Katy Forrester is a teacher and a former member of the British bouldering and ice climbing teams. Unfortunately for several years she has suffered from depression. In a recent Factor 2 podcast, Will Treasure talks to Katy about the impact of her debilitating illness and how she has managed it. They start by talking about an extraordinary blog post that Katy wrote in 2016. Katy has very kindly given us permission to share "I Had A Black Dog" here. It's followed by the thoughts of Tony Page, a consultant psychiatrist and holder of the Diploma in Mountain Medicine (DiMM)... 

"A little over two years ago a relationship broke down, a relationship that, at the time, meant everything to me.

I wasn’t in a good place, my thoughts were dark and violent. My thoughts and I had been stuck in a pattern of self-damage and self-destruction for several years taking a sudden climax that had taken myself and my ex by surprise.

I had a black dog that was keeping me company every day, making each of my movements heavier, my breathing laboured. The dog had gotten so large it blocked out the sunshine. No matter my successes, smiles from friends, love from people close to me nothing was sacred, everything was tainted and spoilt by ‘the dog’. Everything was dark. I was lost, you can’t battle for so many years without taking some serious wounds. I was hurt.

The situation of low mood had gotten so bad I had started to hear voices, voices that were unfamiliar to me. Rather than having an episode of schizophrenia my broken and battle wearied mind was trying to find a last line of weaponry.  Sending ‘good’ voices to stop the full destruction of myself. It’s often found in people who have suffered abuse, your mind is trying to show you what is really ‘true’. Instead of what some part of the world would have your believe.

 A little over two years ago I drove home from Wales to the Lakes, in floods of tears not knowing how I was going to get through the next few hours let alone days or months or years. Acts like brushing my teeth were so exhausting I actually had no idea how I was going to survive, make food, teach, finish my post graduate certificate of education (PGCE). The black dog sat in the car with me telling me I was useless, I should crash the car, that I didn’t deserve any happiness or love or kindness. The guttural grunts and barks of hatred were overwhelming.

Jadey

My shattered psyche sent in one final warrior. Another voice that said ‘buy a dog’ a voice that I didn’t bat away. And the black dog in the car couldn’t really fight against this new voice. No self-hatred could destroy the idea of buying a dog, as it wasn’t about myself, and that voice stuck with me, repeating its message, all the way home.

I was, in most people’s opinion completely mad. I wasn’t mad, just sad. But mad people are expected to make mad decisions. By the time the journey ended I was going to buy a dog.

I had a black dog.

So I bought one.

A 5 month old black Labrador.  Who was scared of everything, incredibly gentle natured and was mine from the moment she came home from me.

No matter how unhappy I was, no matter how much I hated myself, how much I knew I was undeserving of anything good, my black shadow thought the opposite.  I was her world, I could do no wrong and she loved me completely. The black dog didn’t know how to learn new puppy tricks. Didn’t know how to play and so to catch my attention. The more he barked and growled the more the puppy loved me. The black dog shrunk as the puppy grew. His confidence shrinking as hers swelled. Every adventure, 5am walk as the sun came up, climbing mission, each and every moment that Pup and I spent together the black dog lost power over me.

Jadey; my pup, and I made lots of new friends. Smiles began to mean more again. Jokes were actually funny again.

Jadey made friends with a small black dog called Ash. Her owner and I are now engaged, with a baby on the way. Without Jadey, my former black dog would never have allowed me to get this far with my life. He’d have said I didn’t deserve it, that no one could have cared about me enough to love me, that I would be a terrible mother.

Here's to two years of friendship and love Jadey pup. A dog who survives on a diet of dog biscuits, post and expensive mountaineering gloves. She has taught me more about the good things in life than any therapist could. She has taught me to love and be loved".

Here's Tony Page on his experience of treating patients with depression...

In everyday speech, the word ‘depression’ is used to denote both a symptom (low mood) and a disorder, of which low mood is but one symptom. To make the distinction, the disorder is often referred to as ‘clinical depression’. In addition to low mood, anxiety is often present, though irritability is sometimes more prominent. People with clinical depression are likely to be tearful, although in more severe depressive states people are sometimes unable to cry, and find this distressing in itself. Self-reproach and feelings of guilt are common, and range from mild feelings to, rarely, a conviction that they have committed some terrible crime. People may feel that life is not worth living, wish they were dead, experience thoughts of killing themselves or make definite plans to do so and carry them out. Concentration is likely to be affected, along with the ability to make decisions and people may experience loss of interest and pleasure in previously enjoyable activities including work, hobbies and sex.

Sleep disturbance is common and people may experience difficulty getting off to sleep, with cycles of negative thoughts going through their heads, they may wake frequently during the night or may wake early and be unable to get back to sleep. Some or all of these difficulties may occur. More rarely, people may experience increased sleep at inconvenient times. People with clinical depression commonly complain that they lack energy and fatigue easily. They may lose their appetite and lose weight, or more rarely overeat and put weight on. They may be restless and unable to sit still, or may be slowed down so that speech and movement are an effort. 

In 2018 the American Alpine Club launched the Climbing Grieving Fund to help members of the climbing community who've suffered loss in the mountains. In addition to offering real financial help, the CGF has gathered together a number of first hand accounts from climbers. A poignant and highly recommended resource

Naturalistic studies, which do not control for treatment, have shown that most people recover from an episode of depression within a year. There is, however, a significant risk of recurrence and as might be expected the risk varies depending on the diagnostic criteria used, the definition of recovery and the duration of follow-up. Risk factors for recurrence seem to include late onset (over 60), female sex, number of previous episodes, family history, and certain co-morbidities including substance misuse.

In the UK, the majority of people with mild-moderate depression are managed in primary care or by Increasing Access to Psychological Therapy (IAPT) services, though access to these services varies from area to area and may be limited by long waiting times. IAPT services will usually offer guided self-help, or computer-based or brief face-to-face psychological therapies, all of which typically draw on cognitive-behaviour therapy principles. However, because of waiting times for therapy, GPs may find themselves prescribing antidepressants when this would not have been their first-line treatment of choice. 

According to a recent study "awe walks" have been shown to result in, "greater joy and prosocial emotions during the walks and displayed increasing smile intensity over the study". Participants were encouraged to look outwards and focus upon their surrounding environment. A wonderful proponent of this approach is Beau Miles - take a look at his film Run The Line

Severe, complex or intractable depressive disorders are likely to be managed in secondary care by community mental health teams and people may be seen by community psychiatric nurses, psychologists, psychotherapists and psychiatrists, or some combination of these. Antidepressant treatment is likely to be recommended to many people who are seen in secondary care, though for some, cognitive-behavioural or other psychological therapy may be an alternative or an additional treatment.

The standard treatment for the prevention of recurrent episodes of depression in people who have responded to antidepressants is continuation of the antidepressant for at least two years. However, not everybody wishes to take antidepressants, and not everybody wants to take them long term and for this group mindfulness-based cognitive therapy (MBCT) is an evidence-based alternative. MBCT is usually delivered in a group format and is designed to increase awareness of thoughts, bodily sensations and feelings related to relapse or recurrence. To simplify a bit, whereas cognitive therapy usually aims to get people to challenge negative thoughts, MBCT has more of an emphasis on acknowledging negative thoughts but letting them pass so that they do not reinforce the cycle of negative thinking that perpetuates the disorder.

Thanks Tony. In the podcast, Katy talks about her symptoms - in particular anger and the hearing of voices - are these common findings in those with depression? 

Irritability is a very common part of depression. If it spills over as anger, it will often be followed by self-recrimination. The depressed person may be most angry with themselves, for being the way they are.

Auditory hallucinations are conventionally thought to be signifiers of a more severe depression, psychotic depression. Psychiatrists would want to make a judgement as to how much insight the person who is experiencing the voices has. Are they describing things metaphorically - ‘it was like a voice in my head saying.’? If so, this would not necessarily be a symptom of psychotic depression. Either way, the content of the voices is likely to be extremely critical.

Katy goes on to talk about how she has found ways to cope with her illness. She talks about how Jadey and her family have helped her to shift focus, describing it as, "taking you away from yourself". Is this important?

People with depression often struggle to focus on things outside of their recurrent cycle of negative thoughts about themselves, and when they do, they are not uncommonly negative ruminations about the state of the world around them. Being able to hold on to something positive, like the dog, children or climbing represent breaks away from this negative pattern of thinking.

According to Tony, "People with depression will often use alcohol to either help them get off to sleep, or as a sedative to briefly gain some respite from the mental anguish consequent on their low mood and negative thinking. Unfortunately, it is a short-acting hypnotic (haven’t most of us woken at 4am after a heavy night and not been able to get back to sleep again?) and with continued use it exacerbates depressed mood. In the past I’ve admitted more than one severely depressed person who had become alcohol dependent and whose depressive symptoms have disappeared after we've detoxed them"

Does the "clearing of the mind" that she describes whilst climbing difficult and sometimes dangerous routes fit in with what we know about the treatment of depression?

In the podcast, Katy describes an intense focus on the immediate move she is making. She doesn’t let herself get diverted into thinking about what she will do a few moves further on. Some meditation techniques may have parallels here, but I think this is different from the mindfulness techniques that are being used to help people manage depression, where the idea is that people note their thoughts, but ‘let them go’ and not engage with them, as the thoughts are negative and therefore unhelpful.

What about the sense of "being kind to yourself"?

The default position of somebody with depression is often that they are hyper-critical of themselves, so they will frequently struggle to be kind to themselves.

From listening to the podcast, it's clear that her relationship with climbing is a complex one. Whilst helpful at times, on some occasions it's been an enormous source of stress - especially when competing. Amongst those who've enjoyed considerable success it must come as a blow when it disappears?

Irrespective of depression, defining oneself in terms only of success in competition is inevitably going to lead to a negative outcome, as athletes age and their performance falls off. I guess that it is important people develop alternative sources of self-worth and self-fulfilment. For climbers this might include relationships with others, cultivating an enjoyment of activities for their own sake (after all, climbs are often located in beautiful situations) and a diversification into other, related, activities in the outdoors. In the podcast Katy describes the satisfactions of winter climbing, breaking things down into small successes, and in the context of fell running, how she just enjoys being in the mountains. This is probably a healthy way of framing things for the future. Of course, it is also legitimate to invest in pleasurable and absorbing activities that have nothing to do with climbing or the outdoors!

Thanks to Katy and Tony for contributing to this post.

 NEW DATE...

The Birmingham Medical Research Expeditionary Society (BMRES) and the British Mountain Medicine Society (BMMS) have joined forces to organise the 2021 Altitude Research Conference. The face-to-face event will take place in Birmingham on the 11th September. Speakers will include Peter Bartsch, Jo Bradwell and Chris Imray. There will also be presentations from members of the UK's leading research groups as well as ample opportunity for researchers, young and old, to present posters and short talks about their work.

Further details can be found here.