What Can Be Done About Depression in Schizophrenia?
Depression is an important issue for people living with schizophrenia. Most people with schizophrenia will experience depression at some point during their illness but there are a number of ways that its effects can be alleviated. There is more about depression on our information sheet Schizophrenia and Depression.
Selecting the Right Antipsychotic
There is evidence that some antipsychotic medications used to treat the positive symptoms of schizophrenia such as the hallucinations and delusions can also have an antidepressant effect. Antipsychotics that may be useful here are Aripiprazole, Quetiapine, Clozapine and Olanzapine (when used with the antidepressant fluoxetine)1. In general the studies have found that it is the second generation of antipsychotics, the so-called atypicals, that have this benefit.7
Antidepressant drugs have been around for a long time and have been developed over time. They are thought to be effective to some extent in around 70% of cases. The earlier antidepressants known as tricyclics were not as effective for depression in schizophrenia as the newer ones called SSRIs and in some cases could actually make the psychotic symptoms worse. However the newer SSRIs such as Citalopram, Sertraline, Fluoxetine and Paroxetine are effective at alleviating depression in most cases of schizophrenia.8
The effects of antidepressants are not seen immediately and it is usually necessary to take the drug for several weeks before the benefits are properly felt.4 It has been found that adherence with the medication regime can be improved if people suffering from depression are given full information in advance about their medication and how it will help and if taking the drug is closely monitored.6 There is some evidence that antidepressants may not be as effective during the acute phase of a psychotic episode but have greater effect when the psychotic symptoms have passed.9
There are many different types of talking therapies available today that can help in cases of schizophrenia including counselling, support groups and psychotherapy. Talking therapy is an important component in a recovery strategy and after medication it is the most important element of getting well. Research has shown that people with schizophrenia who get regular talking therapy are more likely to take their medication and will have fewer relapses. However remember that although talking therapy is extremely beneficial when used in combination with medication, there is no evidence that it can be used to treat schizophrenia on its own.
Counselling will be an important part of the talking therapy regime. Counselling involves meeting a trained counsellor, face-to-face, periodically for a private discussion. Each session usually lasts about an hour. The discussion can cover any subject that is important at the time. Counsellors do not usually try to make suggestions but rather to guide and support you in finding your own solutions. There are many organisations across the country who provide counselling free of charge or at a nominal fee for people who are on benefits. If this service isn’t available in your area then you may need to see a counsellor privately. Typically rates for an hour’s private counselling session are £30 to £50. If you find the cost of this prohibitive then try applying for the Personal Independence Payment which is a government payment designed to help people with health problems provide these sorts of services for themselves. If you can find someone who can recommend a good counsellor then that is a good way of finding one but you may have to try out a couple of counsellors before you find one you can work with. You can also ask at your GP’s practice, Counsellors can also be found on the internet or by asking at your local reference library.
Remember that your relationship with your counsellor is a confidential one. The only time that they would think of disclosing anything about a counselling session to your doctor is if they think that you were at risk of hurting yourself or somebody else.
In addition to counselling, psychological therapies such as cognitive behavioural therapy (CBT) may have benefits for people with schizophrenia suffering from depression.9 CBT is a form of talking treatment that was developed in the 1950s and has been used for some time now to treat depression. It works by encouraging the sufferer to challenge and correct the negative thinking patterns that typify depression. Some studies have found that talking treatment combined with antidepressant medication is more effective than either alone.5
The current treatment guidelines for schizophrenia in the UK are that people living with schizophrenia should have access to CBT on the NHS however the government has not funded this policy sufficiently well and although CBT is available to people with schizophrenia in most areas there is usually a long waiting list, sometimes as long as a year. If you think CBT may be beneficial then it is a good idea to ask your GP for a referral to one of the NHS services. However, if you do not want to wait and have the resources to fund the service privately there are therapists that work in private practice in most areas and whose details can be found on the internet.
Trans Cranial Magnetic Stimulation (TMS)
TMS treatment consists of applying an electromagnetic coil to the scalp. It is painless and non invasive and should not be confused with old fashioned electro convulsive therapy which was widely used to treat depression before the advent of the antidepressant drugs but whose use has largely declined now. There is some evidence that TMS may be good at treating depression and negative symptoms in people with schizophrenia.2
Omega 3 supplements
Very promising work was carried out in the later part of the 20th century into the benefits of Omega 3 fatty acids in diet for people living with schizophrenia. These fatty acids are found in linseed, oily fish such as sardines, salmon and mackerel, some seeds such as flax, rape and soya bean and hen’s eggs. They cannot be made by the body and must be obtained from the diet. Omega 3 fatty acids can also be found in supplements such as cod liver oil and Omacor. The beneficial component of omega 3 fatty acids is thought to be a chemical called EPA. This compound is vital to some body functions including the functioning of the nervous and immune systems and in children is necessary for good brain development. Professor David Horrobin wrote a pioneering work on the subject in 2002 13 in which he described the use of Omega 3 supplements to successfully treat people with schizophrenia who had not previously responded to antipsychotic medication. Further work by others seemed to confirm this.10
However, subsequent work on this subject has not shown as much promise. In 2007 researchers in Canada carried out a review of the previously published material and found that most trials had been based on small numbers of participants and concluded that there was little evidence of any benefit from Omega 3 fatty acid supplements in schizophrenia. However they did find that there may be benefits in mood disorders such as depression.3
The official advice concerning Omega 3 products today is mixed however. The American Psychiatric Association currently recommends that adults should eat oily fish at least twice per week and that Omega 3 supplements should be considered in cases of mood disorder such as depression.12. However guidance in the UK is slightly different. In the UK treatment guidelines for doctors are laid down by an organisation called the National Institute for Health and Care Excellence (NICE). Current NICE guidance is that evidence concerning the efficacy of Omega 3 supplements in schizophrenia is not conclusive and currently there are no Omega 3 products licensed for the treatment of schizophrenia in the UK.
However other experts have recommended a daily intake of EPA of 450 to 500 mg which can be achieved easily by eating two to four portions of oily fish per week.11
Any recommendation concerning Omega 3 products does not apply to pregnant and nursing mothers and women wishing to become pregnant who should discuss the issue with their doctor before increasing the amount of fish in their diet or including Omega 3 or similar supplements.
Research has shown that rehabilitation, social support and work opportunities all help to reduce depression. It is therefore very beneficial to plug into any help that may be available in your local area aimed at helping you get back into the mainstream.8 This may be for instance groups that provide music or dance therapy, or opportunities for volunteering, study or part-time work. Our information sheet on volunteering gives some useful information about the benefits and practicalities of doing voluntary work.
One particular good scheme in the UK called the Green Gym scheme is run by the Conservation Volunteers charity and involves getting people out into the country to work on conservation projects. It has proved particularly popular with people living with schizophrenia. Schemes such as this have a number of benefits: they are good for physical fitness, help relaxation and sleep and enable you to meet new friends and contribute to your local community.
Getting help from the professionals when you are suffering from depression is of course vital but it is also important to recognise that the doctors often don’t have all the answers when it comes to mental health. You are an expert in your own condition and it is often possible to alleviate depression by using some self help techniques. Research has shown that people with schizophrenia who use techniques to deal with their depression also tended to adhere better to taking their medication. This sets up a virtuous circle with self help techniques working hand-in-hand with medication to get a result that each could not have achieved on their own.6 Below are some suggested self help techniques.
Speak to your doctor
If you think that you or your relative with schizophrenia is suffering from depression then it is important to get professional help and not just to “grin and bear it”. In the first instance it would be useful to talk to your GP, psychiatrist or Community Psychiatric Nurse if you have one. They will be able to help with prescribed antidepressant medications or with referrals to talking treatments like CBT.
Speak to your family and friends
Sharing your problem with family and friends is essential. They may not be able to provide any tangible help but simply telling them will help them to understand any mood changes that they may have seen in you recently. On the other hand some people are really good both at listening and providing practical help.
Take some exercise
Getting more exercise will help you to feel more relaxed and help with achieving a good sleep pattern. There is more information about exercise for people with schizophrenia on our information sheet.
Get enough sleep
Not getting enough sleep (what doctors call insomnia) will deepen any feelings of depression that you have and also make it more difficult for you to concentrate and get things done. Sometimes insomnia can become chronic and badly affect your efficiency particularly if you are in work. There is much that can be done about insomnia from sleeping pills to improving your sleeping environment. There is more information about this problem on our information sheet about Sleep Problems.
Don’t take important decisions while depressed
While you are suffering from depression it is important not to try to do more than you can manage. It may not be the best time for making important decisions and if you can delay making the decision until you are feeling more optimistic then that may sometimes be better. If you cannot put the decision off and you are worried that you may not be in a good mood to make a good decision then try talking to one of your family or a close friend about the issue and asking them for their view.
One of the first things to suffer when we get depressed is our ability to plan ahead. Sometimes, when mood is really low it may seem pointless to think even about what we are going to do tomorrow. This is counter-productive and may actually make the situation worse as we may miss appointments or not do important tasks. Try to keep thinking ahead even if only to what to do the next day.
Challenge negative thinking
One thing that many people living with schizophrenia have observed is that even when the persecutory delusions and voices have ended there is still a tendency in us towards persecutory thinking. We may “catastrophise”: constantly thinking about what is going to go wrong when we attempt something. We may have suspicions about the people that we are close to or even people that we meet casually. It is important to try to challenge these negative thinking patterns.
Break tasks down into smaller more manageable chunks and reward yourself with a treat when you have done a lot
When we are depressed it is sometimes difficult to take on big important tasks and we may end up putting them off. One way around this is to break the task down into smaller more manageable chunks. It is also good to reward ourselves with a small treat when we have done something particularly when it is something that we were putting off doing.
Try to do something about loneliness
If you spend a lot of time on your own and feel lonely then it is a good idea to try to address your loneliness as a way of helping with depression. Social contact will give you someone else to share you problems with and will help to distract you from negative thinking. There are local befriending schemes run by mental health charities such as Mind and Rethink which may be available in your area. There may also be support groups for people with mental health problems. You may also find that joining a gym or activity group such as a walking group may help or that doing some voluntary work for a good cause would be a good way of meeting other people.
1. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial, p190
2. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial, p204
3. Reveley A, 2006, Your Guide to Schizophrenia, Hodder Arnold, p91.
4. Burton N, 2012, Living with Schizophrenia, Acheron Press, p79
5. BurtonN, 2012, Living with Scizophrenia, Acheron Press, p80
6. Tacchi M Scott J,2005, Improving Adherence in Schizophrenia and Bi Polar Disorders, John Wiley, p72.
7. Buckley P, Miller B, Lehrer D, Castkle D, 2009, Psychiatric Comorbidities and Schizophrenia: published in Schizophrenia Bulletin.
8. Mulholland C, Cooper S, 2000, The symptom of depression in schizophrenia and its management, published in British Journal of Psychiatry.
9. Bosanac P and Castle D, 2012, Schizophrenia and Depression, published in MJA Open.
10. 14. Puri B and Steiner R,1998, Sustained Remission of Positive and Negative Symptoms of Schizophrenia Following Treatment with Eicosapentaenoic Acid, Archives of General Psychiatry, February 1998
11. Richardson A, 2008, Omega 3 Fatty Acids for Behaviour, Learning and Mood, Published in Nutrition and Mental Health, Pavilion Publishing, p61.
12. Richardson A, 2008, Omega 3 Fatty Acids for Behaviour, Learning and Mood, Published in Nutrition and Mental Health, Pavilion Publishing, p61.
13. Horrobin D, 2002, The Madness of Adam and Eve: How Schizophrenia Shaped Humanity, Corgi.
Copyright © January 2016 LWS (UK) CIC.