Hello and welcome to the new psychology of Depression.
A series of programmes with me, Dr. Danny Penman and Professor Mark Williams of Oxford University.
The previous episodes we looked at depression and the treatments available in this episode.
We're going to look at why depression tends to return. Mark, can you summarise where we are with treatments for depression today?
Okay, so in the previous episodes, we looked at depression, what it is, as you say,
and we noticed that there was acute depression, but it tends to come back.
And so now people distinguish between the episode itself of depression and then response to any treatment.
And if that response is sort of held up for a few weeks, maybe eight weeks of being symptom free,
already having very mild symptoms, you call that a remission. And then if that goes on for a few months, you call it a full recovery.
And we've seen that acute treatments like antidepressant medication seems to treat successfully about 60 percent of people.
Same is true of cognitive therapy as well. About 60 percent respond really well.
But as we've seen, the problem is that still most people either don't seek treatment or they don't get treatment.
Or if they get antidepressants, they stop taking them. So relapse is a huge problem.
One of the problems with relapse is it wouldn't matter if people say got depressed very late in life where relapse.
There wasn't much time for them to relapse.
But as we've seen, one of the big changes over the last 50 years is that onset is getting earlier and earlier.
And therefore,
there's a whole lifetime ahead of people when they've been depressed for the first time where they may be at risk of getting depressed again.
So this relapse. It's not anything to do with withdrawal or symptom.
This is just people returning to the underlying nature, as it were.
There is some evidence that some forms of depression are genetic, at least to have a genetic hygenic loading in them.
Of course, when you know that something is genetic, it doesn't mean there's nothing you can do about it.
You can intervene. People might have a genetic condition that means they can't eat certain stuff, for example.
So they stay away from that stuff and it's fine. So genetics doesn't mean there's nothing can be done.
So even though the most genetically highly loaded depressions may start early, they may be most recurrent.
It still doesn't mean that we can't intervene. But most depression is not genetic, is it?
It's it's mostly psychosocial problem.
It's not possible to distinguish what's genetic and what's psychosocial problem in the sense they interact very closely.
So, for example,
the recent evidence on this serotonin transporter gene that might affect the ability to develop and make sufficient serotonin in the brain,
this neurotransmitter, which no,
it's very important that that genetic problem is then brought into play only if people have chronic stress or big life events.
So you can have if you have a life free of big events, then it won't affect you.
However, if you don't have that genetic loading, you can have quite big events and still seem to be resilient to them.
So it's a very complex interplay. It's not possible to say, yes, this it's either genetic or it's it's nurture.
For somebody who has just been successfully treated for depression, what can you do to reduce the risk of relapse?
One of the important things to note is that once people have recovered, they can recover for quite a while.
And as we said in the last episode, people can continue to take their antidepressant.
So that's probably the most common way in which a physician would advise somebody to
reduce the risk of future relapse is to continue to take the antidepressant medication.
But as we saw there, some people don't want to take the medication.
For example, if a woman wants to get pregnant, she may be advised not to to take antidepressants if she wants to breastfeed.
She may not want to be taking antidepressants.
And many people either naturally stop when they feel better, because how many of us continue our treatments after we feel better?
We may just forget to take the pills, for example.
And then often physicians don't tell us what to do when we've actually just forgotten to take the pills if we don't find it.
Our symptoms coming back immediately, then the tendency is to keep them in the cupboard or keep them in the bag for a rainy day.
The trouble is antidepressants don't work like that.
So the net effect is that the long term effects that might be delivered by antidepressants don't aren't actually delivered.
Now, there's another thing that's actually just beginning to emerge, and it's really quite serious if it is replicated.
But one study has begun to show that if you take antidepressants for more than a year, then their effect may begin to wear off.
It's too early to say if that's going to be a trend. But I think the fact that people have begun to even suggest it is important.
Of course, our attention then turns to the big alternative,
which is can we find a psychological approach which has this same effect to reduce the long term risk?
Can you really change the underlying thinking processes that somebody may have had for 20, 30, 40 years?
And, you know, in the course of three months of psychotherapy, can you really change their underlying thought processes?
What's an extraordinary discovery is that, A,
you can in at least 60 percent of cases that it has an effect and that's what cognitive therapy attempts to do.
And what is more, that cognitive therapy reduces the risk of depression coming back?
The problem is we don't know how it works.
And it looked as if for a long time, as if cognitive therapy was having its main effect by changing the what you said to yourself.
So instead of saying I'm a failure, when you recognise that thought, you would say are now,
then what's the evidence that faught is really true, is that that's just the Depression speaking.
In fact, when we were studying cognitive therapy in the early days, we thought we knew exactly why people continue to be at risk.
It was down to long term beliefs often picked up in childhood and adolescence beliefs like I should be happy all the
time or beliefs like to admit any weakness is a shameful thing to do or I can't be happy unless everybody loves me.
Now, these in themselves are not depressing. But when you get certain circumstances.
So, for example, if you think that one failure means your failure as a person, then you're perfectly okay.
Until you start failing. But then you conclude I'm a failure as a person.
And in addition to having to do with your recent failure, which is bad enough,
you now have to deal with something else which is feeling a failure as a person.
Or for example, you may think I should be happy all the time. Now, that's not by itself a depressing thing to think.
But what happens if you feel sad? Now, not only do you have to deal with your sadness in a skilful way, it's possible,
but you don't have to deal with something else, which is you should be happy.
You've just you don't feel guilty as well as sad because you've just violated one of
your sort of fundamental attitudes and beliefs and the way you work in the world.
So it looked as if these what they call them, dysfunctional attitudes, these long term core beliefs.
It looks as if you've got to treat those in therapy.
And if you if you go away from therapy with these still, as it were, they're present, then you're at risk for relapse.
That is what cognitive therapy believed. That's why we measured these things in people when they're depressed.
And we found lots of evidence. We in many teams around the world found there's lots of evidence that people,
when they're depressed, they have lots of these dysfunctional attitudes, core beliefs.
Like, I should be happy all the time. We thought we had it beaten.
We thought we knew why exactly. People relapsed. If you dealt with them in therapy, people wouldn't relapse if you didn't deal with them in therapy.
People would relapse. And then we had a great surprise study after study began to show something which prevented that theory from being true.
They found that when you recovered, even with antidepressants, these core dysfunctional attitudes also went back to normal.
In other words, what we thought was a major causal factor in creating the conditions for relapse.
It turns out that antidepressants affect the same process.
So this was a puzzle because we knew the cognitive therapy predicted a lower risk in the long term of it.
A year or two and the antidepressants didn't. You still relapsed after antidepressants if you came off of them.
So what was going on? And that's where the experiment started to have to examine what was the underlying psychological factors that kept you at risk?
And what were they? Was this the famous diving experiments? Yeah.
Well, you mentioned the diving experience. It's it wasn't so much the diving experiments that told us about depression risk,
but it all comes back to what's called context effects in learning and memory.
That's where the diving comes in. So we've known for a long while that if you learn something in one set of conditions,
even if you forget them when you're outside those conditions, you tend to remember them better when you come back.
So, for example, people might find that if they've learnt maths in the maths room at school,
then if they do their maths test in the French room where they learn French, then they don't do so well.
Put them back in the bathroom and all the cues that were around. And you learn maths even if you've taken the symbols and formulae off the walls.
People do better. Or you might know if you should think of something you need upstairs to another room in the house.
You go upstairs when you get there, you can't think what you come for. You go back.
The place where you first thought of it and suddenly it comes back to your mind. So changing context can be quite a powerful effect on memory.
And that's where the diving experiments come in. Deep sea divers.
When the North Sea was being opened up for oil exploration, they found they were forgetting stuff when they went down under the water.
They brought in some psychologists to advise them on what they could do.
And the psychologist realised, my colleagues, Alan Badly and Duncan Godden, doing this work in the 1970s and 80s.
They realised that this wasn't just that when you're underwater, it was very dark and murky and you tend to forget anything.
It's what you learnt on the beach. You forget when you're underwater. But if you learn some stuff underwater, you forget it.
When you came on the beach, it was another example once again of context dependent learning.
So what you learn in one context you may forget, but when you go back into the context, it comes back.
So is this because the brain is somehow learning to use the environment as a store of information?
Precisely. That actually the brain has amazing way of meshing with your environment, that you don't need to store everything in the brain.
You know, the world is a better store of information and knowledge than the brain is.
And therefore, when you go into certain contexts.
I mean, if you know you know, if you go back to a childhood place where you grew up, you might not remember much about it.
But when you're walking down the street in that childhood place, all sorts of memories come flooding back.
In one sense, they are in a rudimentary form encoded in the brain, but they need that extra activation of the outside context.
And the interesting thing about that is this, that about 20, 30 years ago, psychologists discovered that your mood could act just like a context.
In other words, when you get depressed. Anything that you think feel.
Remember, when you're in that state, when you're out of depression.
You know, it may not bother you at all, but just another episode of Sad Mood can bring with it all those memories,
thoughts, interpretations you had when you were last depressed. Can you give us some some interesting experiments along these lines?
Because I understand this is a hot area of research. Yeah.
For the last 20, 30 years, in fact, it's developed very rapidly.
But once people started to realise that mood could act as a context, people start to say, well, how could we actually see that in the laboratory?
And this was a big development when people started to say, well,
let's invite people to come into the lab and to experience depression for 10 minutes in a fairly small way.
And the way to do that is there's a number of ways to do it. Obviously, thinking sad memories or reading sad things on a bit of paper,
but you can actually do an experiment in which you do all of that, but you also play stop music.
And we tend to use Prokofiev if Russia under the Mongolian yoke, played at half speed.
And when you do that, what you find, it's very slow. It's very dirty, together with sad memories and sad things written on paper.
After 10 minutes, people feel quite low. I mean, not devastatingly low, but quite low.
And what you can do is you invite people into the lab, some of whom have never been depressed in the past.
And some of whom have been depressed. But they're now completely recovered.
So at the start of the experiment, you can't tell who has been depressed and who's not.
And then you give them a scale to measure their level of dysfunctional attitudes.
So things like, I should be happy all the time. It's shameful to display your weaknesses.
You know, I have to have succeeded everything.
I'm a quick failure. And at the start of the experiment, they don't score very high on that because they're feeling good.
Now, you give them 10 minutes of Prokofiev. And afterwards, the people who've never been depressed hardly change at all.
But the people who've been depressed in the past, suddenly all these patterns of thinking all turn up again.
And what's most striking, we've done this work as well with people who've been not only depressed in the past, but suicidal in the past.
That extends it even further, because what we discover then is not only do people become dysfunctional as in normal experiments with depression,
but they start to get a tunnel vision about ways of solving their problems, thus revealing suicide as the only option.
It's a sort of sense in which other options disappear. And that happens very rapidly over just eight or 10 minutes of this year of this mood.
And at the end of experiment, you talk to people through that they recover. And actually, at the end of the experience, people are really interested.
They've learnt something important about themselves, which is that their mood creates isn't bad enough.
The mood can create more devastating consequences.
By pulling back, by dragging up all these old regrets, arguments, failures and disappointments from the past.
And that if it's not enough to deal with your mood now to deal with all these things from the past as well.
And it always turns up as if it's relevant now. You don't think, ah, I used to believe I was a failure.
You actually believe now that you're a complete failure and this just proved it. That's what makes it have such a huge impact.
Does this mean we're at the mercy of environment? In a way?
Well, we are, unless we actually wake up to what's happening. And the remarkable thing is that what cognitive therapy actually was doing all the time,
that we thought it was changing people's minds in the sense of changing their beliefs and the content of their belief.
It's much more likely that what it was doing is changing people's relationship to their own thoughts that people
were actually learning when they wrote down their thoughts not to give themselves clever arguments about actually,
am I a failure? No, I'm not a failure. What's the evidence?
But in collecting the evidence, they're beginning to see their thoughts as just mental events like clouds in the sky.
And this new relationship that they had. I mean, the technical word for it is metacognitive awareness.
They were cultivating a way of gaining perspective on the fact that these thoughts were, as it were, not telling the truth about themselves.
And because we mostly thoughts seemed to tell the truth, you tend to believe them all.
Even the ones that say you're useless. And that actually that's depression.
Speaking very often, this mood reactivity, does it actually predict depression?
That's the astonishing thing that Zindel Siegel, my colleague, working with myself and John Teesdale to develop the mindfulness programme.
I had actually been conducting experiments during the 1990s to to look at the
impact of this reactivity using mood induction like Prokofiev and what he found.
He, first of all, took people going through the Clark Institute of Psychiatry, the Centre for Addiction and Mental Health in Toronto.
And some of the sample were getting cognitive therapy. Some of the sample were getting anti-depressants.
And at the end of that treatment, they were all in remission. They all look pretty good.
They weren't depressed anymore. But now he gave them this dysfunctional attitude scale before and after a mood challenge.
And he found that those who'd had the antidepressants looked good. Their scores were low until he gave them Prokofiev.
And then as the sad mood began to take hold. So their associated thought patterns begin to one themselves up.
But in the people who had had cognitive therapy as their mood began to go on their moods, you know, it went down like anybody else's.
But they didn't change. In fact, in some, their dysfunctional attitudes became more functional rather than more dysfunctional.
And then when he looked over the next few months and years, whichever group they were in,
those who had responded badly to his mood induction were the people who relapsed.
What came next was the understanding that what was being affected by this mood was not just a return of certain memories.
I mean, I can give you an example of this. If if. Let's imagine you are out for a walk on a sunny day like this sunny Sunday morning.
You're going for a walk round a lake. And there's not very many people around there, maybe a couple of families feeding the ducks or whatever.
And it's a sunny day. So it's the sort of day where by yourself you feel you'd normally feel happy.
You'd normally feel calm and at peace. But for some reason this morning, you're feeling a bit low.
Your mood is a bit low.
Now, if you imagine how low you are feeling right now in this imaginary scenario we're building and then start asking yourself some questions,
why do I feel so low? I wish that I felt happier than I do right now.
What's going to happen if this mood persists? What's it say about me that I could get this depressed on a sunny Sunday morning like this?
Why? What's it say about me? Where's it going to end now?
How do you feel? Most people say I feel even worse.
That's really interesting because there's nothing in those questions inherently which are depressing.
But what's happened is a certain mode of mind has worked up in basically all those questions are there to try to help solve the problem of your mood.
But because they are, as it were, volunteering to help, you tend to keep on asking them.
But most people find that their mood begins to go down rather than up.
It's evoked a Problem-Solving mode of mind, which is very language based.
You started thinking and often people then thinking turns into overthinking or what we call rumination or brooding.
And the question why often you search your memory for why you're feeling like that.
And one thing we know about memory, as we just said,
like the context effect is like diving back into the place where you had lots of negative memories and events in the past.
So the question, why start bringing up really negative things from the past?
Your mood begins to deteriorate any further and then you start trying harder to think, why am I depressed and where is this going to end?
And so on. All in the service is making yourself feel better. But it's tragically backfiring.
Two things are happened to major. Processes have been brought on line, rumination or brooding and avoidance.
It's all in the service of trying to avoid going back into the depression, into the slough of despond again.
I mean, you say they're questions, but they're almost accusation's people are accusing themselves.
I mean, that's the way it seems to me. Absolutely. And they're often buried in question.
So if you ask what's wrong with me, that seems like a question.
But if you notice the structure, the question, it's already assuming there's something wrong with you.
And if only I could find out what, then it would be better. Or if you say, you know what's going to happen if it doesn't end.
Guess what? It assumed that it might not end.
So you've just frightened yourself in the very asking of the question to people who become repeatedly depressed.
Are they more diligent than the rest of us? For example, they're more determined.
They're more perfectionist. That is often the case.
It's not so much I mean, that can happen.
It's not, however, just perfectionist in the sense it's reaction to your own sad moods by wanting things instantly to be better.
It's often intolerance of sadness. You wanted to told the problem.
You want to solve the problem. Now you can understand why that should be, especially if you've been depressed many times in the past.
You really, really don't want to go there again. And yet this pushing away this avoidance often is a problem.
I mean, there's a certain proposition in psychology.
What we resist persists and lots of experiments which are often called the White Bear experiments, and they're experiments that go a bit like this.
And I want you to think about anything for the next minute,
but do not think of a white bear or I want you to think of anything the next minute, but do not think of a pink elephant.
And guess what? People either can't get pink elephants or white bears out of their head for that minute or when they stop trying to suppress them.
They come back with greater force. Now, if was only white bears and big elephants up be one thing.
But my colleague Tim Dalgliesh in Cambridge and Denny Yean working in Cambridge have done this experiment with negative memories,
asking people to describe the negative events in the past.
Selecting one and then say just just make sure that doesn't come into your head for the next little while, next minute or so.
And people may be able to do that quite well. But afterwards it bounces back.
And what's even more significant, when they do another memory test over the next few minutes looking at negative and positive memories from the past.
Those who have tried to suppress one negative memory, just that one, they find they're faster to retrieve other negative memories in their past.
So the effect of trying to suppress one negative memory has actually made the other ones sort of grow much more forcefully.
So it's a very good example of this.
What we resist persists. And so you have two problems here.
Rumination can get you entangled in these questions that can drive your mood down and down.
Why me? Why me? Why me or why am I so depressed and avoidance or trying to stop and suppress your memories can actually make other memories.
If not, that one actually come back with greater force.
This is very significant because what it suggests is this, that when people are beginning to get depressed again,
it's not just certain memories and attitudes and interpretations.
It's not just the content of their mind, as we used to thinking cognitive therapy, but it's the whole mode of mind that comes up.
This mode of mind that actually begins to try to solve the problem for you
actually turns out to be not a very good problem solver in this particular case.
And I think a number of reasons why. That is so Indore, to understand that, we have to understand why is this mode of mind so persistent?
The lake example, for example, when you walk around the lake and you feel right and all this tend to try to avoid.
I don't want to get depressed again and to ask myself question. I mean, for one thing, it comes on automatically.
That's the first thing about this mode of mind is often automatic. It's very preoccupying.
It mainly uses verbal, ruminative thinking. It's often very over.
General, any memories that come back to you? Often things like I always did this or nobody always did, you know, ever did that for me.
And this overthinking, it's designed to do something to change the current state.
It's what we call discrepancy based processing. That is it.
Focus on the gap or the discrepancy between your current state and your desired state.
So the whole idea, this mode of mind is trying to close a gap. This thinking comes online to try to close the gap,
tries to bring it from the past and bring up from the possible futures evidence that could help you to close that gap.
It tends to be there in the service of avoiding place. You don't want to go again.
These thoughts that come up are taken as real because mostly thoughts are real and they do tell you the truth.
And it depletes your energies. You just go for it. It seems to me the most important thing you can do to try to sort yourself out.
So you stop nourishing yourself. You stop taking breaks. And you just focus on this.
And you deplete yourself and exhaust yourself. It's all quite logical then.
I mean, if you pose I say entirely logical perspective.
This is how you would deal with this problem. Exactly.
Dan, if that's really gets the nub of the problem, this mode of mind comes up not because it's usually unhelpful, but just the opposite.
This mode of mind is usually the most helpful thing you can do.
I mean, imagine a simple example like getting from here to the other side of Oxford.
Okay, here we are sitting in Headington in the Wolfert Hospital in the Oxford Mindfulness Centre.
And let's say you wanted to go to Summertown on the other side of Oxford.
Now you've got to know where you are now and you've got to know what your destination is.
And you get in your car or on your bike and you start out. What if you start actually you turn off the wrong road.
It's perfectly legitimate then to start to think, oh, where do I go wrong and retrace your steps?
Where did I go wrong? Is a very legitimate question there, because you are thinking, how can I get back on track?
But if you're thinking about your life and you say, where did I go wrong?
It suddenly feels a lot more important and a lot more pernicious and a lot more unanswerable.
But that's not the mode of mind's fault. It's doing the best that it can.
So you want to have a Problem-Solving mode of mind that gets you from here to be very smoothly, automatically.
And it's got to close the gap between where you are and your bike or in your car and where you want to be when you get to your destination.
You know, the mode of mind can close down. It's done the job it has to do.
But notice this, the whole point of external problem-solving like getting from here to the other side of town.
If you stop and ask yourself how far I got to go, how far am I from my destination?
That itself asking that question doesn't affect how far you have to go.
You might get off your bike. You look at a map and you are where you are asking.
The question doesn't affect anything. But think about when you're feeling low walking around the lake, you start the same problem solving mode.
Where am I now? Depressed. Where I'd like to be happy. There's the gap.
There's the gap between where you are now, where you'd like to be. As soon as you notice you're not as happy as you wished you were.
What happens? You become sadder. Now, that's very different.
What's happened is the very mode that normally solves your problems so elegantly,
so automatically without any thought or, you know, buy or leave, as it were.
Which gets us out of a whole slew of fixes.
All of that now starts to backfire because the same mode of mind, actually, when you apply it to yourself or your mood begins to make the gap larger.
And the mind usually has been trained only in this problem solving mode. So it tries again.
Okay, so why am I depressed? It says, okay, why?
Where do I go wrong?
And there that innocuous sounding question, which is innocuous when you are going from here to North Oxford turns out to be not so innocuous.
When you're talking about your mood and you get yourself entangled more and more and all of us do this from time to time,
we find ourselves entangled more and more in this ever deepening questions as our mood goes down and the poor mind is doing the best it can,
if you like. It's really trying to help us with this automatic verbal gap focussing discrepancy, focus, past and future evidence.
Avoidant thoughts being taken. Israel depleting. The net result is exhaustion and sadness and depression.
Which means there has to be an alternative. That's right.
It points towards an interesting alternative because the purpose of the research we've been doing over the
last 20 years is to try to find something which can help people even between depressions when they're well,
because we know there are periods for most people when they're well to prevent the next episode of depression.
What do you think about it? Depression keeps coming back. But why?
In the past, you know, from the 1950s onwards until the 1980s, we only had one thing.
We either treated it with antidepressants or we treat it with cognitive therapy. But both of them work.
But they you have to wait until people are depressed. There are treatments there, treatments for the episode of depression.
If you had the same house fire in the same place for two or three years running.
Eventually the fire, as it would be called out to say what structurally wrong with this house.
That means it keeps going up in flames. So you wouldn't want to just say, well, we'll just call out the fire brigade year after year after year.
And the point is, with treatment of depression, we want to get beyond calling out the vet, as it were, the treatments.
Year after year after year, can we find a way? Now, this mode of mind is really interesting because it may well be that even when people are well,
they can begin to see the evidence of this mode of mind showing up.
And therefore, we can train people to recognise it a long time before they get depressed again,
which will stand them in good stead for seeing the tipping points and being able to,
as it were, steered out of the skid before they actually get into another depression.
This is mindfulness based cognitive therapy. This is exactly mindfulness based cognitive therapy.
It's basically saying that, look, if your mind is doing the best it can, you don't have to criticise yourself for this.
You just have to recognise when that mode of mind is turning up and actually backfiring, inadvertently backfiring.
It also says that people are vulnerable. And this is the new theory that came out of the last 20 years,
that what keeps people vulnerable to depression is that some people are highly sensitive to their sad moods so that some people,
a small amount of Staddon mood produces a great context effect in which all these content and processes keep coming back.
Other people can have a lot of sad mood and somehow they don't have these avoidance rumination, sad memories coming back.
That's the essence of what keeps people vulnerable. And that's what we need to tackle in our new ways of helping people stay well after depression.
It is ironic, though, that a technique developed two and a half thousand years ago is proving to be so relevant for the modern world.
It's extraordinary and I was very sceptical at first.
And in the next episode I want to go into detail about what mindfulness is and why something developed two and a half thousand years ago
when combined with modern science and modern cognitive therapy can actually powerfully reduce the risk of depression and coming back.
Thank you very much. In this episode, we were looking at the science of why people relapse back into depression.
And in the next episode, we'll be looking at a new approach to preventing depression.
Known as mindfulness based cognitive therapy. For further information about the issues raised in this programme,
you can read The Mind four Way Through Depression by Professor Mark Williams and his co-workers.
Well, you could read our book, Mindfulness Finding Peace in a Frantic World,
by Mark Williams and me, Danny Penman, where you could visit our Web site.
Frantic World Dot.com. If you'd like to support further research in this area, you could visit Oxford mindfulness dot org.
That's all one word. And follow the links to the development campaign.