Lynne Malcolm: On RN you're with All in the Mind, I'm Lynne Malcolm. Today, alternative approaches to taming the Black Dog.

Depression is the most common mental health disorder, affecting around 1 million Australians. And the condition is responsible for more disability than any other cause.

Chrissie is now in her 30s, but she began her struggle with depression when she was a teenager.

Chrissie: There wasn't a lot of acknowledgement or acceptance of the illness, and also I guess my family was going through a grieving period as my father had just died, so we just assumed that things were going to be quite awry for a long time. But it just kind of turned into this ongoing, untreated issue for me which would come and go. And in my kind of blind way I stumbled through lots of different attempts to sort it out. And when it would go I'd think, okay, now I am a better and I don't think about that any more. But there was this sort of dread that it would come back.

So I tried various things like meditation, fairly intensive meditation through my 20s, and that was effective. But I wasn't able to keep it up. I tried lots of counselling, which is effective for specific periods of life but it wasn't necessarily treating the state itself of depression, it was more looking at specific problems. But I think also I was operating on a kind of deliberate blindness as well because I did not want to accept it.

So eventually I had a child, and then after she was born, she was maybe a few months old and I was seeing a psychologist with the people who help with sleep with children, and she actually was the first person who said to me, 'You are depressed, you need to have some antidepressant drugs, I'm going to give you an appointment with a psychiatrist.' So that was the first time (and I was 35) that someone had sat down and made a diagnosis.

And so then I went on antidepressants, Zoloft, quite a low dose, for three years. And that enabled me to finish a masters. I went back and finished a masters in visual art when my baby was one, and I was able to work like a machine, you know, I churned through it. But at the same time I flat-lined emotionally.

Lynne Malcolm: You just couldn't feel emotions, you couldn't feel the highs?

Chrissie: Yes, that's right. I didn't laugh. I just went through life like a machine. And actually at first it was a real relief, it was great, but then after a while I just felt I couldn't keep that up, I wanted to stop, so I gradually came off the medication and I did it really responsibly, just by reducing the dose very gradually.

And then I had another big bout. I had some big issues in my life. My partner and I separated and at the same time my mother had a major stroke, and bang, I didn't know what had hit me but I was struggling through it again. It was just a struggle to continue with my mothering, to continue mothering, and getting my daughter to school and home and then completing the jobs I needed to do. And so I was juggling crazily my family life and my work life and not sleeping enough and not eating enough and being extremely irritable and really having to try and control that all the time. So it wasn't very pleasant.

I guess I'm telling this story bearing in mind that this is a condition that will play out over a long period of time. It's not like a cold where the symptoms are sudden, you feel them, you know that you are subjected to this particular illness. It can be so vague. You can live through it. I guess people who have very extreme depression can't get up and they can't dress and they can't…and for me I might have a day every now and again like that, but that wouldn't be every day. But still every day is a struggle. So I'm just trying to swim and muddle through my life during these periods, and it makes it really tough.

Lynne Malcolm: That's Chrissie, who is now getting some relief from her depression since her involvement in a clinical trial of transcranial direct current stimulation. More on that later.

Michael Yapko is a clinical psychologist from San Diego, California. He's worked on a range of treatments for clinical depression over many years, including the use of hypnosis. He suggests that a serious revision of people's attitudes towards depression is now required, because while many people focus on the biology of depression, they miss what goes on at the psychological and social levels.

Michael Yapko: And so I really wanted to draw attention to the fact that as the data grow it's becoming more apparent that depression is much more of a social phenomenon than a medical one.

Lynne Malcolm: So you are quite critical now of looking at depression as a chemical imbalance, that was the understanding that we did have in recent years. What is the basis for moving away from that?

Michael Yapko: Well, the drug companies were the ones who offered that hypothesis to people without ever really proving it, and so it became very common to talk about a shortage of serotonin as the biochemical imbalance responsible for depression. The neuroscience has pretty much killed that theory, it's really not something that has credibility anymore. Most depression experts have really stopped talking about the biochemical imbalance and certainly the shortage of serotonin and have started looking at other neurological factors, what are called trophic factors that increase certain proteins. But what we've discovered of course is that the drugs have not been nearly as effective as people had been led to believe. The major medical journals have been publishing article after article about the deceptions of the pharmaceutical industry in deliberately overstating their value in order to sell them. And trying to define depression as a medical illness has really backfired.

Lynne Malcolm: It remains though that many people are still very much helped by medication, aren't they.

Michael Yapko: Sure, but the question that has arisen is; why are they helped? Is it because these drugs have an active chemical value, or is this primarily about placebo effects? Depression has a very high response rate to placebo-based interventions in general, and so as the data are being reanalysed, using the Freedom of Information Act a number of researchers have sued the government to get at the drug data that led to the drugs being approved in the first place. And as it turns out, when you add in all the hidden data, the value of the drugs is barely more than what you would get from a straight out placebo effect. The expectation that the drug will be of help, that's a placebo effect.

Lynne Malcolm: You talked about the social levels being really important in depression, and the fact that depression can be contagious. Tell me a little bit about that and how that operates.

Michael Yapko: One of the things that we have been tracking in a field called epidemiology is the prevalence of depression around the world, and in fact the World Health Organisation predicted that by the year 2020 depression would rise to become the second greatest cause of human suffering and disability. Unfortunately that level was already reached late last year. So depression is spreading, it's growing in every demographic group, and the obvious question is could everybody all of a sudden have the same biochemical imbalance, or is this in fact something that is being socially transmitted through a variety of means from culture, that when you study the field of cross national epidemiology one of the things that you discover is that there are some cultures where depression is a fairly minimal problem and there are other cultures where depression is huge.

That lends support to the notion that people learn depressed patterns, that the kinds of things that we are seeing now, for example the high levels of technological involvement, people spending more time on computer screens and in front of smart phones and everything else, it's no coincidence that we are seeing higher levels of depression the more that people are involved in technology. Curiously, the largest group of depression sufferers are the 25- to 44-year-old's, but the fastest growing group of depression sufferers are their children, the young people. And I think there's a lot to be said for what we are looking at in terms of social transmission as family structures change, as cultural values change, as community standards change, and they have an impact on people's outlook and an impact on people's mood. And I think that's a lot of what we are seeing.

Lynne Malcolm: So what led you to look to hypnosis as a therapeutic tool for the treatment of depression?

Michael Yapko: Well, one of the things to appreciate about depression is that it is in some ways a disorder of focus. What happens in depression is that people tend to focus on what's wrong instead of what's right, what has hurt them instead of what has helped them. They focus on things that work against them. And hypnosis is a focusing process, and one of the things that really attracted me to hypnosis was that here was an efficient way of securing somebody's attention and starting to guide it actively in the direction of focusing on what is positive, what's useful, and that in itself is enough of a reason to want to use hypnosis as a part of treatment.

One of the things that I really appreciate about hypnosis is that it encourages a greater flexibility, a greater willingness to have experiences that go beyond just feelings or just rationality and give people a chance to connect with and develop parts of themselves that are the best parts of themselves, and the parts of themselves that just haven't been very well developed yet.

Lynne Malcolm: So it frees up someone's mind to think beyond their immediate pattern of thinking.

Michael Yapko: I think that's a fair way of describing it.

Lynne Malcolm: So I wonder if you could explain a hypnosis session and how you would use that as a pathway through a depressed state for someone.

Michael Yapko: Well, let me give you an example of someone who is taking things very personally that really aren't personal. So that if somebody doesn't call them back right away they get upset, they feel betrayed, they feel abandoned, they feel rejected. So in doing hypnosis, to be able to invite the person to close their eyes and start to focus themselves, and then I can lead them through a series of examples of how people can misinterpret things that other people do, and then little by little start to orient the person to the idea that so much of life is ambiguous. And in a sense this is one of the patterns of depression, that people have a hard time with ambiguous situations, and what depressed people tend to do is interpret things in ways that hurt them.

So I want to use the hypnosis to teach this person to recognise ambiguous situations before they even get in there and to take extra care not to interpret things in ways that are going to be self-damaging. We want to encourage greater cognitive flexibility. And when you can start generating multiple viewpoints for the same event, you are starting to evolve some flexibility.

Lynne Malcolm: Just lastly, what do we know about the success rates in terms of research of different approaches to treating depression, incorporating hypnosis, cognitive behavioural therapy, antidepressants? Has there been research that shows success rates and compares them?

Michael Yapko: Absolutely, there is a huge domain of research called therapeutic efficacy research. It's one of the most important questions you could have asked; what do we know about treatment success rates? Well, here's what we do know to this point. There are a number of psychotherapies, cognitive behavioural therapy and interpersonal therapy in particular, that have the highest treatment success rates. Cognitive therapy teaches people skills. It helps people with information processing, clearer thinking, better quality of decision making.

Interpersonal therapy focuses on the social side, the relationships. Given how often relationship issues lead people into depression—divorces, betrayals, abuses, violence, all the kinds of things that can happen in relationships that lead people into depression—the interpersonal model really focuses on teaching social skills and helping people build more positive and healthier relationships.

But looking across treatment models, what we've also learned is that there is a factor called behavioural activation that really catalyses the effects of good therapy. And what behavioural activation means is that the more active the person is in treatment, the more they are actively experimenting with their perceptions, challenging their beliefs, practising new skills actively, the better they do in treatment.

And when we look at the role of medications, medication is very so-so, it doesn't work for everybody, it is really a 50-50 chance whether somebody is going to benefit. But the other side of it is just taking the medication alone is under-treatment, just taking drugs alone has the highest rate of relapse of any form of treatment. It's just not the best choice as a sole form of treatment.

So I wouldn't mind if doctors were prescribing antidepressants if they were much, much more determined and consistent about encouraging people to also engage in good skill building therapies. The fact that we have kind of let the medical model predominate has really set us back in some ways. Now that we are starting to understand how much powerful social forces are, I think people need to adjust their expectations accordingly so that they can feel good about themselves, who they are and how they live.

Lynne Malcolm: Michael Yapko, clinical psychologist from San Diego and author of a number of books on depression, and I'll put some of those details on the All in the Mind website.

You're with All in the Mind on RN, Radio Australia, online and on your mobile device. I'm Lynne Malcolm. Today, some alternative approaches to treating depression.

Whilst some clinicians like Michael Yapko are concerned that cultural and social factors have too often been overlooked in past treatments, other researchers are investigating the potential of using techniques based in neuroscience, like brain stimulation.

Chrissie: The first time it happened I was a little bit scared because…well, most of us have probably seen One Flew over the Cuckoo's Nest, and that is what I was thinking about. I managed to joke about that with the psychiatrist at the time. So I sat in a chair and my head was measured, and this happened every treatment, my head is measured so that they can find the centre point on the top of my skull and then from there they can work out where to put the electrodes on the sides of my head. And then they strap these electrodes on with a really wide rubber band. And that's kind of the crazy-lady part, it looks very strange. So I sit in the chair very still, they turn on the machine, and I feel a very light sometimes burning, sometimes tingling sensation going through my brain.

Lynne Malcolm: That's Chrissie, who's participating in a trial of non-invasive brain stimulation as a treatment for depression.

Electro convulsive therapy or ECT might spring to mind at the mention of brain stimulation, and of course, like Chrissie, you may also think of how it was depicted in the film One Flew over the Cuckoo's Nest. ECT has been used over many years as an effective treatment for severe depression.

But a new form of brain stimulation using a much milder electric current is now being trialled at the Black Dog Institute in Sydney. It's called transcranial direct current stimulation or TDCS.

Professor Colleen Loo from the school of psychiatry at the University of New South Wales and the Black Dog Institute leads the research team.

Colleen Loo: TDCS uses a tiny electrical current, so we are talking about one 500th the current of what is used in ECT. And that gently stimulates the surface of the brain. We are kind of trickling in this tiny little current for 20 to 30 minutes, but what has been shown in both physiological studies and also clinical studies is that it does actually change your brain's functioning. And in depression…there would be now about six or seven placebo-controlled trials. People don't know whether they are receiving the treatment or not, which have shown that it has antidepressant effects. So it's a very exciting new development.

Lynne Malcolm: What's understood about the mechanism that actually relieves depression? Why does it work?

Colleen Loo: Yes, so there are different ways of understanding what happens at the brain level when you are depressed, and we are still developing our understanding of this. And one of them, Lynne, is that the brain is a very sophisticated machine. There are many different parts of the brain, each of which does different things, and sitting on top of all these parts is the frontal part of your brain, which is a bit like the command and control centre. So that needs to be active and to have that kind of top-down control and modulation of what the rest of the brain is doing.

So one of the most consistent findings of brain functioning when people are depressed is that that frontal part of the brain is under-active, and that often then you also see overactivity in other parts of the brain, including parts of the brain that are involved in emotion. So if you think about how that relates to what we see clinically, you see that sometimes people are overwhelmed by their emotions, or they ruminate and they just can't control all these very strong and, in depression, negative feelings. So one of the theories of depression is that that top-down control isn't working, that part of the brain is not functioning adequately, and that everything is kind of out of balance.

And it's exciting because what some of the emerging evidence is starting to show is that effective treatments affect the whole connection, the functional connectivity between these different parts of the brain. So it kind of restores the balance between these different parts of the brain.

Lynne Malcolm: And what are the trials showing so far about its effectiveness?

Colleen Loo: The trials are looking very good. We've completed two clinical trials and we are now onto our third and fourth trials. So in the trials people receive the real treatment or something that feels like the real treatment, and we measure their mood and see whether they are getting better. So the trials on the whole look very promising, that people are getting better with this treatment. Of course in all of our trials people can go on to receive the real treatment, and we are also seeing that as we extend the treatment the results are even better.

Lynne Malcolm: Colleen Loo says that this transcranial direct current stimulation treatment is best used for people with clinical depression who haven't responded to other treatments. There are very few, if any, side-effects and some participants have even noticed benefits beyond changing their moods.

Colleen Loo: Yes, and this was very exciting. So when we did our first depression trial we were measuring things like memory and thinking…you know, it was just to be safe, to check these things. And one of the things we measured was we asked people to do a test which really showed you how quickly the brain was working. And as people went through the trial they were saying things like, 'Gee, I don't know what kind of stimulation I'm having, but it's almost like my brain clears and I can concentrate and think so much more clearly after the stimulation.'

So we were very excited when we got the end of the study and we formally analysed the results of the formal test, that it showed exactly what people were saying to us, that after the act of stimulation the actual thinking speed was faster, and that has led our team to develop a whole parallel line of research of using TDCS to improve memory and thinking. So our main line of research is in treating depression, but I also have a very promising young researcher who is a clinical neuropsychologist, Dr Donel Martin, who is heading a whole program of research into using this to improve memory and thinking. For example, in people who are older and who are just starting to notice some changes in their memory and thinking.

We find that people really like TDCS, and in fact if you look on the internet there's a whole kind of do-it-yourself movement where they encourage people to buy a machine off the internet. They are not the same as the machines we use, these are a few hundred dollars. I don't think they are quite as carefully designed in terms of all the built-in checks and balances. They tell you, well, you can do this at home by yourself. And it's promoted not just for treating illness but for people who are well, that you could improve your gaming ability by doing TDCS while you are playing computer games, for example.

I have a number of concerns about this. One is that we've found that the whole technique that you use is very important. If you don't do it correctly you can actually damage the skin. Or if you continue with the stimulation even cause mild skin burns. Another one is that we have very carefully studied for a number of years exactly where you should put the electrodes and what kind of stimulation parameters work best. Whereas my concern is if you buy one of these off the internet you don't really know anything about it. You read the brief instructions that come with it, and you could be putting the electrodes in the wrong place. And because these techniques do actually change your brain functioning, you could actually be changing your brain functioning for the worse. And then again, people might think, well, I did five minutes, it was good, 10 minutes is better, one hour is even better, doing it 10 times a day might be even better, and who knows what they might be doing to themselves.

Lynne Malcolm: Professor Colleen Loo.

Chrissie has been in the transcranial direct current stimulation program at the Black Dog Institute since the beginning of this year, and she feels that her depression symptoms have significantly improved.

Chrissie: Well, I can function, I feel quite normal. My mood swings and my highs and my lows are manageable, that I'm not overtaken by this tide of negative emotion. I think negative emotion is really natural and normal, but in depression it just gets really out of balance.

So the trial has been really great for that. It's the treatment itself, but at the same time, every time I go in I have to evaluate my emotion. In a sense there has been this kind of therapeutic response to that too because I now just habitually go, well, how am I today? And I'm just a bit more aware of my vulnerability and the imbalances that I can have. It's such a funny beast, depression, it can really trick you and you can trick it. It's like flicking switches sometimes, very strange.

Lynne Malcolm: So overall do you feel positive about this treatment, that it has been good for your depression?

Chrissie: Yes, absolutely. I'm operating in a really good level, really amazing treatment. One of the big reasons I'm talking to you today is because I think it should be in mainstream treatment. I think we should be talking about this in the public realm and getting it out there. There's no fallout for the patient. They don't have to take medication. Medication is kind of a last resort. I can't say it didn't help me, it did help me, but there's a cost. There's always a little bit of fallout trying to get the balances right, and some people it doesn't affect so well. And look, I know that with this particular treatment it's not going to treat everybody successfully either, but if we had this in the mix, just in the broader health community, then it would really help a lot of people.

Lynne Malcolm: Thanks to Chrissie for sharing her experience with us today.

This TDCS treatments is not yet available outside of the research trials, but Colleen Loo sees some promising potential for it in the future.

Colleen Loo: We are interested in a number of things. One is looking at all the potential applications. Depression I think is a very promising field. I think we might well find ourselves in a few years' time looking at TDCS translating to becoming a clinical treatment. But then other disorders, such as people who have cognitive problems, either because they are elderly and they are starting to lose their memory…we are also collaborating with other people and looking at, say, people who have had traumatic brain injury, you know, could this be a useful part of the rehabilitation in rebuilding their brain circuits. So you combine it with…you know, they do training exercises and at the same time you give them a boost by stimulating their brain alongside.

In collaboration with other people we are also looking at can this be useful in other illnesses such as schizophrenia, which again is another brain based disorder. Another line of research is, you know, how can we improve the way we give the stimulation. What should be exactly the type of electrodes used, what should be their size? What are the best parameters for giving this stimulation? And then of course we are also trying to understand, say coming back to depression, what kind of people do best with this, because depression is very complex. You know, we talk about depression as if it's one type of thing, but there are many different types of depression. And which types of depression and what kind of people are the most likely to get better?

Lynne Malcolm: Professor Colleen Loo, from the Black Dog Institute and the University of NSW.

Head to the All in the Mind website for details on today's program, and you might like to share some of your thoughts in the comments section at the bottom of the page. We always love to hear from you.

I'm Lynne Malcolm, thanks for your company.