Up Front by Emma Hart

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Up Front: Good Counsel

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  • Judith Fursdon,

    Thank you all for your comments so far. The range of experiences underlines that both talk therapies and medications have their places, and their use depends entirely on the individual's needs. The service in Christchurch sounds like something that should be available everywhere, and I'm disappointed that it's not.

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

  • Emma Hart,

    This is not, of course, just about depression. There is no drug that could even theoretically replace relationship counselling.

    I have sat in a counsellor's office and been told, "Because you have said that, I can't let you leave until you've made a safety plan," while I protested that I was fine, really, everything was fine. Two weeks later, I had to use my safety plan. Counselling provided a safe place to talk, where I knew talking wouldn't escalate into an abusive shit-fight because someone was watching, and an impartial voice to say things we didn't want to hear. Like the word 'abuse'.

    Relationship counselling can also save lives. Sometimes a 'successful outcome' is that the couple breaks up, and everyone is still alive afterwards.

    Christchurch • Since Nov 2006 • 4651 posts Report Reply

  • Mike Kilpatrick,

    Thanks for writing this, Judith.

    I've been severely depressed for many years and go through massive ups and downs.

    After taking a variety of SSRIs, none of which seemed to work, I was offered six free Cognitive Behavioural Therapy sessions about three years ago. The CBT went well and I thought I developed a good relationship with the therapist - but if I wanted to keep going after my free sessions then I had to pay an absolute fortune.

    There was definite value in the CBT sessions, but I have forgotten everything that I learned in there because I never got the chance to embed it. It was over way too soon.

    Unfortunately SSRIs continue to be the focus and I'm still unconvinced that any have really helped me. Just last week I had to go back to the doctor and my dosage was simply increased.

    When I mentioned prominent thoughts about dying - and being as low as I've ever been - it was pretty much ignored. I gather because I didn't say 'I'm going to find a cliff to throw myself off', their was no real response.

    I don't think it's that the doctors don't care - I just think they don't know what to do.

    Talking therapy needs to be available for those who need it, otherwise those with mental illness remain at a real risk.

    Auckland • Since Feb 2007 • 16 posts Report Reply

  • Judith Fursdon, in reply to Mike Kilpatrick,

    When I mentioned prominent thoughts about dying – and being as low as I’ve ever been – it was pretty much ignored.

    If this is how you are feeling, then you need to go back and keep asking for help. You can't go on with a treatment plan that is not working and suicidal ideation. That's just a recipe for disaster. Go back to your doc. Tell them again that you're suicidal. If that doesn't work, or if you can't, call your hospital and ask for the mental health crisis team, and tell them. Don't leave it until it's completely too late. I've lost people who never got help. It's an aching void in my life. And I have been so close to being that loss, saved by the power of modern medicine and an unusually hardworking liver.
    Doing what you need to do in order to get help can involve a lot of banging your head against the wall. But it's worth it, for the sake of your life.

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

  • Judith Fursdon, in reply to Emma Hart,

    This is not, of course, just about depression. There is no drug that could even theoretically replace relationship counselling.

    And then there's also ACC counselling. Debriefing for victims of sexual abuse and trauma. Down from 16 sessions to four. How on earth is that anywhere near enough time to work through what horrors they have been through? These people are traumatised, and they've had to relive their horrors for a stranger in order to access the funded counselling. How can anyone in good faith say that these victims can realistically be helped properly in four bloody sessions?

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

  • Kyle MacDonald, in reply to Judith Fursdon,

    Fortunately that was an error, their is no drop from 16 to four. In fact due to ongoing political pressure and work by the Greens and the NZAP, ACC are bucking the current trend.

    Auckland • Since Nov 2006 • 82 posts Report Reply

  • Mike Kilpatrick, in reply to Judith Fursdon,

    "Doing what you need to do in order to get help can involve a lot of banging your head against the wall."

    This has been my response right across the board in New Zealand - at the doctor, from the depression hotline and from the mental health crisis team. And I know there's a lot of others who feel like that.

    It's not that I feel suicidal - ie I'm not at the point where I'm actively contemplating it - it's just that when I'm low it feels as if being dead is a much better option. When I've iterated this in the past it's been ignored across the board.

    I'm presuming because I'm articulating it, it means I'm less likely to do so. It doesn't make me feel like I'm getting appropriate help, however.

    Auckland • Since Feb 2007 • 16 posts Report Reply

  • Judith Fursdon, in reply to Kyle MacDonald,

    Fortunately that was an error, their is no drop from 16 to four

    Well, that's bloody good news!

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

  • Judith Fursdon, in reply to Mike Kilpatrick,

    it’s just that when I’m low it feels as if being dead is a much better option

    And it's ridiculous that because you passively don't want to live, instead of actively wanting to die, you don't get adequate treatment. It's like they take on the actively suicidal because it looks bad if you turn away a suicide risk and they kill themselves, but they don't adequately treat people who, with the right help, can actually have a decent quality of life. Because quality of life doesn't matter in the wildly overstretched system we have - they can barely cope with the most ill of the mentally ill - what resources do they have for those that are just very unwell instead of extremely unwell?

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

  • Sacha,

    Coley Tangerina discusses this.

    Ak • Since May 2008 • 19706 posts Report Reply

  • Chris Miller,

    I'm one of those with severe depression, the kind that actually is able to be treated with drugs. It's diagnosed as "chronic" and "endemic" - always there, not going away - but I'm not on SSRIs either. I take an SNRI because the first medications we tried didn't work, or had bad side effects, or worked at first and then lost effect. (The months where I had to wean myself off one drug and onto another were a living hell. One of the most awful things I've ever experienced.) SSRIs are probably some of the least reliable drugs on the market. Even aside from the side effects they can make you worse, actually cause suicidal tendencies. There are terrible stories out there about people dying during trials who previously, as unwell as they were, hadn't been a danger to themselves. My SNRI is hardly much better of course - it has a short half-life. If I don't take it for a day, I notice. I couldn't not, through the nausea, the fatigue, the fogginess, the leaden weight. It's notoriously difficult to quit, as well, with whole forums on the internet dedicated to people who are in the process of it. Sometimes it takes over a year to do it safely, and I'm on a high dose. It works, though, so for me it's worth the downsides, because even if there were no withdrawal symptoms I couldn't simply stop taking it. Off the medication I'm useless. For people with less severe depression, where it's mild to moderate or due to external events that need to be worked through, the side effects and the withdrawal could not be worth it, not if there's an alternative. Therapy is hardly perfect either - it depends largely on finding someone you connect well with. Some therapists are outright harmful, and many more just plain might not be the right fit no matter how good they are at their job. But typically therapy is not, in and of itself, dangerous. Not like the drugs can be.

    Otautahi, Aotearoa • Since Nov 2011 • 17 posts Report Reply

  • Bart Janssen,

    There's something I'd like to add to this discussion.

    I'm lucky to have had really good parents in the sense they had good genes. They both suffered badly through WWII and so were less able to teach some social skills but hell they gave me good genes. I'm fit(ish), mostly healthy, and my brain can pick up and remember knowledge pretty quickly. I have learnt many diverse skills outside my profession as a scientist (housebuilding, gardening, woodwork) and have learnt to play any sport. I am lucky! Up until a few years back I was pretty confident there wasn't anything I couldn't do at least adequately given a bit of time to read up and practice.

    Then I got depressed.

    And I discovered not only was there a whole class of things I was demonstrably really bad at, but also that some of those things I really struggled to learn.

    It was my therapist/counsellor who showed me my limits and showed me what I had failed to realise I was not doing well. He also showed me how to do better at those things. And in the process I learnt that his skill as a counsellor was not a skill I would ever be even remotely competant at.

    There is a sick culture is NZ that revolves around being tough mentally. It is strongest in men but is there in women as well. That culture dismisses the skills of counsellors, it dismisses their value and it does so because to acknowledge their contribution would be to acknowledge a weakness. Or in the case of some insurance companies, it would cost money.

    We need people to talk with, to listen to, and to listen to us and time to do it. We need people we can share our worries and pain with, even/especially when there is nothing that can done except to listen. Sometimes those people can be friends but sometimes we need people who are really skilled.

    Auckland • Since Nov 2006 • 4458 posts Report Reply

  • Kyle MacDonald, in reply to Kyle MacDonald,

    I'm actually going to retract my ranty comments about APN, just spoken to them and they're ken to keep pursuing this, so good for them, retractions and back downs were Sovereigns, and it seems that this story may indeed have some legs yet!

    Auckland • Since Nov 2006 • 82 posts Report Reply

  • Konrad Kurta,

    This strikes very close to home. A close relative has dealt extensively with depression, and the doctor tried a few different medication combos for her. What we were most thankful for, though, were the 'talk' sessions she was able to have with a psychologist. From memory they were fully funded, though only for an initial three sessions(?).

    I understand one-on-one psychological help isn't cheap, but I don't like to think where she'd be without it.

    South Korea • Since Dec 2012 • 43 posts Report Reply

  • James,

    This meta-analysis of all the drug company data on 6 of the 7 SSRIs found that drug is better than placebo ONLY for people who were severely depressed.

    This study (paywalled) found that monthly sessions of 'behavioural activation therapy' is as effective than drugs in the severely depressed, and cheaper after 9 months (at US prices).

    Oddly, Cochrane collaboration doesn't appear to have a study comparing drugs with therapy more generally. Does anyone else have a better reference?

    New Zealand • Since Feb 2007 • 34 posts Report Reply

  • Bart Janssen, in reply to James,

    This meta-analysis of all the drug company data on 6 of the 7 SSRIs found that drug is better than placebo ONLY for people who were severely depressed.

    It is worth noting two things about this. Placebo's do work. And importantly, the more complex the placebo, the better it works. So a pill with side effects actually works better than a pill without side effects even if the only effect from the pill is the placebo effect.

    The second thing is a problem with meta analyses in particular and large scale trials in general. It is that the data averages the effects from all participants. So if one person is very positively helped by a drug and 19 people have no effect then the average becomes statistically indistinguishable from no effect. Think of it as one person saying yes while at the same time 19 others say no then what you hear is "no". With really good statistics you can tease some of that data out but it is really hard.

    This latter effect is particularly important for SSRIs because we know for certain that each person responds differently in both efficacy and side effects. It's almost certain that part of that is a result of the specific set of liver enzymes each person has to degrade the drug (pretty much each person's liver is different).

    The take home message is that even though on average we can't see any positive effect from the drugs - it's very likely that for some people the drugs are very helpful, even for mild depression. This is one reason it would be really cool to link drug studies to genome analyses, because it may become possible to predict who will respond and who will just get the shitty side effects.

    Auckland • Since Nov 2006 • 4458 posts Report Reply

  • linger,

    Way back in 2008, Ben Goldacre wrote quite a balanced article about the results of tests of antidepressants (not just SSRIs) against placebo, and the media misreporting of same as “proof” that SSRIs don’t work. As Goldacre points out, antidepressants do work, better than placebo – but their level of proven effectiveness only outweighs the risk of side effects, in a majority of patients, for cases of severe depression. [ETA: See also Bart’s point just posted – some minority of patients with mild depression may also be helped by antidepressants.]

    Goldacre has also written extensively (e.g. here and here) about the nature of the placebo effect, which he ascribes not just to the effect of patient beliefs about a treatment itself, but also to the cumulative effect of all aspects of the presentation of the treatment to the patient. His description suggests to me that it may not strictly be possible to compare drugs vs. therapy directly, as the two types of treatment would need to be compared with very different types of placebo: the familiar “sugar pill” on the one hand, vs. say, a series of conversations with friendly “medical personnel”, avoiding the topic of the patient’s depression, on the other hand.

    But also, such a comparison would ignore the point that many patients may need both types of treatment.

    Tokyo • Since Apr 2007 • 1923 posts Report Reply

  • Kyle MacDonald,

    Of course lets not forget talking therapy has very few, if any side effects. And is recommended by NICE ahead of medication for that, amongst other reasons.

    Auckland • Since Nov 2006 • 82 posts Report Reply

  • Bart Janssen, in reply to linger,

    the nature of the placebo effect

    It is a profoundly interesting effect. It's possible that talking therapy might just in fact be a very very good placebo effect - which would kind of make it a really good treatment really.

    BTW there is also something called the nocebo effect - really. That's where people will have side effects more often if they are told what the side effects might be. So you may actually be doing a patient harm by notifying them of possible risks. To say this messes with medical ethics would be an understatment.

    Auckland • Since Nov 2006 • 4458 posts Report Reply

  • linger, in reply to Bart Janssen,

    Yep; the nocebo effect is described in the second of the two Goldacre links above, and a 5-minute version is in this Nerdstock speech.

    Tokyo • Since Apr 2007 • 1923 posts Report Reply

  • Bart Janssen, in reply to linger,

    the nocebo effect is described in the second of the two Goldacre links above

    I should have clicked through :(.

    But I'll offer this article in compensation, where unlike the placebo effect people have found at least one biochemical mechanism for the nocebo effect.

    Auckland • Since Nov 2006 • 4458 posts Report Reply

  • Isabel Hitchings,

    It's been around 15 years since I was treated for depression. I no longer recall if counselling wasn't offered or just wasn't offered assertively or frequently enough to make it through the fog. Either way I didn't get any sort of talk therapy for a depressive episode that was, in part, quite situational in origin.

    I'm lucky that I responded well to a low dose of Prozac with few side-effects (there was some weight gain and loss of libido but depression had started both those jobs already) and I was able to find my way out of the dark.

    Even so I think adding counselling to the mix would have made my climb out of the hole a lot easier and less tenuous. I still carry a few demons from that period and I do wonder if some of those hang-ups might have been avoided with a more comprehensive treatment plan.

    Christchurch • Since Jul 2007 • 719 posts Report Reply

  • wendyf,

    Thanks to Judith - thanks to all of you. I'm finding it hard to write anything at all here - memories are tossing around in my head, and in my gut. Pills yes. I'm having Citalopram which is working well for me, and I'll stay with it. But what has made the biggest difference is counselling, and I'm so grateful, so very very grateful that my GP insisted that I take advantage of the free counselling available here.

    Many years ago I talked to someone about feeling 'low' and he said it was because I was a newly-engaged (to a man) lesbian. I said I didn't think so but agreed to think about it. The next week I told him I was pretty sure I wasn't and he gave me the "See! You deny it! That proves it." line. 40 years of mostly joyous marriage makes me think I was probably right.

    Next time I was 'low' my GP gave me Librium or some such. Which came in handy swallowed with sherry when I decided that my family would be sooo much better off without me. My husband came home early and wasn't convinced when I assured him everything would be just fine, soon.

    Psych ward at hospital for 2 weeks, with shock treatment, no talk therapy but instructions to tell my GP if I felt 'low' again. So I didn't wait too long before I saw my GP again and he gave me...a bottle of Librium or some such.

    When earthquake counselling was suggested last year I was not keen, but it was brilliant. Thanks to Pegasus. And then this year when I found it hard not to be able to tell my adult kids how I was feeling - I felt angry that I couldn't tell them (self-centred cow!) I told my GP that I was again in that dark place. Again, thanks to Pegasus, more counselling and a much more realistic view of who I am and who I am not.

    If Citalopram is just a sugar pill, then for me it works. But it's the counselling that allows it to work. For me

    Thanks again all you people.

    Christchurch • Since Nov 2006 • 88 posts Report Reply

  • B Jones, in reply to Bart Janssen,

    There is a sick culture is NZ that revolves around being tough mentally. It is strongest in men but is there in women as well. That culture dismisses the skills of counsellors, it dismisses their value and it does so because to acknowledge their contribution would be to acknowledge a weakness.

    I've known people to totally reject counselling as an appropriate treatment for their issues, but accept that SSRIs treat a chemical imbalance, which is less stigmatised than being mentally unwell. Probably to their detriment.

    Wellington • Since Nov 2006 • 976 posts Report Reply

  • Judith Fursdon, in reply to B Jones,

    I’ve known people to totally reject counselling as an appropriate treatment for their issues, but accept that SSRIs treat a chemical imbalance, which is less stigmatised than being mentally unwell.

    Being on antidepressants is much easier to hide than having to take time off for lengthy counselling appointments, so it can appeal to people who don't want other to know they're unwell.

    I wish people didn't feel like they have to hide these things, but then, it took me a good ten years or so to 'come out' fully. Our culture has some way to come on this.

    Wellington, New Zealand • Since Jul 2013 • 10 posts Report Reply

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