not have gone through with therapy without being...
Emily might not have gone through with therapy without being...
But I do think if I only had the medication and not the therapy I’d probably still be on it now because I think if I hadn’t actually learnt about these coping mechanisms and got to, I wouldn’t say the root of the problem because there was no real individual root but it was more about how I coped with stress and how I coped with sort of unravelling that, I don’t think, I don’t see how medication could have, I could come off medication if I hadn’t dealt with that.
Sharon saw her CPN (Community Psychiatric Nurse) for talking...
Sharon saw her CPN (Community Psychiatric Nurse) for talking...
And do you think that being on medication that you could think about those things more easily?
Yes, yeah, yeah. We touched on cognitive therapy which I have tried since. At the time it all seemed very, well if you're feeling OK yes that's going to be very good. If you're not feeling OK it's going to be very difficult to challenge your negative thoughts because they're your thoughts, you don't see them as negative thoughts that's just how they are .
It's a distorted reality isn't it but you can't…
Yeah, yeah.
When you're in that position it's very hard to recognise that.
Yeah when you're well you can see how it would work. When you're not well it's, it's quite difficult to put into practise. But I think the medication certainly helped me to be able to talk a bit more and listen a bit more and think and reflect on things that have been said and subsequent therapies definitely.
Andrew went to a group based CBT programme, and said it was...
Andrew went to a group based CBT programme, and said it was...
I think that the combination worked for me and I think the CBT was incredibly useful in the practical day to day things which, which help me deal with situations. But the, the tablets have helped the sort of underlying cause that has allowed me to embrace the CBT kind of perhaps better and be more open to it. I have to say when I, when the first, the first thing I went to at CBT was a group meeting so the doctor said you can go along on this course, sign up on this course and I did and the first thing I did was a group meeting and I came out of that really feeling terrible, really thinking this isn’t, this isn’t for me. You know I wasn’t expecting it to be such a large group of people and we were talking about, you know, ways you might, you know, ways you might approach fixing the dishwasher or something practical, and I thought oh my God why am I here these people clearly have no idea how I feel this has got nothing to do with my life, you know, and how can, you know, a group of forty people.
That was a lot.
It was... about 36 people, you know, how can we, how can we kind of deal with it. But it was a relief to see so many people there, you know, with the same sort of symptoms because it didn’t occur to me it could possibly be so common. But anyway I came out thinking that and then I looked at their website and I went for a one to one with the councillor who would see me through it and I spoke to her and I thought just give it a go, you know, just let’s see what’s on offer, nothing ventured nothing gained. And I found talking to her was very useful and having someone again there who would support you through it seemed to me to be a good thing. And I did the first, you do an online system and I think you have eight tutorials and stuff you do during the week.
And the first two I thought oh, you know, I’m still not sure but as I did it because I persevered and I spoke with her, after about week four I just thought I can see where it’s going, you know, this is , it starts here [talking over] but it takes you through. And what I, when it kind of clicked with me after maybe week four I actually got quite excited about it and I wanted to do it and I wanted to do the tutorials.
Flora found therapeutic support helpful in addition to taking...
Flora found therapeutic support helpful in addition to taking...
Yes quite a few people have mentioned that they have tried this, I think it’s a kind of new up and coming tool to use.
Well I kind of accessed already mindfulness type meditation through, it’s evolved through Buddhist meditation techniques and I already did... do Buddhist meditation techniques in various forms and some of them incorporate kind of the mindfulness. But obviously they weren’t in a mental health kind of setting or for that purpose. And I was lucky enough to be referred to a mindfulness course and what, and what I really, really found and discovered was that it really, really strengthened my own personal meditation practice and it really, it was a mindfulness based and cognitive based course so it was kind of in relation to people who may have suffered anxiety and depression so it was kind of helps you see connections I think with what goes on in your mind and how you process things but what you can do which is through breathing techniques and, and kind of more formal kind of meditation to kind of disengage from that. For me that’s more effective in many ways than CBT. Because CBT involves thinking again but your thinking is skewed when you’re depressed very, very hard to use your thinking mind. Whereas mindfulness what that teaches you is that when you're focusing with, first of all you disengage what is going on in your head because you are taught to focus on your breath you can focus on other things but it’s generally your breath and it might be a certain part of your body. but there’s always an anchor point so whatever is going on in your mind you’re taught to acknowledge it notice it but as soon as you start going off in the story of it and reviewing it or replaying videos in your head, as soon as you realise it’s happened just gently bring yourself back to the breath and don’t judge yourself.
It helped to meet other people and to go to some of the groups and realise that, you know I wasn’t completely crazy and other people had similar thoughts and feelings and suddenly it was the first time even though I know that other individuals, for example, in my family had suffered, it was the first time that I really heard from other people things that I had thought myself, felt myself and that was actually one of a key, key supportive development to my recovery was just feeling connected again.
People varied in when they thought was the best time to access talking therapies. Some had not felt ready or able to talk openly about things when they first sought help and felt an antidepressant helped them to feel more stable and able to engage with therapy eventually.
Some people we spoke to would like doctors to be more willing to suggest talking therapies before prescribing an antidepressant, but they felt that there were constraints on what they could offer. A common complaint was that the availability of therapeutic services was limited and most people who would have liked to have the option said they had not been able to access services immediately. Some people felt let down by the lack of options. Melanie was prescribed an antidepressant and wanted to have counselling, but was told there was a waiting list ‘I was lucky enough to get the private counselling that’s helped me through. If I had still had to have waited to see the counsellor through the GP surgery I don’t know how I would have felt’. Others also felt it was unacceptable to have to wait a lengthy period for an appointment, and that if you were in crisis it could feel as though nobody cared enough to help you. Some expressed concerns that without someone to talk to, people who were seriously depressed could be at risk of harming themselves.
Steve felt let down when he was told he’d have to wait 18...
Steve felt let down when he was told he’d have to wait 18...
But when it’s affecting you maybe that changes how you feel about it?
It’s just that, just, I mean I’m ready to do this kind of now and everything seems to be set up for it to happen now and the drugs are kind of working, you know, and the citalopram seems to be working, I’m in a good relationship that’s just getting to a point where I either fix it or it’s probably not going to happen and I don’t want that to happen. But the actual therapy counselling side of it I can’t have for 18 weeks.
In some instances it had been a counsellor who had suggested the GP should be consulted about whether an antidepressant might help. Flora saw a counsellor through the occupational health department at her workplace. The counsellor was concerned about her when she filled out a depression questionnaire and recommended that she should see her GP. Melanie had some telephone counselling sessions provided by a workplace scheme before she decided to consult her GP.
Not everybody wanted to access talking therapies straight away, or at all. It’s not uncommon for people to feel that they just want to take medication to alleviate the symptoms they are experiencing. Some people hadn’t wanted to talk to anyone about their lives or problems, or felt reluctant to talk to anyone for fear of being judged. Others said they had felt numb and detached and incapable of engaging on a meaningful level with talking therapy. Collette reflected that although she had seen a counsellor she hadn’t felt able to ‘open up’. ‘I play games... dance around subjects I would throw questions back at them instead of answering the questions that they want me to, I don’t always mean to, I don’t always want to I just seem to do it as a, I suppose a self- defence’. Charlotte had been offered an appointment for group counselling but said, ‘I didn’t want to talk about my situation in front of lots of people so I didn’t go’. Victoria commented that although she thought it was something worth looking into, ‘it’s one of those things when everything’s going fine you don’t think about it, you only really think about it when you’re having a bad day’. Lucy Y had been referred for counselling when she was younger but had cancelled the appointments beforehand because she felt too anxious about it. It’s only more recently as she’s become older that she’s felt less overwhelmed and has benefitted from seeing a therapist.
Greg feels it’s a good idea to have counselling or therapy...
Greg feels it’s a good idea to have counselling or therapy...
I love talking so I would love to go to a counsellor and, you know, chat but I, my life, again my life I make excuses like my life’s so full, you know, I’ve got my full time job I do and I’m an artist, I’m a photographer, I‘ve got this relationship, I’m doing this, I always make excuses that I’m too busy to go and probably do the thing that I should.
But the medications quite convenient to fit in with all of that?
Yes because you’re just, it’s swallowing a pill in the morning isn’t it and it’s, it’s kind of, you know, it’s an instant hit, well not an instant hit but it’s something where you don’t have to go and spend some time seeing someone and thinking are they judging you or, you know, all those things that you may think but they’re not but, you know, yeah so you know I think counselling’s something that I, I personally probably should be looking into.
Tim felt CBT was too formulaic and patronising...
Tim felt CBT was too formulaic and patronising...
On the internet?
No through the local services that were available I think it was the IAP service. So I did a six week course over the summer which was called Guided Self Help and I, you know, I found some use in that, I felt but afterwards I didn’t really, I still was quite, because at this point I’d changed jobs because that workplace was really not very good for me and but nevertheless I was still feeling equally not that great about things. and then I did a second more intensive course of CBT, intensive probably in the sense that it lasted longer, it was more like twelve or fourteen weeks spread over about three or four months and that was, you know, I found it, there was a security in the knowledge that I was going to see somebody and that was good but it wasn’t particularly, I felt like always the person I was seeing had to go and check their notes at the beginning of the session to think who is this guy again and that we would go through things in quite a kind of, quite a deliberate kind of slightly patronising fashion and it felt a little bit like this wasn’t really about me this was about that person going through the stages that they’d been taught to go through for people with depression so I felt like a bit of a cog in a machine basically.
I guess my, from my perspective the thing that’s helped me a huge amount is doing a kind of personal long term in-depth kind of psychotherapy and that’s, that’s helped a hundred times more than anything else that I had.
Gerry feels antidepressants can help...
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So all the while that you’ve been on the antidepressants then you’ve been going through this course of CBT as well.
Yes.
I mean how would you say that those two things combine together?
Really well. The CBT or the antidepressants help, like I say these....physical, these physical feelings like the other thing was when I used to try and go to sleep at night I’d always feel like there was this black shadow like, it was weird like weird to describe you know I felt like I had the weight of the world on my shoulders when I went to bed at night and almost like having, you know big black ghost behind me like really pressing down on my shoulders, these are the sort of physical manifestations I was feeling. But stuff like that was, that’s what I mean by ‘levelling off’ you know, that, that really dissipated and I can contribute that to the antidepressants, I’m pretty sure in my mind. But you still think depressed thoughts and what the CBT’s done is help me stop thinking like that so ....realising when I’m having irrational thoughts how I can, you know, (A) realise that I’m having them but (B) sort of like developing strategies to cope with them really I guess. So there are definitely two... attacks from two different sides you know what I mean. And I would never ever I wouldn’t have wanted to and I’d never recommend anyone just having antidepressants because that’s like anything that’s a, for me they ‘re a medicine, they make you feel, you know, it’s like if you were diagnosed with a heart condition you’d get a triple bypass or something like that but, you know, if you have triple bypass and then like didn’t change your lifestyle and continued to eat fatty foods then you know you’re not, you know, it’s like going on antidepressants ...it’s fine for the condition but you’ve got to go, for me, do like talk therapies or like CBT or, you know, counselling or whatever because that’s what’s going to fully cure you and hopefully, touch wood, keep you healthy in the future and stop it reoccurring.
Sonia pays to have therapy privately. It can feel as though her therapist is the only one who is ‘on my side’. She thinks it would be more helpful if the therapist and other health professionals responsible for her care worked together, rather than separa
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Sonia pays to have therapy privately. It can feel as though her therapist is the only one who is ‘on my side’. She thinks it would be more helpful if the therapist and other health professionals responsible for her care worked together, rather than separa
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I had a private therapist there.
Right and was that helpful?
It was, it was incredibly helpful it was, it’s a bit of a funny one, I liked her from the moment I met her, she just, you know when you meet someone and you just think I like you, I trust you I know I can.
It’s very important if you’re going to open up to somebody that you feel that way about them?
And in retrospect I think it’s quite possible that I kind of got a bit attached to her and it was incredibly difficult when that ended for me but yeah it was, it was, she was the only person at the time because I didn’t get along with my consultant psychiatrist and she was the only person that I felt I could be honest with, she was the only person I felt that was on my side.
Where you able to talk to her about your concerns about your antidepressants and the medication that you were on?
Yes I did but she didn’t really have, I mean subsequently you’ve got a team, there’s always a team, you’ve got the consultant and when you’re an inpatient you’ve got the nurses, you’ve got your therapist, you’ve got your CPN who is always kept involved even when you’re admitted to hospital, you’ve got GP’s and she, the therapist certainly in that situation was not, didn’t really have much of a say in, in kind of how my treatment was going. You know, they kind of looked at her to do right well you do therapy and that’s all you do, you don’t need to be involved in anything else and they weren’t, you know, I think they were very much aware that she was the only one I trusted but they didn’t seem to care.
So would it be more helpful if things where a bit more joined up?
Very much so yeah, and I think that continues, it continues to be an issue certainly even now. I have a private therapist who I see, I see him privately for several reasons, mainly because I have never been able to get talking therapy on the NHS despite being on the waiting list for God knows how long and because if you get talking therapy on the NHS you have to go during work hours which I can’t, can’t do. So I started seeing him because he works during the evenings and I kind of, I found him on the on the internet I found him on the BACP website, met him, liked him, thought yes I can work with this guy and at the time it was fine because I wasn’t under the mental health team because I was quite well but since kind of, in the last kind of two years I’ve been back under the mental health team and it’s incredibly difficult because they don’t like the fact that they have no awareness of what he’s doing with me. I think they feel very left out, very in the dark and equally he feels very frustrated because he feels that he, they’re stopping him from doing the work that he wants to do with me because of certain things that they’re doing, he doesn’t agree with the medication I’m on, the fact that they want to, for me to have therapy with them rather than him.
Thomas felt that all the different health professionals he saw...
Thomas felt that all the different health professionals he saw...
And going back when I was seeing the lady at the university counselling service - group therapist again there was this non, no communication. They were just - no you don’t take medication; you talk things through, that’s how you solve problems. And they didn’t talk to the GP or the psychiatrist whose main business to be honest was kind of crisis management and giving out medication. There was no communication between the two.
Sharon’s CPN helped to integrate other therapies into her care as well as antidepressants.
Sharon’s CPN helped to integrate other therapies into her care as well as antidepressants.
And I thought; I was looking at other people and they were looking at me and we're thinking, 'What are we doing here? What, how on earth is this going to help?' It was a twelve week course so a couple of hours a week and you had homework to do. Based on Buddhism, meditation and things like that so I thought, 'Oh shit, airy fairy stuff whatever,' but it was very good, it was very good. It helps you focus and take time out and step back and assess situations for what they are and it helps with a lot of things other than depression but I found it very helpful for me especially if I was feeling overwhelmed in a situation and normally I'd have just burst into tears and that's it I can't cope. Just to do a breathing exercise for example that's a couple of minutes, step back, look at the situation and think, 'OK this is what you can do, this is what you can't do, what's the point in, in worrying or is it worth doing something? Should you act or not? Accept the situation for how it is and carry on.' And it enabled me to do that quite a lot and it's something that I've continued to do.
How does it feel doing that kind of thing in a group?
I'm not, I'm not a great one for group work but I thought I'd try and everybody; it was, everything was confidential, you didn't have to share anything you didn't want to share so you didn't even know why other people were there. And you can help each other I think, you always get a few that are more talkative than others but you could share your experiences of doing the practises and you’d quite often find that somebody else felt the same as you did for one or somebody felt something totally different and you sit and talk about it and how you can change your approach or how it could be useful in day to day life. And sharing what we'd been practising at home and what we'd used it for and things so it was OK and we'd; definitely there was some sort of bond there between a few of us. Not that we've seen each other outside but yeah it was OK, it was OK.
Doctors are very good but they're a jack of all trades whereas the mental health nurse specialises in mental health and I think it's very easy for the doctors to just, "Oh well we'll try you on another one," and not to look at what effect it is having, what emotional effects it's having or not dealing with and trying to interlock it with other therapies, that's certainly what the mental health nurse did was put it alongside psychotherapy and the mindfulness and bring them all together and use them altogether and I think that's been the key to not just have therapy or just have anti-depressants but to use it all because I think for me definitely you need the anti-depressants to get you up to a level that you can engage and make use of the tools that they can you provide you.
Olivia X said there was no therapy offered at the acute hospital...
Olivia X said there was no therapy offered at the acute hospital...
Even though everybody was casually telling each other what their problems were there was no structure to it and there was no and how do you get out of that hole to it. And at least the private clinic there was, you know, like and here’s how you do, you know they introduced us to CBT, they told us about the methods, you’ve got this fear, how big is this fear, is it real, does it really affect that situation and so you started to like wake up to how you can control those thoughts and things so. I think learning CBT really, really helped because it did stop me and made me analyse. And also being amongst people who were wanting to be protected and wanting to get better actually helped me to get more in that mindset. And I also, it helped me to get my problems into relative respective as well.
Last reviewed June 2016.
Last updated June 2016.
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