Depression: Don't let it get you

Hollywood star Robin Williams' death turns the spotlight on those battling demons within

Depression. The ailment is a silent killer.

Appearing uninvited, it meanders its way to the darkest corners of our mind, moving ever so slowly that it is difficult to tell when it is beginning to strengthen its hold.

It knows no age, inflicting the young and old alike. It doesn't recognise gender.

Gifted comedian Robin Williams' death has shaken many of his fans.

His wife has revealed that the actor was suffering from Parkinson's disease and medical experts say that could have compounded his misery and put him at risk "of depression".

Did he get enough care? Was he lonely? Couldn't it have been prevented?

These are questions that will bother us for time to come. And we don't really have answers.

Samaritans of Singapore: 1800-221-4444
Singapore Association for Mental Health: 1800-283-7019
Institute of Mental Health's Mobile Crisis Service: 6389-2222
Care Corner Counselling Centre (Mandarin): 1800-353-5800

We look into our archives for stories on depression, on how to cope with the illness and beat the demons within.

Lifting depression

This article was first published in The Straits Times' Mind Your Body magazine on Oct 4, 2012

By Dr Joshua Kua

Peter, a German in his 50s, came to consult me two weeks ago.

He is based in Taipei and works for his brother.

He was in Singapore on a business trip when, one evening, he felt breathless and some tightness in the chest.

He does not have any heart problems.

But as his father died from a heart attack at a very young age, he decided to see a cardiologist at Raffles Hospital.

After some tests, his heart was found to be fine.

He felt relieved but, somehow, was still carrying a "gloomy feel".

"I should have been happier, but I wasn't," he said.

In addition, he was feeling very tired, having problems sleeping and was not able to focus.

"I know I am on the fringe of depression," he murmured.

It turned out that Peter had a bout of clinical depression in Germany five years ago for which he received inpatient treatment.

With antidepressant treatment and cognitive behavioural therapy (CBT), he recovered.

However, he felt somewhat "numbed" and "flat" after taking the medication and decided to stop doing so.

"I knew it was a risky thing but I thought the CBT had given me some coping skills to prevent a relapse," he told me.

At that time, he had also left a well-paid but highly stressful job and changed his lifestyle dramatically.

He moved to another country and led a quiet and relatively stress-free life for a few years.

About one year ago, he decided to return to his previous lifestyle and took up a new job in Taipei.

He enjoyed the work, but soon found that being a one-man show was too stressful for him.

Sitting across from me, Peter went on to talk, in a rather sombre tone, about his pent-up feelings and struggles.

He knew he could not go on doing the same thing.

"I drink too much alcohol at times and smoke too much. I am not exercising. I am getting 300 e-mail messages every day. I am currently overweight," he said.

I was impressed by his eloquence and insight into his illness.

When I asked him what he intended to do about it, he was able to calmly articulate some of the things he could do to alleviate stress.

These included confiding in his wife, who is supportive, taking a break every two hours from work, putting up a business case to his boss about getting an assistant, getting an office space as he currently works from his rental flat in Taipei and reducing his e-mail load by not handling e-mail messages that were meant for his boss but copied to him.

As I had just given a talk to a local bank on stress management, I shared a few slides on areas relevant to Peter.

He listened attentively and could identify with many, if not all, the points I raised.

I then helped him to organise his thoughts and advised him on a few strategies to develop an action plan to combat his stress and depression.

Although he declined medication, I gave him some information and suggestions on when he should return for medication.

At that moment, I was prompted to put on my psychotherapy cap and talked about self-esteem issues.

Peter was able to identify that one of the reasons he was driving himself so hard at work was because, since young, he had always wanted to prove his worth to his brother and to live up to his expectations.

With much insight, Peter said: "I was foolish. My self-worth should not be based on this alone.

"I guess I have been carrying these unnecessary thoughts unconsciously all these years."

At the end of the hour-long session, Peter was visibly delighted.

He said he felt so much better after the session.

He hit the nail on the head when he said it was such a huge relief to be able to speak to someone who could understand how he felt and what he had gone through.

He said in his previous episode of depression, some well-meaning family members even asked him to "just be a man and snap out of depression".

I would say that the session was led by Peter 80 per cent of the time.

I wish more of my patients could be like him - understand their conditions and have the courage to seek treatment early and take ownership for their own recovery.

Of course, his decision regarding medication is controversial.

But I am sure he will seek help and accept medication if his condition does not improve.

I felt a great sense of satisfaction in being able to help Peter.

I was gratified when he complimented me and said: "Doctor, you are good and I am glad I came to look for you."

Peter then told me he would be meeting his wife the following week for some leisure time in Singapore.

"Doctor, if I don't see you next week, it means I am fine," he said confidently.

He did not return the following week and I could not be happier.

Dr Joshua Kua is a consultant psychiatrist at Raffles Counselling Centre. His areas of expertise include adult psychiatry, geriatric psychiatry, psycho-oncology, psychotherapy and counselling.

Music to improve well-being

This article was first published in The Straits Times on Sept 9, 2012

By Grace Chng

Music is known to energise, excite or calm listeners.

But can this response be tracked scientifically, and can it be used to help people with a problem?

Since last year, scientists at the Institute for Infocomm Research (I2R) have been looking at how to use music for those living with depression.

They developed a software to track a person's mood by measuring his brain waves. Electrodes on a head strap measure the electrical signals emitted by brain waves. If the person is happy, the brain waves tell the software to compose an upbeat foot-tapping music score. If he is depressed, the result is a sombre piece.

Dr Guan Cun Tai of the I2R's BCI Lab, which is doing the research, told The Sunday Times: "We can also measure a person's emotional state by looking at the genre of music he is listening to."

A blaring rock song may put the person in a good mood whereas a melancholy ballad may make him sad. These measurements of a person's positive or negative state may one day help doctors diagnose, monitor and treat those with depression. Called iComposer, the software is awaiting clinical trials, said Dr Guan.

A spin-off, iMusic, can tell a person's music preferences by allowing him to pick a song randomly from a playlist and monitoring his brain waves. If he dislikes the song, that subconscious feeling is picked up by his brain waves as a negative response. The software then discards that song and others like it from the playlist.

This can be repeated to let the person arrive at a final selection he likes. Dr Guan said: "We see this as a potential technology that music companies may want to license."

The technology could also be used by those who meditate.

"Meditation is to get to a calm state where brain activity drops to a quiet level. Our software can show a graph that charts low or high level of brain activity," said Dr Guan. "This will tell you whether each meditation session is successful and whether over time, you've improved."

Get moving to get happy

This article was first published in The Straits Times' Mind Your Body magazine on May 29, 2014

By Ng Wan Ching

Perhaps you feel like reaching out for that tub of ice cream when you are feeling down, hoping the sugar high will give your mood a lift.

Or you may prefer drowning your sorrows in a drink or two.

Yet others smoke or use drugs, legal and illegal, to try and forget their troubles.

These attempts to take one's mind off things may or may not work. But one thing is certain - their effects are only temporary.

In fact, the person may end up feeling worse after a high from getting drunk or overeating.

If this becomes a habit or is done excessively in the long run, he may end up having to deal with issues such as obesity and alcoholism.

A much better strategy for feeling good about yourself is exercise, and lots of it.

But is there a link between exercise and happiness or mental well-being?

Studies suggest that there could well be.

Exercise or being physically active has been found to improve mental health by reducing depression, anxiety and stress as well as improve self-esteem and cognitive function, said Dr Tan Hwee Sim, consultant psychiatrist at the Raffles Counselling Centre at Raffles Hospital.

Researchers have demonstrated that active people are less depressed than inactive people, he added.


Other studies have found exercise can be as effective as anti-depressant medication for mild depression, and in preventing relapses, Dr Tan added.

While it is unclear how moving one's muscles can have such positive effects, some researchers suspect that exercise alleviates depression by increasing serotonin, a chemical in the central nervous system that simulates happiness, said Dr Tan.

Exercise also helps create new brain cells in the part of the brain responsible for learning and memory.

Other beneficial effects may include giving the person a sense of accomplishment and providing distraction and social interaction, which are important in combating day-to-day stress.

Exercise is linked to boosting the immune system, and also with the release of endorphins (feel-good hormones). It helps the person feel healthier, concentrate and sleep better, and even look better, said Dr Tan.

A Singapore study published last year in Biomed Central, Public Health, a British peer-reviewed online journal, also found that those who spent 10 hours a day slouching around or being sedentary were 29 per cent more likely to report having psychological distress.

Those who took part in moderate to vigorous physical activity had 27 per cent lower odds of feeling psychological distress.


However, the study also found that the positive effects of doing an hour or two of physical activity, such as jogging or cycling, were dampened if the person spent the rest of the day slouching around, living a mainly sedentary lifestyle.

People who exercised and who also spent less than five hours a day being sedentary had the best chance of attaining optimal mental well-being, with 40 per cent lower odds of feeling distress.

In short, if you want to be happy, exercise or get out and about, even if you are not engaging in vigorous activity.

In a Canadian study published in the American Journal Of Epidemiology in 2012, people who were inactive were more than twice as likely to be unhappy as those who were active.

The study, on the long-term association between happiness and physical activity, analysed data from national population health surveys conducted between 1994 and 1995, and 2008 and 2009.

Happy respondents were classified as physically active or inactive as a baseline and were then followed up in subsequent surveys to examine their likelihood of becoming unhappy.

Leisure-time physical activity was found to be associated with lower odds of unhappiness when the researchers checked in on the participants two years and four years later.

Those who reported being inactive during both two-year cycles were more than twice as likely to be unhappy when they were followed up two years later, compared with those who were already active.

They were also more likely to become unhappy compared with those who made the switch from a sedentary lifestyle to an active one.


Going from active to inactive was also associated with increased odds of becoming unhappy two years later.

Questions remain about the type of exercise that is most beneficial for each person, said Dr Tan.

It is likely that age, gender and medical history can affect the amount of exercise needed to treat or prevent symptoms of psychological distress.

"As there is no clear answer for this yet, we may have to do some trial and error to find what works best for us," said Dr Tan.

In general, almost-daily cardiovascular exercise is best and this can range from walking and dancing to yoga and pilates.

Just anything that gets you moving is good and even better if you do enough of it, said Dr Tan.

Preferably, the exercise should be enjoyable or it would be hard to sustain, he added.

The general recommendation is to do 30 minutes of moderate physical activity on most or all days of the week and to start slowly before expanding on the routine, he said.

Depression: Is it just a reflection of pharmaceutical companies' marketing prowess?

This article was first published in The Straits Times on Aug 4, 2011

By Andy Ho, senior writer

A World Health Organisation study finds depression to be unusually widespread in all nations, whether low-, middle- or high-income.

More than one out of every 20 persons said they had been severely depressed for at least two weeks in the previous 12 months, the study avers.

The diagnostic criteria for all mental illness including depression are based purely on symptoms the patient complains about, or descriptions of his observed behaviour. These criteria are vague enough so that their boundaries can be stretched.

Thus, depression clearly overlaps with sadness. But there is no test or scan to prove or disprove this or any other psychiatric diagnosis. Hence, how widespread depression might be depends on how many people say they feel depressed, how depressed they say they are, and how depressed others observe them to be.

In other words, there is much room for subjectivity in such an assessment. Loosening the diagnostic criteria - turning emotions into a medical condition - will result in reports of more depressed people. If you feel generally uneasy, psychiatrists can diagnose you as having General Anxiety Disorder.

Once a person has been medicalised, a prescription can be written. That is how 10 per cent of Americans over age six are now on some anti-depressant drug or other.

These diagnostic boundaries can be stretched because there is no fundamental biological explanation for any psychiatric condition. The discipline's stage of development is like internal medicine 100 years ago. Then, all chest pain was diagnosed as "angina", with three subtypes.

First, there was crushing pain behind the breast bone that shot up into the jaw and left arm. Another was more like burning between the breasts. A third was sharp chest pain when breathing deeply.

Only a century later was it known that these were caused by the heart muscles lacking oxygen, acid reflux in the gullet, and inflammation of the lung coverings, respectively. Lesson: The three types of chest pain could not be distinguished until their differing causes were identified.

That is, symptoms alone do not a diagnosis make. Unfortunately, that is where psychiatric diagnosis still is today.

There are no physical signs of mental illness - no swollen joint or broken rib that a doctor can see or feel.

Psychiatric diagnosis depends solely on symptoms, and these are often self-reported. Without objective signs, blood tests and X-rays to nail down the diagnosis, how does the doctor know if a patient is just sad, severely depressed, or plain acting?

No other medical specialty uses drugs to treat symptoms without understanding their cause.

While the cause of rheumatoid arthritis is unknown, the underlying disease processes are well understood at the molecular level.

This is how scientists can make drugs that ameliorate the condition by acting on certain choke points in these disease processes.

No other medical speciality puts patients on long-term medication for non-specific symptoms.

No doctor except one dealing with mental illness will write a long-term prescription for symptoms that can occur in unrelated conditions without knowing what the underlying cause was.

Only psychiatry puts patients on long-term medication to treat symptoms without understanding their cause(s).

In 1987, however, this unhappy state of affairs seemed to be on the verge of ending when Prozac was introduced.

This apparently very effective antidepressant was said to work by increasing the levels of a brain chemical called serotonin.

A new theory was born that depression (and thus also other mental disorders) resulted from brain chemical imbalances.

A biomedical model of mental illness seemed to be in the offing.

However, in Unhinged: The Trouble With Psychiatry (2010), Tufts University psychiatrist Daniel Carlat notes that this theory has not been proven after decades of very well-funded research.

In fact, neurochemical dysfunction has never been shown in psychiatric patients: Prior to ever being put on psychoactive drugs, brain chemicals function normally in the mentally ill. It is only after they have been put on antidepressants for several weeks that their neurochemical levels become abnormal.

Thus, it is drugs, not the disease, that alter brain chemistry.

The brain chemistry dysfunction theory might be pure myth.

But Prozac was a blockbuster for Big Pharma, which woos psychiatrists with consulting fees, honoraria, junkets and the latest magic drug.

Studies show that psychiatrists receive more money from Big Pharma than any other specialists.

Through their publications and teaching, key psychiatrists influence how mental illness is diagnosed.

They decide what goes into the Diagnostic And Statistical Manual Of Mental Disorders (DSM), which is used to classify mental illness.

It is telling that the number of DSM diagnoses has swelled from the original 182 to 365 today. Of the 170 contributors to the current version of the DSM, some 95 have received money from Big Pharma, including every contributor on the DSM entry for depression.

Most of the evidence that Prozac and other antidepressants seemingly work comes from very short-term studies.

The Emperor's New Drugs: Exploding The Antidepressant Myth (2010) by Irving Kirsch shows that even this unimpressive evidence depends on selective data cherry-picking by industry-linked psychiatrists.

Using the Freedom of Information Act, Dr Kirsch, a University of Hull psychologist, procured all trial data that Big Pharma has to present to the US regulator (which only looks for positive data for efficacy.)

His analysis of that unpublished data showed today's popular antidepressants to be really just strong placebos.

Thus, the finding that so many people seem to be severely depressed may reflect nothing more than Big Pharma's marketing prowess.

Diabetic? Get screened for depression early

This article was first published in The Straits Times on Feb 9, 2011

By Poon Chian Hui

Depression may affect how patients manage their condition, say experts

Early screening of diabetic patients for depression is critical, say the researchers of a study by the Institute of Mental Health (IMH) and Khoo Teck Puat Hospital (KTPH).

Depression may influence how the patient manages his condition. "They may not diet properly, exercise regularly or take their medication," said Associate Professor Swapna Verma, a psychiatrist who heads the IMH's early psychosis intervention department and is a collaborator in the study.

The study, done between August 2006 and February 2007, asked more than 530 diabetic patients - of whom 31 per cent had already been identified as suffering from depression - to give their perceptions of their quality of life in eight areas.

These were physical functioning, physical role (how well they could do various activities), bodily pain, general health, vitality, social functioning, emotional role and mental health.

Those suffering from depression gave negative responses in all eight areas.

But other survey participants who were not depressed were more positive in their perceptions, even diabetes sufferers with serious medical complications.

For example, those with complications like stroke and retinopathy, a potentially blinding eye disease, perceived they fared poorly in only two
areas - physical functioning and physical role.

These findings were published in the latest edition of Annals, a journal by the Academy of Medicine Singapore.

In Singapore, about 11 per cent of adults aged between 18 and 69 are diabetic. Most have Type 2 diabetes where cells fail to properly use insulin, a hormone that keeps blood sugar levels normal. Such levels are then maintained via an appropriate diet and exercise.

Type 1 diabetes is where the body fails to produce enough insulin, and sufferers may need daily insulin jabs.

Patients in the study who said they exercised regularly performed better than those who never exercised.

They reported better physical functioning, vitality and mental health as well as less bodily pain.

Researchers said early screening will be useful as many diabetic patients are unaware of their depression, with some symptoms, such as fatigue, viewed merely as a consequence of diabetes.

"As a result, the symptoms get masked," said Prof Swapna.

Most diabetes clinics in private and public hospitals currently do not have a structured screening system in place.

Endocrinologist Stanley Liew of Raffles Hospital, who is not part of the study, said most doctors here carry out "opportunistic screenings".

They look out for signs of depression during the patients' regular consultation visits, and refer them to a psychiatrist where necessary.

At KTPH, the study has spurred it to assess diabetic patients via three questionnaires that look at depressive symptoms, diabetes-related distress and quality of life.

A preliminary review showed that patients managed better scores after going through a programme called Management of Depression and Distress in Diabetes, said Dr Chan Keen Loong, a senior consultant at the department of psychological medicine at KTPH.

The programme offers counselling, education and anti-depressant medication.

Dr Liew noted that doctors have traditionally focused more on the health aspects of diabetes, such as maintaining proper blood sugar levels.

"But maybe we should also put more emphasis on the psychological and emotional effects," he said.

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