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.      
Dear NHS, When I write to the National Health Service, really I am appealing to you as its users. But you users are also the care providers, administrators, managers and policy shapers. In this country our health service is part of the lifeblood of society. I am proud to be part of that despite the current challenges facing us. So many of the news stories about the NHS currently sadden me. Services are cut back, patients are let down by the system, individual health care workers are overwhelmed and stretched to breaking point. The health of the nation raises cause for concern and we reflect on the trend of living longer but with doubt over the quality of that life in our more senior years. There are many ways that we as a society and providers of health care could address these problems and I want to bring Yoga to the table as an intervention on an individual and public health level that offers positive and sustainable improvements to health across the board. Before scepticism prevents you from reading further, please consider the following. On a personal level I came across yoga 15 years ago to help me with back pain. My terrible posture and lack of exercise due to most of my week being spent sat at a desk was taking its toll. Subsequent to this I suffered a bout of depression, which nearly resulted in my leaving the medical profession. Unexpectedly, I found that rather than the well-pushed interventions of talking therapies and medication, it was my yoga practice that sustained me and helped me get back on track. As time goes by the many facets of yoga practice become more apparent to me. It is so much more than just exercise and now, with confidence from personal experience I recommend yoga to my patients. Every day in my job as a GP I think of the potential of Yoga. Yoga could have a positive impact on almost every health related situation that comes into my consulting room. It comes up in discussions about weight loss, anxiety, back pain and depression, pregnancy, cancer, cardiovascular health and ageing. I could go on. The more I consider the role yoga has for an individual person coping with a particular health concern, the more I see the potential for Yoga to become a public health intervention that society could opt for to bolster the health of the nation. From a public health perspective, if a Think Tank was trying to devise an intervention that had potential to improve physical and mental health parameters across all age ranges with great accessibility and appeal, with little outlay for the individual in set up costs, I challenge you to find a better intervention than Yoga. I want to see whether there is a way to marry the amazing healing sustaining practice that is Yoga with the services offered by the NHS. The NHS already sends people to the gym and to swimming pools. Find me a physiotherapist who doesn’t think yoga is a good idea. It is time yoga became the default option to get people moving, improve strength, flexibility and posture and while you’re at it, to bring a helping of mindfulness to promote mental health. This idea has credibility is gaining momentum. Just last autumn The Mindfulness All-Party Parliamentary Group reported on the evidence and best practice of mindfulness. It plans to develop policy recommendations for Government with respect to applications in health, education, the workplace and the criminal justice system. Mindfulness is an integral part of Yoga, which has the potential to offer yet more benefits in those domains than just mindfulness alone. Yoga is not new to the UK. Manchester in particular has very strong links to the yoga tradition with international expertise. The yoga infrastructure here grows year on year. Should the users of the NHS wish it, we can capitalise on this base of expertise and offer it as tool to improve health care. Essentially I am asking you to consider offering Yoga on prescription. GPs have been put centre stage in the process of commissioning services. What strikes me is that in this process we should be representing the needs and wishes of the community when commissioning a service. This is a unique opportunity for you, as consumers of the NHS to have a voice and help shape a service if you want to. Share this letter via any medium you choose. Open up the debate. Do you see a role for yoga in your health care? Do you have questions or reservations? If you show your interest and get a conversation going, we can encourage the NHS to drive this forward. I truly believe in this idea. I hope you see its potential too. Yours Sincerely Dr Matt Joslin GP Manchester