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Hello and welcome to the new psychology of Depression.

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A series of programmes with me, Dr. Danny Penman and Professor Mark Williams of Oxford University.

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The previous episodes we looked at depression and the treatments available in this episode.

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We're going to look at why depression tends to return. Mark, can you summarise where we are with treatments for depression today?

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Okay, so in the previous episodes, we looked at depression, what it is, as you say,

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and we noticed that there was acute depression, but it tends to come back.

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And so now people distinguish between the episode itself of depression and then response to any treatment.

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And if that response is sort of held up for a few weeks, maybe eight weeks of being symptom free,

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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.

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And we've seen that acute treatments like antidepressant medication seems to treat successfully about 60 percent of people.

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Same is true of cognitive therapy as well. About 60 percent respond really well.

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But as we've seen, the problem is that still most people either don't seek treatment or they don't get treatment.

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Or if they get antidepressants, they stop taking them. So relapse is a huge problem.

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One of the problems with relapse is it wouldn't matter if people say got depressed very late in life where relapse.

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There wasn't much time for them to relapse.

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But as we've seen, one of the big changes over the last 50 years is that onset is getting earlier and earlier.

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And therefore,

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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.

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So this relapse. It's not anything to do with withdrawal or symptom.

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This is just people returning to the underlying nature, as it were.

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There is some evidence that some forms of depression are genetic, at least to have a genetic hygenic loading in them.

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Of course, when you know that something is genetic, it doesn't mean there's nothing you can do about it.

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You can intervene. People might have a genetic condition that means they can't eat certain stuff, for example.

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So they stay away from that stuff and it's fine. So genetics doesn't mean there's nothing can be done.

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So even though the most genetically highly loaded depressions may start early, they may be most recurrent.

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It still doesn't mean that we can't intervene. But most depression is not genetic, is it?

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It's it's mostly psychosocial problem.

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It's not possible to distinguish what's genetic and what's psychosocial problem in the sense they interact very closely.

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So, for example,

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the recent evidence on this serotonin transporter gene that might affect the ability to develop and make sufficient serotonin in the brain,

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this neurotransmitter, which no,

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it's very important that that genetic problem is then brought into play only if people have chronic stress or big life events.

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So you can have if you have a life free of big events, then it won't affect you.

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However, if you don't have that genetic loading, you can have quite big events and still seem to be resilient to them.

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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.

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For somebody who has just been successfully treated for depression, what can you do to reduce the risk of relapse?

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One of the important things to note is that once people have recovered, they can recover for quite a while.

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And as we said in the last episode, people can continue to take their antidepressant.

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So that's probably the most common way in which a physician would advise somebody to

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reduce the risk of future relapse is to continue to take the antidepressant medication.

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But as we saw there, some people don't want to take the medication.

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For example, if a woman wants to get pregnant, she may be advised not to to take antidepressants if she wants to breastfeed.

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She may not want to be taking antidepressants.

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And many people either naturally stop when they feel better, because how many of us continue our treatments after we feel better?

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We may just forget to take the pills, for example.

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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.

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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.

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The trouble is antidepressants don't work like that.

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So the net effect is that the long term effects that might be delivered by antidepressants don't aren't actually delivered.

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Now, there's another thing that's actually just beginning to emerge, and it's really quite serious if it is replicated.

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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.

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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.

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Of course, our attention then turns to the big alternative,

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which is can we find a psychological approach which has this same effect to reduce the long term risk?

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Can you really change the underlying thinking processes that somebody may have had for 20, 30, 40 years?

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And, you know, in the course of three months of psychotherapy, can you really change their underlying thought processes?

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What's an extraordinary discovery is that, A,

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you can in at least 60 percent of cases that it has an effect and that's what cognitive therapy attempts to do.

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And what is more, that cognitive therapy reduces the risk of depression coming back?

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The problem is we don't know how it works.

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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.

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So instead of saying I'm a failure, when you recognise that thought, you would say are now,

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then what's the evidence that faught is really true, is that that's just the Depression speaking.

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In fact, when we were studying cognitive therapy in the early days, we thought we knew exactly why people continue to be at risk.

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It was down to long term beliefs often picked up in childhood and adolescence beliefs like I should be happy all the

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time or beliefs like to admit any weakness is a shameful thing to do or I can't be happy unless everybody loves me.

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Now, these in themselves are not depressing. But when you get certain circumstances.

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So, for example, if you think that one failure means your failure as a person, then you're perfectly okay.

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Until you start failing. But then you conclude I'm a failure as a person.

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And in addition to having to do with your recent failure, which is bad enough,

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you now have to deal with something else which is feeling a failure as a person.

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Or for example, you may think I should be happy all the time. Now, that's not by itself a depressing thing to think.

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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,

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but you don't have to deal with something else, which is you should be happy.

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You've just you don't feel guilty as well as sad because you've just violated one of

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your sort of fundamental attitudes and beliefs and the way you work in the world.

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So it looked as if these what they call them, dysfunctional attitudes, these long term core beliefs.

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It looks as if you've got to treat those in therapy.

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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.

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That is what cognitive therapy believed. That's why we measured these things in people when they're depressed.

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And we found lots of evidence. We in many teams around the world found there's lots of evidence that people,

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when they're depressed, they have lots of these dysfunctional attitudes, core beliefs.

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Like, I should be happy all the time. We thought we had it beaten.

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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.

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People would relapse. And then we had a great surprise study after study began to show something which prevented that theory from being true.

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They found that when you recovered, even with antidepressants, these core dysfunctional attitudes also went back to normal.

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In other words, what we thought was a major causal factor in creating the conditions for relapse.

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It turns out that antidepressants affect the same process.

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So this was a puzzle because we knew the cognitive therapy predicted a lower risk in the long term of it.

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A year or two and the antidepressants didn't. You still relapsed after antidepressants if you came off of them.

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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?

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And what were they? Was this the famous diving experiments? Yeah.

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Well, you mentioned the diving experience. It's it wasn't so much the diving experiments that told us about depression risk,

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but it all comes back to what's called context effects in learning and memory.

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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,

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even if you forget them when you're outside those conditions, you tend to remember them better when you come back.

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So, for example, people might find that if they've learnt maths in the maths room at school,

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then if they do their maths test in the French room where they learn French, then they don't do so well.

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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.

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People do better. Or you might know if you should think of something you need upstairs to another room in the house.

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You go upstairs when you get there, you can't think what you come for. You go back.

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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.

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And that's where the diving experiments come in. Deep sea divers.

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When the North Sea was being opened up for oil exploration, they found they were forgetting stuff when they went down under the water.

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They brought in some psychologists to advise them on what they could do.

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And the psychologist realised, my colleagues, Alan Badly and Duncan Godden, doing this work in the 1970s and 80s.

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They realised that this wasn't just that when you're underwater, it was very dark and murky and you tend to forget anything.

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It's what you learnt on the beach. You forget when you're underwater. But if you learn some stuff underwater, you forget it.

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When you came on the beach, it was another example once again of context dependent learning.

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So what you learn in one context you may forget, but when you go back into the context, it comes back.

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So is this because the brain is somehow learning to use the environment as a store of information?

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Precisely. That actually the brain has amazing way of meshing with your environment, that you don't need to store everything in the brain.

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You know, the world is a better store of information and knowledge than the brain is.

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And therefore, when you go into certain contexts.

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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.

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But when you're walking down the street in that childhood place, all sorts of memories come flooding back.

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In one sense, they are in a rudimentary form encoded in the brain, but they need that extra activation of the outside context.

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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.

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In other words, when you get depressed. Anything that you think feel.

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Remember, when you're in that state, when you're out of depression.

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You know, it may not bother you at all, but just another episode of Sad Mood can bring with it all those memories,

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thoughts, interpretations you had when you were last depressed. Can you give us some some interesting experiments along these lines?

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Because I understand this is a hot area of research. Yeah.

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For the last 20, 30 years, in fact, it's developed very rapidly.

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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?

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And this was a big development when people started to say, well,

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let's invite people to come into the lab and to experience depression for 10 minutes in a fairly small way.

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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,

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but you can actually do an experiment in which you do all of that, but you also play stop music.

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And we tend to use Prokofiev if Russia under the Mongolian yoke, played at half speed.

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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.

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After 10 minutes, people feel quite low. I mean, not devastatingly low, but quite low.

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And what you can do is you invite people into the lab, some of whom have never been depressed in the past.

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And some of whom have been depressed. But they're now completely recovered.

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So at the start of the experiment, you can't tell who has been depressed and who's not.

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And then you give them a scale to measure their level of dysfunctional attitudes.

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So things like, I should be happy all the time. It's shameful to display your weaknesses.

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You know, I have to have succeeded everything.

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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.

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Now, you give them 10 minutes of Prokofiev. And afterwards, the people who've never been depressed hardly change at all.

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But the people who've been depressed in the past, suddenly all these patterns of thinking all turn up again.

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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.

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That extends it even further, because what we discover then is not only do people become dysfunctional as in normal experiments with depression,

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but they start to get a tunnel vision about ways of solving their problems, thus revealing suicide as the only option.

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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.

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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.

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They've learnt something important about themselves, which is that their mood creates isn't bad enough.

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The mood can create more devastating consequences.

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By pulling back, by dragging up all these old regrets, arguments, failures and disappointments from the past.

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And that if it's not enough to deal with your mood now to deal with all these things from the past as well.

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And it always turns up as if it's relevant now. You don't think, ah, I used to believe I was a failure.

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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.

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Does this mean we're at the mercy of environment? In a way?

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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,

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that we thought it was changing people's minds in the sense of changing their beliefs and the content of their belief.

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It's much more likely that what it was doing is changing people's relationship to their own thoughts that people

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were actually learning when they wrote down their thoughts not to give themselves clever arguments about actually,

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am I a failure? No, I'm not a failure. What's the evidence?

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But in collecting the evidence, they're beginning to see their thoughts as just mental events like clouds in the sky.

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And this new relationship that they had. I mean, the technical word for it is metacognitive awareness.

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They were cultivating a way of gaining perspective on the fact that these thoughts were, as it were, not telling the truth about themselves.

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And because we mostly thoughts seemed to tell the truth, you tend to believe them all.

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Even the ones that say you're useless. And that actually that's depression.

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Speaking very often, this mood reactivity, does it actually predict depression?

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That's the astonishing thing that Zindel Siegel, my colleague, working with myself and John Teesdale to develop the mindfulness programme.

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I had actually been conducting experiments during the 1990s to to look at the

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impact of this reactivity using mood induction like Prokofiev and what he found.

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He, first of all, took people going through the Clark Institute of Psychiatry, the Centre for Addiction and Mental Health in Toronto.

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And some of the sample were getting cognitive therapy. Some of the sample were getting anti-depressants.

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And at the end of that treatment, they were all in remission. They all look pretty good.

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They weren't depressed anymore. But now he gave them this dysfunctional attitude scale before and after a mood challenge.

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And he found that those who'd had the antidepressants looked good. Their scores were low until he gave them Prokofiev.

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And then as the sad mood began to take hold. So their associated thought patterns begin to one themselves up.

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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.

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But they didn't change. In fact, in some, their dysfunctional attitudes became more functional rather than more dysfunctional.

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And then when he looked over the next few months and years, whichever group they were in,

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those who had responded badly to his mood induction were the people who relapsed.

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What came next was the understanding that what was being affected by this mood was not just a return of certain memories.

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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.

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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.

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And it's a sunny day. So it's the sort of day where by yourself you feel you'd normally feel happy.

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You'd normally feel calm and at peace. But for some reason this morning, you're feeling a bit low.

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Your mood is a bit low.

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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,

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why do I feel so low? I wish that I felt happier than I do right now.

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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?

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Why? What's it say about me? Where's it going to end now?

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How do you feel? Most people say I feel even worse.

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That's really interesting because there's nothing in those questions inherently which are depressing.

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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.

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But because they are, as it were, volunteering to help, you tend to keep on asking them.

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But most people find that their mood begins to go down rather than up.

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It's evoked a Problem-Solving mode of mind, which is very language based.

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You started thinking and often people then thinking turns into overthinking or what we call rumination or brooding.

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And the question why often you search your memory for why you're feeling like that.

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And one thing we know about memory, as we just said,

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like the context effect is like diving back into the place where you had lots of negative memories and events in the past.

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So the question, why start bringing up really negative things from the past?

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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?

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And so on. All in the service is making yourself feel better. But it's tragically backfiring.

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Two things are happened to major. Processes have been brought on line, rumination or brooding and avoidance.

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It's all in the service of trying to avoid going back into the depression, into the slough of despond again.

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I mean, you say they're questions, but they're almost accusation's people are accusing themselves.

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I mean, that's the way it seems to me. Absolutely. And they're often buried in question.

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So if you ask what's wrong with me, that seems like a question.

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But if you notice the structure, the question, it's already assuming there's something wrong with you.

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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.

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Guess what? It assumed that it might not end.

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So you've just frightened yourself in the very asking of the question to people who become repeatedly depressed.

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Are they more diligent than the rest of us? For example, they're more determined.

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They're more perfectionist. That is often the case.

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It's not so much I mean, that can happen.

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It's not, however, just perfectionist in the sense it's reaction to your own sad moods by wanting things instantly to be better.

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It's often intolerance of sadness. You wanted to told the problem.

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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.

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You really, really don't want to go there again. And yet this pushing away this avoidance often is a problem.

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I mean, there's a certain proposition in psychology.

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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.

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And I want you to think about anything for the next minute,

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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.

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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.

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They come back with greater force. Now, if was only white bears and big elephants up be one thing.

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But my colleague Tim Dalgliesh in Cambridge and Denny Yean working in Cambridge have done this experiment with negative memories,

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asking people to describe the negative events in the past.

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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.

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And people may be able to do that quite well. But afterwards it bounces back.

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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.

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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.

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So the effect of trying to suppress one negative memory has actually made the other ones sort of grow much more forcefully.

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So it's a very good example of this.

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What we resist persists. And so you have two problems here.

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Rumination can get you entangled in these questions that can drive your mood down and down.

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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.

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If not, that one actually come back with greater force.

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This is very significant because what it suggests is this, that when people are beginning to get depressed again,

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it's not just certain memories and attitudes and interpretations.

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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.

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This mode of mind that actually begins to try to solve the problem for you

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actually turns out to be not a very good problem solver in this particular case.

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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?

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The lake example, for example, when you walk around the lake and you feel right and all this tend to try to avoid.

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I don't want to get depressed again and to ask myself question. I mean, for one thing, it comes on automatically.

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That's the first thing about this mode of mind is often automatic. It's very preoccupying.

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It mainly uses verbal, ruminative thinking. It's often very over.

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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.

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And this overthinking, it's designed to do something to change the current state.

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It's what we call discrepancy based processing. That is it.

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Focus on the gap or the discrepancy between your current state and your desired state.

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So the whole idea, this mode of mind is trying to close a gap. This thinking comes online to try to close the gap,

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tries to bring it from the past and bring up from the possible futures evidence that could help you to close that gap.

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It tends to be there in the service of avoiding place. You don't want to go again.

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These thoughts that come up are taken as real because mostly thoughts are real and they do tell you the truth.

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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.

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So you stop nourishing yourself. You stop taking breaks. And you just focus on this.

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And you deplete yourself and exhaust yourself. It's all quite logical then.

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I mean, if you pose I say entirely logical perspective.

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This is how you would deal with this problem. Exactly.

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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.

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This mode of mind is usually the most helpful thing you can do.

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I mean, imagine a simple example like getting from here to the other side of Oxford.

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Okay, here we are sitting in Headington in the Wolfert Hospital in the Oxford Mindfulness Centre.

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And let's say you wanted to go to Summertown on the other side of Oxford.

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Now you've got to know where you are now and you've got to know what your destination is.

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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.

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It's perfectly legitimate then to start to think, oh, where do I go wrong and retrace your steps?

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Where did I go wrong? Is a very legitimate question there, because you are thinking, how can I get back on track?

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But if you're thinking about your life and you say, where did I go wrong?

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It suddenly feels a lot more important and a lot more pernicious and a lot more unanswerable.

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But that's not the mode of mind's fault. It's doing the best that it can.

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So you want to have a Problem-Solving mode of mind that gets you from here to be very smoothly, automatically.

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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.

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You know, the mode of mind can close down. It's done the job it has to do.

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But notice this, the whole point of external problem-solving like getting from here to the other side of town.

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If you stop and ask yourself how far I got to go, how far am I from my destination?

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That itself asking that question doesn't affect how far you have to go.

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You might get off your bike. You look at a map and you are where you are asking.

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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.

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Where am I now? Depressed. Where I'd like to be happy. There's the gap.

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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.

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What happens? You become sadder. Now, that's very different.

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What's happened is the very mode that normally solves your problems so elegantly,

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so automatically without any thought or, you know, buy or leave, as it were.

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Which gets us out of a whole slew of fixes.

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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.

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And the mind usually has been trained only in this problem solving mode. So it tries again.

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Okay, so why am I depressed? It says, okay, why?

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Where do I go wrong?

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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.

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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,

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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,

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if you like. It's really trying to help us with this automatic verbal gap focussing discrepancy, focus, past and future evidence.

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Avoidant thoughts being taken. Israel depleting. The net result is exhaustion and sadness and depression.

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Which means there has to be an alternative. That's right.

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It points towards an interesting alternative because the purpose of the research we've been doing over the

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last 20 years is to try to find something which can help people even between depressions when they're well,

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because we know there are periods for most people when they're well to prevent the next episode of depression.

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What do you think about it? Depression keeps coming back. But why?

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In the past, you know, from the 1950s onwards until the 1980s, we only had one thing.

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We either treated it with antidepressants or we treat it with cognitive therapy. But both of them work.

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But they you have to wait until people are depressed. There are treatments there, treatments for the episode of depression.

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If you had the same house fire in the same place for two or three years running.

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Eventually the fire, as it would be called out to say what structurally wrong with this house.

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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.

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And the point is, with treatment of depression, we want to get beyond calling out the vet, as it were, the treatments.

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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,

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they can begin to see the evidence of this mode of mind showing up.

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And therefore, we can train people to recognise it a long time before they get depressed again,

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which will stand them in good stead for seeing the tipping points and being able to,

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as it were, steered out of the skid before they actually get into another depression.

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This is mindfulness based cognitive therapy. This is exactly mindfulness based cognitive therapy.

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It's basically saying that, look, if your mind is doing the best it can, you don't have to criticise yourself for this.

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You just have to recognise when that mode of mind is turning up and actually backfiring, inadvertently backfiring.

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It also says that people are vulnerable. And this is the new theory that came out of the last 20 years,

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that what keeps people vulnerable to depression is that some people are highly sensitive to their sad moods so that some people,

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a small amount of Staddon mood produces a great context effect in which all these content and processes keep coming back.

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Other people can have a lot of sad mood and somehow they don't have these avoidance rumination, sad memories coming back.

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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.

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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.

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It's extraordinary and I was very sceptical at first.

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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

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when combined with modern science and modern cognitive therapy can actually powerfully reduce the risk of depression and coming back.

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Thank you very much. In this episode, we were looking at the science of why people relapse back into depression.

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And in the next episode, we'll be looking at a new approach to preventing depression.

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Known as mindfulness based cognitive therapy. For further information about the issues raised in this programme,

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you can read The Mind four Way Through Depression by Professor Mark Williams and his co-workers.

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Well, you could read our book, Mindfulness Finding Peace in a Frantic World,

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by Mark Williams and me, Danny Penman, where you could visit our Web site.

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Frantic World Dot.com. If you'd like to support further research in this area, you could visit Oxford mindfulness dot org.

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That's all one word. And follow the links to the development campaign.