Popularised by Winston Churchill, the Black Dog metaphor for depression is a powerful image for this most disabling of mental health conditions. With spring nearly sprung, the sun is coming out and there is lightness of step again after the long grey of the Manchester winter. So let’s lengthen the leash a little on the Black Dog of depression and run him around the metaphorical park through the metaphorical daffodils. This blog has been harder to write than my previous one on anxiety. Anxiety is full of energy, albeit misplaced energy with an inappropriate direction. There is a certain dynamism to anxiety, which when redirected can turn around quite quickly. Depression is more like an oil tanker (I know I am mixing my metaphors but indulge me…). It is much slower to react and to readjust. Sitting heavy and low in the water the captain knows to change direction; the steering wheel is on full lock but it is aeons later that the most imperceptible shifts start to happen. So how to make those changes when feeling overwhelmed, sapped of energy and crushed by the weight of depression? Well as a GP I have discussions about depression all the time, perhaps even on a daily basis. People use a variety of strategies to cope. Increasingly they choose to get on their yoga mats. One of my patients suffering with depression, let’s call him Winston, has given the gift of sharing his experiences and talks about how yoga has helped him. Winston’s Black Dog is a heavy, shaggy, energy-sapping mutt. He never noticed him creeping into the room but once the Dog is there he resides resolutely on the mat immovable and stubborn. He is brooding, resentful and passive. His negativity wafts around and is tangible not just to Winston but also to all those around him. So without going into all the gruesome details, Winston has had his fair share of the usual interventions for depression. Medication, talking therapies, self-help materials, boundary setting and hiding under the duvet for weeks on end… They all have their place and sometimes a combination thereof was required. But for Winston, getting on his yoga mat has become his therapeutic intervention of choice. When depression bites the world closes in. He couldn’t imagine coping with all the responsibilities of daily life. But after trial and error with a variety of depression busting methods, he came to understand that what works for him, is to get himself onto a yoga mat. Even the simplest of tasks in this mind state can be daunting. The thought of doing a full session of practice seemed overwhelming. So Winston didn’t approach it with such goals in mind. He just used the yoga as a framework to stand, to breathe then to move through one posture at a time. Soon he’s linking postures together and things start to flow. He gets just as far as he gets, with no self-recriminations.  But as time goes by his motivation to do a deeper practice starts to grow and the sessions get longer. While he is on the mat moving and breathing, his Black Dog depression is temporarily banished. So Winston explains “I feel good when actually doing my yoga practice, but initially my mood slides away and it feels like I am back to square one by the next morning”. But experience tells him that he is not back to square one. As he does his practice day by day, his dark mood lifts little by little, confidence grows and the changes move off the yoga mat into his day to day. For Winston, the act of bashing out a few sun salutations gets him on his way. The discipline of yoga pays dividends over time.  It is by no means a quick fix. Just like the slow-to-turn oil tanker, the practice of yoga can steer you back to a healthy balanced mind and perspective. It might take weeks or months but trust that it always will. The Black Dog can be turned into a down-dog and maybe even an up-dog.      
Dr Matt Joslin’s open letter calling upon the NHS to put yoga on prescription had me banging my fist on the table and saying, “Yes, yes yes!” Not because I see yoga as the panacea to treat all health ailments or because I want more students (although that’s always nice). Rather, I know first hand how empowering the practice of yoga is and the transformation that occurs physically and mentally. Let’s look around our current situation. Obesity is sky rocketing and resulting illnesses such as diabetes, heart problems, cancers are following suit. On the other side of the spectrum, eating disorders such as anorexia amongst teenagers and young adults are increasing with the mental effect of such illnesses diminishing vitality and health both now and in later life. Depression, anxiety, stress, insomnia - most of us have been afflicted by at least one of these states at some point in our lives and we have to face up to the fact that in large part, these have occurred through the life choices we’ve made. My partner, Christoph Seiland, who is a yoga teacher and doctor recalled his year in vascular surgery. Involving the amputation of feet, hands, and limbs, he said that nearly all patients lying on the operating table was there because of the choices they had made. It may seem like an extreme example, but the snowball effect of one single choice can result in chronic poor health. As I write this now, overworked junior doctors have gone one strike for the first time in 40 years against a proposed contract that will see them working longer and harder. It’s easy to blame the Health Secretary, Jeremy Hunt, for imposing such a contract, and sure most of the blame lies at his Whitehall Door, however, what about us? What can we do? Let’s start by looking after ourselves, treating our wonderful bodies with the full respect they deserve. And this is where yoga comes in. In yoga, we have a mat and a body. We listen intimately to the signals of the body conveyed through muscles or the breath, and we learn to see the discrepancy between what the mind tells us is and isn’t possible and what we are actually able to do. No machines required, the mat can be rolled out at any time, simply manipulating the body to create leverage, weight bearing, and cardiovascular elements. Slowly we cotton on to how bloody brilliant the body is, regular practice takes our hands closer to our toes, and we realise that our volition pays dividends as vitality from within and not an outside substance leaves us feeling lighter, more alert, and most importantly, empowered to make more beneficial choices. It is this empowerment to make the right choices that cuts through the snowball effect of choices that lead to bad health, and ultimately a strain on NHS services. Whilst living and teaching in Berlin, I noticed a huge contrast to the UK: people are generally leaner and are willing to invest in their health regardless of their income. Recognising the health and mental benefits of yoga, the German health insurance companies (private and state run) reimburse almost 80 percent of the yoga class fee every year or two years. For them, the reimbursement acts as a preventative measure and helps to reduces the costs of hospital stays and treatments - this is probably a huge factor in why so many people in Berlin practised or taught yoga! I truly believe that optimum health starts from within, and whilst yoga certainly does not make us immune to ill health, it does make us more empowered to be aware of what we are saying yes and no to, and provides a space in which to offer ourselves respect, love, and vitality. We have one body and one life, it is up to us how we choose to live it. #PrescribeYoga    
Balancing upside down gives a novel perspective. I like to do this frequently even though my family finds it odd and even embarrassing. For example I have been known to tip up into a headstand whilst out and about on holiday. My daughter then disowns me and extorts heavy financial compensation before she will again admit that we are related. Wall space at home gets commandeered for elbow balance and handstands; there is a tide-mark where sweaty heels have left an impression. Once the tussle with the physical unusualness of the situation settles down I do get moments of reflection. The other day whilst head standing and contemplating the fluff that had accumulated under the sofa that otherwise I would not have seen, I was thinking about how to balance. This refined itself to an awareness of balance in general. Lots of yoga is about balance. There is the obvious headstand, handstand, elbow balance thing. Initially it’s a struggle to get up and stay up. After time, when the body seems to know what it is doing some stillness may come. But you don’t have to be upside down for balance to come into play. Just standing in Samastitihi requires equanimity. Left side has to equal right side, weight evenly distributed across the toes and the heels with evenness of breathing. Apply this concept to some more challenging one-legged standing postures and awareness has to be balanced between the grounding of the standing leg and the work of the lifted leg. After spying a bit of Lego and one child’s sock under the sofa from my new vantage point, I thought some more. There is a balance required in any posture, seated, supine, standing or inverted, between the intensity of the muscle work required and the softening and release that allows you to deepen a little. In twists the attention is drawn to the side to which you turn, but this has to be balanced with the release on the other side. These subtleties are particularly important injury prevention. Overworking and overstretching can cause grumbling tendon inflammation, muscle tears or joint pains. The art is to challenge yourself beyond what is cosy and comfortable to the full capabilities of the body yet balancing this with a softening in the intensity. Taking a look at the practice of yoga as a whole there is balance to be considered here too. I notice there are times when I do more practice and other times when I do less. Life can get in the way of yoga! If I practiced every day for as many hours as I would like to, the impact of yoga on my life could swing in the wrong direction. I have a wife, children, friends, a job, colleagues and many other facets of my life to consider. If I over commit and try to squeeze in as much practice as I can, or I push and try too hard, then friction builds. My coping mechanisms for stress and worry management go out he window and trying to do yoga can become a problem in itself. I notice if I get the balance of practice right then other areas of my life jog along quite nicely. From a professional point of view, my yoga practice helps me to help my patients. The physcial health benefits aside, it is the mental composure that is one of the benefits that can have the biggest impact. Of all the hundreds of thousands of GP appointments that take place very day in the UK, more than 25% of them have a significant mental health component. Using the balance of yoga and its inherent mindful approach is one tool available to help manage the stresses, anxieties and worries that assault us all. So I’m nearly ready to come down now from my inverted perspective, but what occurs to me is that I need to turn this balance idea on its head. I am not doing yoga to learn to balance in postures that I practice in class. The lesson of balance that I achieve in my yoga practice is actually something I need to apply more widely in my life. Yoga helps me bring balance to relationships, to the intensity which I do any activity. It teaches equanimity from moment to moment.  
This one is written from the heart. To all of you out there who are troubled by anxiety I hope you find a way to redefine its impact upon you. Maybe some of these ideas will help. Anxiety is part of the human condition. We all have it to varying degrees and it serves a purpose. An adrenaline boost from time to time may be just what is required to get us through a difficult situation. However anxiety over spilling and permeating any and every aspect of life can become disruptive, distressing and disabling. More than that it can dominate one’s thinking and feelings to the point of being a truly terrifying experience. So what to do about it? There are many ways of addressing anxiety. I do not want to explore the pros and cons of each method here. Neither do I wish to undermine anyone’s coping strategies. The medical model of anxiety management certainly has its place. After all that is part of my day job: to lay out options available and help people choose what is right for them. Medication, counselling Cognitive Behavioural Therapies and deeper psychological methods may be just what is needed. They are tools in a toolkit to help manage mood, feelings, thoughts and their consequences. So I want to highlight another tool and in my opinion one of the best to help manage anxiety. I have said this before: yoga is an all-rounder, no-brainer amazing activity to boost your wellbeing. If you were to design a new treatment for any medical condition, physical or psychological, yoga ticks so many of the boxes. It brings exercise together with a mindful and social approach that is accessible to all. Anxiety busting is high on the benefits list. Those of us who know yoga have come to it for a reason. It may be for a physical reason; back pain, fitness, weight-loss or better posture etcetera. This purely physical perspective may be what we share with friends and colleagues when we discuss why we first got on a mat. But if you dare to have a deeper conversation with your fellow yogis many will acknowledge that it is the mood boosting effect that drew them to yoga AND keeps them coming. "It's the mental health benefits that I'm after baby", to quote Ernest Yogi. A one-off yoga session is top notch for stress busting. After the physical work the body can relax on a cushion of calm, deep and steady breath. There is also a sense of well being which accompanies the achievement of completing a class and challenging your body. Practice regularly and you will build on this, not least from the commitment of turning up regularly, the structure this provides, the social interaction and the general physical health improvements. All of these help with anxiety. The breath aspect of yoga develops over time. Linking movement with inhalation and exhalation shifts attention away from the distractions of an overactive anxious mind. The breath may become a tool to navigate intense physical experiences, and in turn help with the intensity of anxiety. Commit yet further and you may explore a mindful even meditative aspect of the practice. In essence developing a new relationship and perspective towards anxiety. The longer-term goal is to bring what is practiced in class and on the mat into day-to-day life and experiences. What are the side effects of this intervention to manage anxiety? Well you might sleep better, you may consider more carefully what you eat and generally be more health conscious. You might get a bit of ribbing from your mates. If you get really into it yoga can be quite time consuming, but otherwise I’m hard pushed to find any down sides. So if you were to design a state of the art therapy to help manage anxiety what would you want from it? Something that you can access easily any time or place. Something that gives benefits from day one but furnishes the potential to build upon it over a lifetime. Something that stays with you even when you are not practising. This is yoga.