News and Research

One way exercise protects against stress induced depression

It has long been known that regular exercise can help overcome the effects of depression. However the reason for this have been not been clear.
Recent research from the Karolinska Instituet in Stockholm, Sweden has shed some light on the problem.

A protein, PGC-1alpha1, increases in muscle after exercise and helps the beneficial muscle conditioning caused by physical activity.

During the study a group of mice genetically modified to have high levels of PGC-1alpha1 were compared to normal control mice.

Both groups were subjected to a stressful environment of loud noises, flashing lights and reversed circadian rhythm at irregular intervals.

After 5 weeks of mild stress the normal mice had developed depressive behaviour whereas the genetically modified mice did not.

Jorge Ruas, the principal investigator at the Dpt. of Physiology and Pharmacology, stated that they found that the genetically modified mice also produced an enzyme that purges the body of harmful substances. Thus the muscle was acting in a manner analogous to the liver or kidneys.

The enzyme is called KAT. It converts a substance, kynurenine, into kynurenic acid that is not able to pass from the blood into the brain.

The researchers later showed that normal mice when given kynurenine displayed depressive behaviour; whereas the mice with high levels of PGC-1alpha1 were not affected. Indeed these animals did not even show raised levels of kyurenine, as the increased KAT enzymes quickly broke it down to kyurenic acid.

Maria Lindskog of the Dpt. of Neuroscience said that this study represents another piece in the puzzle of understanding in neurobiological terms what depression is.



Agudelo L, Femenía T, Ruas J, et al.
Skeletal Muscle PGC-1α1 Modulates Kynurenine Metabolism and Mediates Resilience to Stress-Induced Depression.
Cell , September 25, 2014;159(1):33-45.



Jorge Ruas and Marai Lindskog of the Karolinska Institutet.

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Why we need our 40 winks.


young sleeping woman seeing sweet dreamsProlonged loss of sleep either from anxiety or shift work is one of the prime causes of depression. Insomnia is also a major symptom of the disorder.


It is thought that all animals sleep, although some marine mammals such as the Porpoise, Bottlenose Dolphin, Beluga Whale and Pilot Whale and a variety of birds can put one side of their brain to sleep whilst the other remains active.


During sleep most animals are in an increased anabolic state with increased growth and rejuvenation of the immune, skeletal, muscle and nervous systems.


It is also thought that sleep is also a very important step in the process of  allowing new memories from the day to be laid down into storage.



Another reason has been found and reported in Science in October 2013.


Researchers showed that’s during the day waste products build up in the spaces between brain cells. These include proteins such as amyloid and tau proteins which are associated with neurodegenerative diseases such as Alzheimer’s Disease


Their study showed that in mice the flow of Cerebral Spinal Fluid (CSF) through the brain is increased by 60% during sleep thus bringing about an greater reduction in these dangerous wastes.




Science. 2013 Oct 18;342(6156):373-7. doi: 10.1126/science.1241224.

Sleep drives metabolite clearance from the adult brain.

Xie L1, Kang H, Xu Q, Chen MJ, Liao Y, Thiyagarajan M, O’Donnell J, Christensen DJ, Nicholson C, Iliff JJ, Takano T, Deane R, Nedergaard M.



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The cost effectiveness of CBT for depression in Primary Care

The January 2014 edition of the British Journal of Psychiatry [(2014) 204, 69-76] contained a paper entitled:


“Cost effectiveness of cognitive –behaviour therapy for treatment resistant depression in primary care: economic evaluation of the CoBaIT Trial.”



Sandra Hollingworth et al (2014) implemented a randomised control trial of usual care versus usual care plus CBT to patients who suffered from treatment resistant depression.


The Star*D study in the USA showed approximately a third of depressed people do not respond to antidepressant treatment alone.


CBT can be delivered face to face, in a group setting, by computerised packages or now with a mobile app. Numerous studies demonstrate it is effective in treating previously untreated depression and treatment resistant depression.


The researchers recruited UK based primary care patients, aged between 18 and 75 years, who had adhered to antidepressant medication for at least 6 weeks, but who continued to suffer significant depressive symptoms as indicated by the Beck Depression Inventory, BDI-II, (score>14).


Patients in the active treatment group were randomised to receive 12 to 18 one hour-long sessions at their GP’s surgery. Eleven therapists working across 3 sites used the same CBT manual.The control group received unrestricted usual care from their GP. All patients were taking antidepressants at the time of randomisation.


The primary outcome for the trial was a reduction in BDI –II score of at least 50% at 6mths compared to the baseline score. A range of other outcomes were recorded at 12 mths to determine the sustainability of the effect. ( BDI –II, remission BDI-II,10, SF-12 and ED-5D-3L)


A total of 469 patients were recruited; 234 to CBT plus usual care and 235 to usual care alone. 73% were women, the average age being 49.6 years.


The mean baseline score on BDI-II was 31.8 ( 29 and above is interpreted as severe). Seventy per cent had been on antidepressants for more than 12 mths.

Over 90% had at least one prescription for antidepressants and 10% had more than 15.


Use of hospital services was low, 4% attended A&E, 6% attended an out patient clinic and only 1% had an in patient over night admission. 22% had some time off work because of their illness, the mean duration being 54 days.


The mean cost per patient in the CBT group was £766 and the usual care group cost £786 per patient. The increased costs were mainly due to more GP visits and more medication expenses (both pharmacological and complementary).


All three outcome measures were better in the CBT group, at 12 months the mean score was 5.1 points lower and twice as many in the CBT group recorded a 50% reduction on BDI-II.


Thus CBT is a cost effective adjunct to usual care for the treatment of treatment resistant depression in a primary care setting.


The cost of the face- to- face CBT provided was  £910. The cost effectiveness of mobile CBT, which can be provided at a much less cost would be far more.sad

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The Effectiveness of Internet CBT

The Effectiveness of Internet CBT

The Effectiveness of Internet Cognitive Behaviour Therapy (iCBT) for depression in Primary Care : A Quality Assurance Study

Alisha Williams Gavin Andrews.
PLoS ONE 8(2): e57447. Doi:10.1371/journal.pone.0057447

There are at least 25 controlled trials that show the efficacy of internet CBT.
Meta analyses of RCTs of iCBT for depression have shown evidence that it is comparable to best practice face-to-face CBT.

The Williams and Andrews research, which was carried out at St Vincent’s Hospital Sydney, looked at whether iCBT was effective in clinical primary care practice, not just in the confines of randomised control trials.

Patients were referred by their GPS to enrol in the Sadness Program of the CRUfAD clinic. Approximately 75% of referrals comprised mild to moderate levels of depressed mood as the doctors were advised the program was less likely to benefit patients with very severe presentations (depression, persistant suicidal thoughts, drug and alcohol dependence, schizophrenia, bipolar disorder and those taking benzodiazepines or atypical antipsychotics).

The doctor was alerted if the patients’ Kessler-10 (K10) Psychological Distress Scale indicated elevated distress or the patient indicated suicidality on the Patient Health Questionnaire (PHQ).

The Sadness Program consists of 6 online lessons of best practice CBT and regular homework and access to other resources. Within the program the patient has to complete a lesson before moving onto further lessons, then wait 5 days to complete homework tasks and review the materials. All patients have 10 weeks to complete the program and are encouraged to complete the lessons at a pace of one lesson per fortnight.

Data was collected from 359 patients between October 2010 and November 2011. The mean age was 41.59 years and 59% were female. 54% were from a rural or remote community.

Outcome was measured using the Patient Health Questionnaire (PHQ-9), Kessler-10 (K10) Psychological Distress Sacle and the WHO Disability Assessment Schedule (WHODAS-II). Clinically significant change was defined in 3 ways.

1. Remission when a post treatment score was below the cut off for probable diagnosis of depression.
2. Recovery when there was reduction of at least 50% of pre-treatment PHQ-9 score.
3. Reliable improvement, which was defined as a decrease of at least 5 points and a change of severity category such from moderate to mild.


359 patients enrolled

26.5% were within the 0-9 sub-threshold range
26% were mild
23% were moderate
17% severe
7.5% very severe.

194 (54%) completed all the 6 lessons.
113 (32%) completed 4 lessons (Non completers)
52 (15%) completed 1-3 lessons , (Dropouts).

The risk of non completion was not related to gender of the patient, the profession of the referrer (e.g.GP, Psychologist, Nurse), or to the geographical location of the patient . Completion was however related to the age of the patient where the older the patient the more likely s/he was to complete the program.

There was a significant reduction in scores in all 3 measures for those who completed the course.

• 112 (31%) of patients admitted to suicidal thoughts during the program. The majority of these 53% completed the program. 68% completed at least 4 lessons. Suicidal thoughts were not found to be a barrier for improvement from treatment.
• 91 of 144 (63%) patients who met the criteria for depression (PHQ9 >9) who completed all six lessons reached remission .
• 71 of 144 (49%) patients showed evidence of recovery (at least 50% reduction in PHQ-9 baseline score)
• 77 of 144 ( 54%) showed evidence of clinically reliable change.

The greatest reduction on K10 scores occurred within the first 4 lessons.
Almost half of the patients (44%) who dropped out after lesson 4 managed to benefit from the program despite non-completion.

This study certainly clarifies the effectiveness of Internet-based CBT. These programs have comparable rates of engagement and outcome and are a very good treatment option in primary care.

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Connecting to Social Groups Alleviate Depression

art classA new research study has shown that developing a strong connection to a social group can help adults to reduce their depressive symptoms and to prevent them from experiencing relapse. This adds on to past research that advocates for interpersonal relationships for improved mood and managing depressive symptoms.

That is, having a sense of group identity (i.e. belonging to a group) as well as engaging in interpersonal relationships will greatly improve your recovery from depression as well as reducing the likelihood of you experiencing depressed mood again.

Haslam, Cruwys and colleagues (in press Journal of Affective Disorders) from the University of Queensland had depressed and anxious patients join groups in the community that focused on activities such as sewing, yoga, sports, art and group therapy. Patients who reported that they did not identify strongly with the social group had approximately 50% likelihood of continued depression one month later. However, those who developed a stronger connection to the group reported that they felt supported by the group and that they were “in it together”. Less than one third of these connected patients continued to experience clinical symptoms of depressed mood.

Know what to do to reduce depressive symptoms? Connect in with your community! It is not only important to relate to other people on an interpersonal level but also to join a group and develop a sense of group identity.


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Are you contributing to your community?

aus flagWith it being Australia Day yesterday I thought it timely to write a piece on community and it’s direct relationship on happiness.

International research has shown that happiness can be improved by contributing towards others and the local community. Not only does contributing to the community bring about a greater sense of belonging, it assists in the development of life purpose and meaning. Egocentrism and self preoccupation on the other hand dramatically impacts on negative mood states for the individual and everyone around them.

Many of us contribute to the life of those directly around them including family and friends by offering their services, giving them a helping hand and socially connecting and checking in about how they are going but how many of us contribute to the larger community?

You can belong to 1) yourself, 2) a family, 3) a social network, 4) a workplace or educational institution, 5) a community group, 6) a national community and 7) to the world.

While contributing to the community should not be at the detriment of your mental and physical well-being, finding a way to contribute in a meaningful way without too much consequence is important to well-being and long-term happiness and meaning.

What ways can you contribute to your community? It may be by attending and participating in a community event, it may be about contributing financially to a charity or not for profit organisation or volunteering your services to an organisation or educational institution for an event or on an ongoing basis. At the very least for those that are time or money poor, help someone across the street that needs it or take unwanted clothing to the community clothes bins for people less fortunate.

If you already contribute to your community! Well done and keep it up. The world needs more people like you.






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The Do’s and Don’ts of New Year Resolutions

New year resolutionNew Year Resolutions are commonly considered and rarely followed through. While New Year resolutions are driven by positive qualities of hope and optimism, they can also be related to a belief that the year brings a “fresh slate” to work from. Common resolutions include saving money and budgeting more effectively, losing weight and/or getting fitter, stopping smoking and attending more to meaningful relationships.

In saying this, resolutions and goals are a worthwhile concept- if considered realistically and with good levels of insight and motivation for change. Cloud Clinic provide the following recommendations for identifying New Year Resolutions that increase the likelihood of change.

  1. Start with reflection and insight: Before planning for the future, reflect on the past year in each important part of your life. For example, taking a “helicopter” perspective, consider your year in the key areas of physical and mental well-being, relationships with important others, work, financial stability, education, etc. Note some positives in your achievements in each of these areas and then list 1-2 areas that require attention or haven’t gone so well.
  2. List possible goals for the New Year: on a separate piece of paper write a list of possible New Year resolutions/goals to be considered from each area of your life.
  3. Consider your motivation for each goal and barriers to change: For each possible goal make notes of the advantages and disadvantages of change in these areas and also make a note about your motivation to change. There is a difference between thinking that it is important to work on this and being ready to commit yourself to action. In fact, research demonstrates that motivation to change happens in different stages that include precontemplation ( limited insight and thought about changing), contemplation (considering the importance of this), preparation (making plans for change), action (implementing the plan) and maintenance (continuing to implement behaviours post the change occurring to make it a routine and way of life). Most people reach the contemplation and preparation stage at New Years without moving it into action and then maintenance. In this section, also consider things that may get in the way (barriers) to changing. These may include finances, a long history of problematic behaviour, dependence on others for support, addiction.
  4. New Behaviours and Routines take months to make: It takes consistency over a period of approximately 3 months to form new routines. For those who do reach ‘action’ stage, most do not continue to implement these changes for long enough for the efforts to pay off. If you are motivated for change, ensure that you are motivated for change over a period of months, rather than thinking that you can take it one day at a time.
  5. Choose 2 goals from your list that a) have good benefits, b) that you are motivated to change, c) that have few barriers and that d) you believe are realistic for you to expect of yourself. Also ensure that these goals are ones that you are willing to follow through on over a period of months.
  6. It is ok to not make resolutions: if the resolution activity is too overwhelming and leaves you feeling anxious, make a more general commitment to a short-term task such as reading a self-help/happiness book, to setting up reminders in your phone to remind you to reflect and do the best that you can do in each area of your life, to calling a friend or contributing to the community for one day, to starting your year off with a clean bedroom, to telling the people that you love that you love them.
  7. Maximise each day for what it brings: the best approach to happiness and well-being is to do the best you can do on each day. Face the challenges that the day brings and approach it with curiosity and willingness to ride any negativity that comes with it. Knowing what is important to you and doing the best that you can will bring about success and well-being.
  8. Remember it doesn’t have to be New Years to set goals for yourself: successful and happy people remain insightful throughout the year and consistently work on the areas that are important to them. Reflect throughout the year and be willing to set goals for yourself as they come up if they are realistic and achievable for where you are at that time in your life.

Cloud Clinic wish you a Happy and Fulfilling New Year!


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Older Veterans Benefit from CBT Intervention for Depression

war veteran

The US Department of Veteran Affairs have published a study this month (Nov, 2013) that demonstrates the comparable efficacy for older veterans in the management of depression through CBT as the younger veteran population aged 18-65 years.

This study included 100 older veterans and 764 younger veterans and there were similar outcomes for both populations suggesting an approximate 40% reduction in depression symptoms and scores.

Depression in the older population is associated with reduced quality of life, increased mortality, increased risk and difficulties associated with medical illness and social and environmental difficulties.

Adults from 18 years to well above 65 years benefit from CBT therapy for the management of depressed mood, including in the Veteran population. Motivating the older adult population to seek psychological treatment of depressed mood is a worthwhile goal both for the veteran and general community.

Karlin, B.E., Trockel, M., Brown, G.K., Gordienko, M., Yesavage, J., & Taylor, C.B. (2013). Comparison of the effectiveness of cognitive behavioral therapy for depression among older versus younger veterans: Results of a national evaluation. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences

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Dr Keith Roberts recently attended the ENCP ( European College of Neuropsychopharmacology) Congress in Barcelona.


Researchers and clinicians from around the world gathered to hear the results of some of the most advanced research in neuroscience.


The keynote speech was given by Prof Henry Markram from the Blue Brain Project of the École Polytechnique Fédérale de Lausanne Switzerland.

This project aims to reconstruct the brain using supercomputers.

The project started in 2005 and as the first step the project succeeded in simulating a rat cortical column. These neuronal networks consist of approximately 10,000 neurons. They are around the size of a pin head. They occur repeatedly throughout the brain. A rat brain has around 100,000 columns. The human brain has many many more.


Each cortical column appears to be allotted a single simple role. For example in the rat brain one specific column is devoted to each whisker.


It takes 20,000 experiments to map a neural circuit. The human brain consists of around 86 billion neurons with 100 trillion synaptic connections. It would be impossible to map these out using routine experiments.


What the Blue Project intends to do is to understand the building blocks of the brain, the neuronal columns, and using statistical simulations predict the way the neurons combine and function, and compare these simulations against real data from biology.


Many in the field doubted whether this was possible or realistic but recently the Blue Brain project was funded by the European Union to the tune of 100 million Euros.


The aim of the research is further understanding of the brain.

This, it is hoped, will lead to better medications and treatments for brain illnesses including addictions, depression and schizophrenia.


There is also another thread of research that hopes to point in another direction. That is to change the architecture of computers to be more like a brain, with the aim of producing a computer which works much quicker than a brain but uses far less energy than today’s supercomputers.



The Blue Brain Project can be compared to the Human Genome Project, which mapped 3.3 billion base pairs making the 20,000 to 25,000 genes within our chromosomes. This too was initially thought to be overly ambitious. However the task was completed 5 years ahead of target and costs involved dropped significantly. Much basic science has been discovered about our genes but the hope for personalised medicine held out by many is still some way off in the future. Probably the benefits of the Blue Brain Project will be profound but distant.



There was recently  a very informative newspaper article in “The Guardian” about Prof. Markram and the Blue Brain Project.

The Blue Brian project made an introductory video to explain their work.


HBP-videoverview from Human Brain Project on Vimeo.

There is also a 10 year project to make a series of documentary films on the project.

Currently the latest film is “Year Three”

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Accepting what you can’t change- managing stress

acceptanceTrying to fix a problem isn’t always the right approach! While problem solving is a good approach based coping style for situations within your control, preoccupying your mind and efforts with a need for change in situations outside of your control is not helpful!

That is, change the situations that you can but work towards accepting the situations that you can’t! Perseverating on issues outside of your control with negative thoughts and ongoing efforts for change will only reinforce a sense of hopelessness and negativity.

Accepting a situation doesn’t mean that you are ok with it happening in the first place. It simply means that you are acknowledging that it has either happened or that it is happening outside of your control and that given that there is nothing you can do about it, there is no positive function of getting emotionally involved and enmeshed with it.

Focus your attention on the things that you can change! Remember that goals for change should follow the SMART acronym that includes the goal being achievable.

What is going on in your life that you would be best accepting rather than ruminating negatively about? Maximise the potential of your day by not involving your mind in negative situations or stressors and focusing on being calm and accepting that situations happen outside of your control.

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