The link between depression and back pain

When it comes to depression, we seem to spend a lot of time, collectively, trying to figure out the cause. But there is a group of patients for whom the cause might readily be identified - those with chronic back pain.

Depression is easily the most common emotion associated with back pain. In fact, research has shown that depression and chronic pain are the two most common conditions presenting to health professionals, and the rate of major depression increases in a linear fashion with pain severity. This should make the treatment of chronic back pain a high priority, both for the individual and society at large.

It's not so difficult to see how this relationship is being mediated, when you consider the many symptoms often experienced by patients who present with chronic back, or other spine-related, pain. These can predispose to feelings of hopelessness, despair and other symptoms of clinical depression. They might include:

• Difficulty with sleeping at night, leading to tiredness and irritability during the day
• Restricted movement, which may lead patients to stop participating in social activities 
• Inability to work, leading to isolation and financial difficulties
• Gastrointestinal problems caused by anti-inflammatory medications, as well as mental dullness from pain medications
• Mental distraction, leading to memory and concentration difficulties

The consequences on family life can also be significant. Physical limitation hampers parents' ability to take care of children, perform necessary household chores and engage in family leisure activities. Stress and strain in family relationships can then contribute to a growing depression.

At 96 Harley Psychotherapy, we are well equipped to treat patients seeking relief from back pain as well as depression, be it endogenous or directly caused by pain.

Physiotherapist John Rutherford is a leading practitioner in the treatment of back pain, and works alongside our mental health team to provide relief for those chronically afflicted. With over 25,000 back treatments to his name, there are few who can offer such expert diagnosis and equally few who can so rapidly pinpoint a course of treatment designed for a return to functional mobility. You can read more about him here.

With depression being so very prevalent, it makes sense to eliminate that which can be relatively easily treated. Allowing back pain to continue is to run the risk of feeding a downward emotional spiral which can ultimately lead the patient to feel it is impossible to change the situation.

Do you have hands-on experience of depression linked to chronic back pain? Perhaps you've experienced a dramatic turnaround with the resolution of your own symptoms? If you have any reflections on this topic, please comment - we'd love to hear from you.


Written by Jacqui Hogan

Exercise is good for your brain

We all know the benefits of physical exercise, such as sustaining and improving muscle tone, increasing circulation, keeping tissues well oxygenated and a myriad of positive long-term effects. But do we know the impact of exercise on the brain?

A recent study, published in Neurology, found that exercise has a very distinct neurological benefit which has, up until now, gone unnoticed.

White Matter Hyperintensities (WMH) are tiny areas of damage to the brain, which are age-related and frequently found in the brains of middle-aged and older people. They have commonly been associated with impaired motor function, such as difficulty walking.

In the current study, 167 elderly participants were asked to wear movement monitors to track their physical activity over the course of up to 11 days. Magnetic Resonance Imaging (MRI) scans were used to assess the volume of WMH in their brains.

The findings showed that those who were more physically active were less affected by WMH damage than those who were less active. In other words, physical exercise appeared to be protecting participants against the standard effects of age-related neural damage.

Lead author Dr Debra Fleischman commenting on the results said:

"These findings may indicate that exercise can make neural networks more resilient. Physical activity may create a 'reserve' that protects motor abilities against the effects of age-related brain damage."

That's good news for those of us who regularly take that 20 mile jog or cycle there and back from London to Hastings. But for those of us who are more inclined to inglorious couch-potatodom, there is help at hand.

At 96 Harley Psychotherapy, we are not only home to some of the world's leading psychotherapists and other psychological practitioners, but also have a whole floor dedicated almost exclusively to physical therapy, including a gym.

John Rutherford and Giles Webster, a physiotherapist and exercise physiologist respectively, specialise in helping those who are physically compromised because of.back pain, injury, ME or other conditions, restore pain-free functional mobility. They also work with those who have simply been chronically inactive and wish to improve their levels of fitness, strength and flexibility.

If this latest piece of research is anything to go by, the more we exercise, the lower our risk of succumbing to age-related neurological damage connected to poor mobility. Working at exercising optimally and regularly is one of the most important ways we can insure ourselves against future disability.

Written by Jacqui Hogan

When is depression not depression?

No one can dispute that depression is now a major public health issue, with incidences skyrocketing all over the Western world.

A new piece of research by Fried et al., published in the Journal of Abnormal Psychology, seems to offer a glimmer of hope by suggesting that depression is being over-diagnosed among the bereaved.

In the study, entitled 'From loss to loneliness: the relationship between bereavement and depressive symptoms', the researchers followed 515 married men and women over the age of 65, who lost a spouse during the observation period. They compared the depression symptoms of those who had lost a spouse with an equally large (n=241) still-married control group.

Lead author, Dr Eiko Fried, identifies the two key findings:

"First, we found that spousal loss causes a very small number of specific depression symptoms, the most important of which is loneliness. Second, we observed that these few initial depression symptoms, in turn, trigger a specific network of subsequent depression symptoms."

The implications are significant, Fried notes, because it opens the door to targeting symptoms, such as loneliness, to prevent the activation of further symptoms and possibly full-fledged depression.

One of the concerns raised by the team is the fact that the Diagnostic and Statistical Manual of Mental Disorders (DSM) in its latest edition (the DSM-5 published in 2013), actively removed the distinction between depression and natural bereavement. This has been highly controversial, since pathologising normal sadness increases the risk of labelling and medicalising those who are simply passing through the normal stages of grief.

This is not the first time the DSM-5 has been called into question. In 2013, another notable change to the text designated paedophilia a 'sexual orientation' rather than its former description as a 'disorder'. This is a radical shift, indicating as it does, that the desire for sex with children is just one other variant in the normal spectrum of sexual behaviours.

In the case of blurring the lines between bereavement and depression, it would appear that the DSM-5 has introduced the potential to put people at risk of misdiagnosis and unnecessary medicalisation; but in the case of reclassifying paedophilia as a lifestyle choice, it has potentially entered another realm.

We need more research like this to promote common-sense findings, which can make a real difference in peoples' lives and ensure they get the help they need, rather than suffer unnecessary harm. The authors are also to be applauded for shining a light on this subtle, but highly significant, edit to the DSM-5.

Do you have any thoughts on this topic? If so, we'd love to hear from you. Please comment.


Written by Jacqui Hogan

Concerning children's mental health

A recent government task-force review sheds some rather disturbing light on the state of child mental health services in England. The review focuses on concerns highlighted by a survey of Clinical Psychologists working across 43 separate specialist Child and Adolescent Mental Health Services (CAMHS) in 2014.

According to the Psychologists, in the last three years some 62% of services have decreased their staffing levels, with a bias towards the loss of more highly skilled professionals. In addition, further cuts are being planned for 42% of services.

Other findings showed that:

• 71% of services have tightened their acceptance criteria and raised severity thresholds for being seen
• 54% of respondents were concerned about the deterioration in provision for young people in crisis
• 66% of services reported a decrease in the quality of treatment provision
• 56% said the availability of psychological therapies had decreased in the last three years
• 53% had noticed a more medicalised approach to treatment

On this last point, Professor Jamie Hacker-Hughes, President-Elect of the British Psychological Society commented:

"We are seriously concerned that over half the respondents reported a move to more diagnosis-led, medicalised approaches given the significant weight of evidence in favour of psychological interventions for the majority of child mental health issues."

He has a point. There is a substantial and growing body of outcome research from the UK and abroad demonstrating the efficacy of child and adolescent psychotherapy, which is one of the reasons why the National Institute of Clinical Excellence (NICE) clearly recommends it. And while medical treatment has its place, it would be a tragedy to see it become the mainstay of treatment for conditions such as childhood depression.

Corroborating the survey findings, figures released last month showed that NHS spending on children's mental health services in England has fallen, in real terms. by 6% since 2010. The charity Young Minds has also recently found that over half the councils in England cut or froze budgets for child and adolescent mental health spending between 2010-2011 and 2014-2015.

These are troubling times for mental health services in general, but it is especially upsetting to think that our children, who are our future, are being let down in the critical area of mental health service provision. And as the culture around them becomes increasingly dysfunctional, we can only expect the crisis to deepen.

Do you have thoughts on this important topic? If so, we'd love to hear them.


Written by Jacqui Hogan

Bedlam now on open display

This week, I heard the story of a mother whose son had been conscripted to Afghanistan with the Territorial Army. One of her anecdotes which particularly touched me was that of her son asking her to send, along with protein bars and practical sundries, a colouring-in book. She told of how, in a quiet moment, his commanding officer had given him advice about how to stay within the lines - a wonderful cameo of simplicity and humanity in a world gone mad around them.

Perhaps this incident gives a clue as to the potential role of making art, no matter how rudimentary, for those trapped in a mental war zone.

This week, a new £4m gallery and museum, Bethlem Museum of the Mind, opened up at the Bethlem Royal Hospital in South London (pictured above), the world's oldest psychiatric institution. Formerly known as Bedlam, Bethlem has been treating patients with mental illness for almost eight hundred years.

Over that time, it has acquired a large collection of art and artefacts, many of them created by patients, and it is this body of work which has just gone on display. The collection itself dates back to the sixteenth century, making it the oldest archive of objects related to mental health in the world.

As one of the former patients acknowledges in a short promotional video put together by the BBC, creating art helped him to express the darkness he felt inside, while at the same time providing liberation from the strictures and disciplines of being in the clinical environment. He speaks of how the experience helped him to communicate what was happening for him and the great extent to which it contributed to his recovery.

The collection now on display is significant, bringing together the work of patients from Bethlem, The Maudsley and other psychiatric institutions.

Some artists, such as Richard Dadd, who was painting during the reign of Queen Victoria, have achieved international acclaim, while some of the exhibits, such as a pair of seventeenth century statues entitled 'Raving and Melancholy Madness' by an artist named Caius Cibber are of historical significance as former major London landmarks.

Victoria Northwood, Head of Archives and Museum, hopes that the current exhibition will help stimulate debate among visitors and lead to a better understanding of the lives of those living with mental illness. We echo that aspiration. And if you decide to visit, you'll be able to enjoy world class works of art and learn more about the history of mental health through the museum's unique archive.

Do you have experience of working with art in patients with mental illness? Or have you, perhaps, been helped by art in making a recovery from mental illness? We welcome all contributions on this fascinating topic. And do consider visiting Bedlam.


Written by Jacqui Hogan

Valentine's Day Special

I've been trying to figure out the connection between the original St Valentine, a Roman priest who was beheaded under Claudius II on 14 February in the year 270 AD, and the restaurant-and-rose-fest we practice every year in his name. Maybe it has something to do with him sheltering Christians from persecution and, in losing his life for their sake, demonstrating perfect love.

Now, I'm not sure how many of the couples in candlelit restaurant windows on Valentine's night would lay down their lives for their paramours; with the wind behind them, they won't have to. They will simply be able to bask in the bliss of the rather more comfortable derivative passed down by St Valentine - that is, romantic love.

But what is romantic love and how does it impact our mental health?

It would appear that romantic love is certainly good for overall health. This was demonstrated by a study of 3,000 people, aged between 57 and 85, who reported that being in a satisfying romantic relationship improved their sense of wellbeing. Participants in close relationships were more likely to report that they were in "excellent" or "very good" health than merely "good" or "poor" health.

Such positive thinking, according to the Mayo clinic, has all sorts of positive knock-on effects for objective measures of physical and emotional health, including reducing the risk of depression and protecting against the common cold.

And indeed, it's hard to argue against the affective pleasures of being in a good romantic relationship (whatever exactly that is!).

But is all romantic love good for your mental health?

Show up at any 12-Step meeting catering to the needs of people suffering from love addiction and I'm sure you'll get a different response to the one you'd get from diners in the hypothetical restaurant above.

Because what passes for love in this case is usually neurotic attachment, in which things can go horribly wrong. When the reason for being with another is to assuage unconscious feelings of discomfort or inadequacy (which usually hail from the family of origin), life is not all beer and skittles.

The typical love addiction cycle waxes with periods of intense engagement (usually pleasurable, at least on the face of it), then wanes with one or both partners entering into avoidance. It's a roller coaster ride that can get very messy, especially when the object of attachment (i.e. one's partner) is removed from the scene, as happens in a break-up.

Which leads on to the question how do people fare in the mental health stakes when there is no romantic love? Should singletons gaze through that restaurant window with sadness and longing?

Not necessarily! According to the NHS, having a healthy network of friends can have many of the same positive benefits as being in a romantic relationship. And reported on the same platform, a longitudinal study of almost 700 older nuns found that many are keeping fit and mentally agile well into their 90s and past 100!

Which brings us back to St Valentine. He clearly understood that love is not a feeling but an action (or perhaps a committed set of actions). As M Scott Peck in his classic book 'The Road Less Travelled' writes 'Love is the willingness to extend oneself for the purpose of nurturing one's own or another's spiritual growth'. I do like that definition.

Happy Valentines!


Written by Jacqui Hogan

Getting up close and personalised

You may not have noticed it, but personalised medicine is about to be all the rage. It's one of the biggest trends in modern medicine and what it may mean to the average punter is fewer side effects on medication. The idea is that the drug you will be prescribed will be tailored to your own personal genetic profile, thereby avoiding pesky side effects that may apply to the broader gene pool. Sounds good in theory, doesn't it? And maybe it will be.

There's a new initiative reported on the starting blocks this week which aims at using personalised medicine to reduce the side effects of medication in people with mental illness. Potentially this could be a winner, given the well known problems with side effects on antidepressants and other mental health prescriptions.

Geneticists at the University of Pittsburgh Graduate School of Public Health in Pennsylvania are to implement the research project which will be conducted over 28 months. According to Dietrich Stephan, PhD, Professor and Chair of the Department of Human Genetics at the School of Public Health:

"An individual's genetic makeup defines how many common drugs are processed by the body and who is at risk for an adverse reaction from such therapies. Individuals can suffer immensely from the very drugs that are meant to improve their health if given drugs they cannot tolerate, often resulting in increased emergency room visits and elevated healthcare costs."

Participants will be selected from a pool of adults with mental illnesses who are currently prescribed, or who will be prescribed, at least one psychotropic medication during the study period. Participation will be voluntary and oversight provided by a senior counsellor and a recognised ethicist in the Pennsylvania region.

Now, as someone who, this very week, experienced an adverse reaction to an anaesthetic, I can assure you the idea of personalised medicine is sounding mighty appealing. In my case, the doctors were utterly perplexed by my reaction and, in what could have been a television advertisement for personalised medicine, exclaimed things like 'we've never seen this before' and 'never say never in medicine'.

So if it's sounding like a relief to me, how much more of a relief will it be to those prescribed a cocktail of drugs with no insight into their genetic susceptibilities, perhaps triggering interactions and symptoms which might be misdiagnosed as part of their symptom profile?

All too often, the vulnerable, the mentally ill and the elderly, obediently (and sometimes not so obediently) imbibe drugs with a side effect list the length of your arm, based on best guesses as to their problem, only to feel even worse for the treatment.

Personalised medicine, especially in the area of mental health, seems to me to be a step forward, so let's hope this US study yields some positive results.

Written by Jacqui Hogan