1 00:00:00,120 --> 00:00:01,050 We'll get started now. 2 00:00:01,050 --> 00:00:09,750 Thank you all very much indeed for joining us this morning for our latest talk in Experimental Psychology's Our Mental Wellness Series. 3 00:00:09,750 --> 00:00:12,540 We're really delighted to be joined by number of our colleagues from the 4 00:00:12,540 --> 00:00:17,910 Department of Psychiatry today to talk about managing depression and low mood. 5 00:00:17,910 --> 00:00:21,780 And before we just get started, I should just introduce myself. My name's Cathy Creswell. 6 00:00:21,780 --> 00:00:29,250 And just to let you know, this is part of a series and you will be up to find previous sessions, on managing 7 00:00:29,250 --> 00:00:34,500 stress and anxiety and also overcoming sleep difficulties, on our YouTube channel. 8 00:00:34,500 --> 00:00:40,450 So please do have a look at those. And we've got another session coming up in January on the twenty eighth of January. 9 00:00:40,450 --> 00:00:45,370 And on overcoming mistrust and paranoia. So please do join us for that, too. 10 00:00:45,370 --> 00:00:53,530 I'm also just want to highlight that we'll be sharing some resources and also be asking your feedback, which will come to you in an email tomorrow 11 00:00:53,530 --> 00:01:01,530 so it would be wonderful to have your responses to that. But without further ado, I'd like to introduce you now to Professor Willem Kuyken. 12 00:01:01,530 --> 00:01:08,370 who is the John Riblat Family Foundation Professor of Mindfulness and Psychological Science. 13 00:01:08,370 --> 00:01:15,540 He's a principal investigator in the University of Oxford Mindfulness Research Centre (and director of the University of Oxford Mindfulness Centre), 14 00:01:15,540 --> 00:01:23,820 as well as being a fellow at Kellogg College. So we're absolutely delighted to have him here today talking to us about managing depression and low mood. 15 00:01:23,820 --> 00:01:28,550 Thanks so much, Willem. Thank you, Cathy, 16 00:01:28,550 --> 00:01:38,540 and it's an absolute privilege to have a chance to speak as part of this fantastic series on mental wellness for university staff and beyond. 17 00:01:38,540 --> 00:01:42,830 And to have a chance to speak to you all about something which is clearly very much on people's 18 00:01:42,830 --> 00:01:49,140 mind of how to manage one's mood and possibly depression in the midst of this pandemic. 19 00:01:49,140 --> 00:02:00,180 So I'm just going to share some slides. I'd like to start by kind of, in a way, just a bit of a thought experiment, 20 00:02:00,180 --> 00:02:10,910 if you imagine that my title today was not managing depression and low mood, but instead was managing heart health. 21 00:02:10,910 --> 00:02:18,680 What would come next would feel, I think, probably quite straightforward. All the things I put up next would be perhaps not surprising at all. 22 00:02:18,680 --> 00:02:23,750 Seven steps to a healthier heart. Diet. Maintaining one's weight. 23 00:02:23,750 --> 00:02:30,170 Managing cholesterol. Moreover, there wouldn't be much stigma associated with this. 24 00:02:30,170 --> 00:02:35,960 So here's my hope, if you like, that for the next five, 10, 50 years, 25 00:02:35,960 --> 00:02:43,180 the work that we do in experimental psychology and psychiatry here at the University of Oxford will move us to the same place with mental health, 26 00:02:43,180 --> 00:02:53,630 that managing mental health will have that same clarity, but also won't have the same stigma that it currently does. 27 00:02:53,630 --> 00:03:00,920 So what I'd like to do in the next 20 minutes or so that I have, is to strike a 28 00:03:00,920 --> 00:03:07,300 realistic balance between optimism and hope and also the reality of what depression is. 29 00:03:07,300 --> 00:03:13,190 And just start by saying what depression is and then go on to talk about the treatments that are available, 30 00:03:13,190 --> 00:03:20,260 but then also what we can all do individually to manage our mental health and wellbeing. 31 00:03:20,260 --> 00:03:27,430 So what is depression? We sent round a illustration recently from from a recent illustrated book by 32 00:03:27,430 --> 00:03:34,370 Matthew Johnston called I Had a Black Dog. First I'll state what depression isn't. 33 00:03:34,370 --> 00:03:48,270 It isn't sadness. And it isn't grief. It also isn't the kind of feelings that we have around being cooped up in the midst of this pandemic. 34 00:03:48,270 --> 00:03:54,020 These are just normal human emotions, normal human reactions. 35 00:03:54,020 --> 00:04:00,090 Yes, sure, Depression might be on the dimension, but it is a qualitatively different phenomenon. 36 00:04:00,090 --> 00:04:03,780 It's captured beautifully, I think, in this slide. 37 00:04:03,780 --> 00:04:11,910 It has this sense of these two cardinal symptoms, sense of unrelenting low mood, usually pretty well every day, 38 00:04:11,910 --> 00:04:20,430 all of the day, for about two weeks or just a sense of loss of pleasure that has other symptoms which the slides speak to - early morning, 39 00:04:20,430 --> 00:04:33,150 waking to thinking, low self-worth, lack of energy, irritability and in extreme forms, suicidal thinking and suicidality. 40 00:04:33,150 --> 00:04:41,070 It tends to have a life course. Typically onset is late adolescence, early adulthood. 41 00:04:41,070 --> 00:04:46,320 People who've had a single episode of depression have a 50 percent chance of having a second. 42 00:04:46,320 --> 00:04:49,960 And the more episodes people have, the more it's likely to have a recurring cause. 43 00:04:49,960 --> 00:04:53,520 I say that not to sort of strike a pessimistic note, 44 00:04:53,520 --> 00:05:01,930 but rather just to strike the note that at that point it becomes more like living with diabetes or a more long term condition. 45 00:05:01,930 --> 00:05:11,680 Women are more likely to suffer from depression than men, and depression is something that is associated with deprivation, low socio economic status. 46 00:05:11,680 --> 00:05:18,700 The pressures of those kind of social conditions affect people and they affect people in the long term. 47 00:05:18,700 --> 00:05:24,250 So what I'd like to do now is just put a poll up for you all to have a look at. 48 00:05:24,250 --> 00:05:28,390 The poll is a very simple yes or no question. 49 00:05:28,390 --> 00:05:37,770 Do you know anyone in your immediate circle of family or friends who have suffered from depression or have you yourself suffered from depression? 50 00:05:37,770 --> 00:05:43,350 So just look at that. Isn't that extraordinary? I don't if you can see the same screen as I can. 51 00:05:43,350 --> 00:05:53,620 96, 97 percent. All of you are in incredibly good company. 52 00:05:53,620 --> 00:05:59,290 It's a common condition. Two hundred and fifty million people around the world right now are suffering from depression. 53 00:05:59,290 --> 00:06:06,300 If you look at the world's population at some point in their lives, one billion people will suffer from depression. 54 00:06:06,300 --> 00:06:11,610 Winston Churchill. Stormzy. Marilyn Monroe. Lady Gaga. 55 00:06:11,610 --> 00:06:17,280 Hugh Laurie. Dolly Parton. Many, many people have suffered from this condition. 56 00:06:17,280 --> 00:06:29,640 It's a common condition. What does the evidence say about what works? 57 00:06:29,640 --> 00:06:34,050 If you want to have a look at the evidence and look at the treatments that are available, in the U.K., 58 00:06:34,050 --> 00:06:41,910 the National Institute for Health Care Excellence NICE produces a synthesis of the evidence widely available on the Web link is up here. 59 00:06:41,910 --> 00:06:45,920 I had the privilege of serving on the last nice slide guideline group. 60 00:06:45,920 --> 00:06:53,490 And I think, broadly speaking, one could talk about biological, psychological and social treatments. 61 00:06:53,490 --> 00:07:00,300 We have some world leading experts on the panel today who can speak to anti-depressants in the biological category. 62 00:07:00,300 --> 00:07:10,260 So I'm not going to say too much about that just now. But in the psychological area, we have a whole range of treatments that we know work, 63 00:07:10,260 --> 00:07:15,000 cognitive behavioural treatment, behavioural activation, interpersonal therapy. 64 00:07:15,000 --> 00:07:21,080 Actually, one of the things that's interesting about depression is many different treatments seem to work about the same. 65 00:07:21,080 --> 00:07:29,010 But we've also here in Oxford developed treatments that are focussed on helping people in the long term stay well. 66 00:07:29,010 --> 00:07:38,700 In particular, mindfulness-based cognitive therapy. These are all trials and projects that I've been involved with over the last 10 or so years. 67 00:07:38,700 --> 00:07:44,190 All of these are recommended either in the last NICE guideline or the forthcoming NICE guideline. 68 00:07:44,190 --> 00:07:50,480 These are on the optimistic note treatments that we know that work. 69 00:07:50,480 --> 00:07:58,320 There are also treatments that you will can access. And I'll say more about that in just a moment. 70 00:07:58,320 --> 00:08:05,690 How can we all collectively manage our mood, depression and well-being? 71 00:08:05,690 --> 00:08:10,340 I love this image. It's the sort of life course of depression and well-being, if you like. 72 00:08:10,340 --> 00:08:17,000 And one of things I like about this image is that it has this sense of a person travelling through their life and encountering different areas. 73 00:08:17,000 --> 00:08:24,820 So you could call this maybe perhaps a period of low mood, this perhaps a period of more enduring difficulty. 74 00:08:24,820 --> 00:08:32,840 This a period perhaps of depression. This a period of just maybe a bit like the pandemic, just a pretty, I don't know, grotty time. 75 00:08:32,840 --> 00:08:36,200 You can see the weather clouds. And it has an indeterminate cause. 76 00:08:36,200 --> 00:08:43,100 But what I think is lovely about this image is the way the person traverses each of these challenges in their life 77 00:08:43,100 --> 00:08:49,910 is different. And I think that's the challenge for all of us, too, is to figure out the puzzle of what supports our mood, 78 00:08:49,910 --> 00:08:57,680 what helps us when we become depressed or the people that we love become depressed, and what supports our well-being. 79 00:08:57,680 --> 00:09:04,970 And one of things I'd like to say, I guess on the on the kind of optimistic note here, is I actually don't think it's rocket science. 80 00:09:04,970 --> 00:09:12,680 I think actually in the same way as we now know a lot about heart disease, in the next five, 10, 20 years, 81 00:09:12,680 --> 00:09:20,330 we will have the same currency about the sorts of things that support our mood, depression and wellbeing. 82 00:09:20,330 --> 00:09:27,440 Broadly speaking, I think one can separate them out into biological, psychological and social approaches. 83 00:09:27,440 --> 00:09:28,460 And the other thing to say is, 84 00:09:28,460 --> 00:09:34,280 I think the sort of things that we do when we're going through low mood are different to the things that we might do 85 00:09:34,280 --> 00:09:40,780 when we go through a depression are different to the things that we might do in the midst of something like this pandemic. 86 00:09:40,780 --> 00:09:45,050 And just before I get into this, I want to have one major caveat. 87 00:09:45,050 --> 00:09:51,440 And the caveat is this, that sometimes people are encountering things in their lives, 88 00:09:51,440 --> 00:09:56,560 which are just very difficult things, and those things need to be addressed, need to be addressed. 89 00:09:56,560 --> 00:10:05,480 Somebody, for example, who is caught in an abusive relationship, somebody who's at work and is in a toxic work environment and is burnt out. 90 00:10:05,480 --> 00:10:10,520 Somebody who is in the midst of conflict at home. 91 00:10:10,520 --> 00:10:16,370 Somebody who's living with very, very pervasive and difficult health conditions. 92 00:10:16,370 --> 00:10:23,160 Those things in those cases clearly need to be addressed and addressed first. 93 00:10:23,160 --> 00:10:30,330 That being said, I think there are things that one can do to look after ourselves. 94 00:10:30,330 --> 00:10:38,610 What would low mood, low work with depression and that sort of levels that I'm connoting on this slide here are about things to do when we're well, 95 00:10:38,610 --> 00:10:46,960 things to do when perhaps we're encountering low mood and things to do when we're perhaps actually depressed. 96 00:10:46,960 --> 00:10:51,100 When we're well, rest, we know is really important. 97 00:10:51,100 --> 00:10:57,940 Sometimes that kind of business and the franticness of life means that we lose the balance and we forget to rest. 98 00:10:57,940 --> 00:11:07,360 There's a beautiful recent book by Claudia Hammond, which is called Rest and the many different ways in which people choose to rest sleep. 99 00:11:07,360 --> 00:11:13,240 It's absolutely vital to mental health in a way that we're only beginning to really fully understand. 100 00:11:13,240 --> 00:11:20,470 And I highly recommend the talk on YouTube from this series by Colin Espie and others. 101 00:11:20,470 --> 00:11:27,910 Diet and eating well is important and the judicious use of alcohol and other drugs as well, which can be depressants, 102 00:11:27,910 --> 00:11:31,710 ut people sometimes use to self medicate. 103 00:11:31,710 --> 00:11:41,660 Low mood response to activity and exercise, anti-depressants are also something that we know works and works to keep people well in the long term. 104 00:11:41,660 --> 00:11:48,710 And when people get more severely depressed, medication review and hospitalisation may be indicated. 105 00:11:48,710 --> 00:11:53,600 Now, of course, the area that I know best as a psychologist is the psychological area. 106 00:11:53,600 --> 00:12:01,220 And here, I think, is where in a sense, as I said before, it really isn't rocket science. 107 00:12:01,220 --> 00:12:06,620 A lifelong question that we can all ask ourselves is what is meaningful? What's rewarding? 108 00:12:06,620 --> 00:12:14,700 What do I value in my life? And asking ourselves that question and answering it by doing more of the things 109 00:12:14,700 --> 00:12:19,740 that make us feel better and fewer of the things that make us feel worse. 110 00:12:19,740 --> 00:12:28,610 It's not rocket science. And to keep that under review, appreciation, gratitude, journals, people describe as being tremendously helpful. 111 00:12:28,610 --> 00:12:33,990 I think it's partly because it helps people signal what actually gives value to their life, 112 00:12:33,990 --> 00:12:38,580 what gives pleasure to their life. Learning new skills, mindfulness. 113 00:12:38,580 --> 00:12:44,310 These are all things that we now can support, mental health and wellbeing. 114 00:12:44,310 --> 00:12:47,300 What about when we hit a period of low mood and depression? 115 00:12:47,300 --> 00:12:57,300 Ask for help. Here in Oxford, in the surrounding areas, through the incredible work of David Clark and Richard Layard, and many others around the country, 116 00:12:57,300 --> 00:12:59,910 evidence-based treatments are readily available. 117 00:12:59,910 --> 00:13:06,900 You can actually self refer here in Oxford to the IAPT service, the Improving Access to Psychological Therapy Service, called Talking Space. 118 00:13:06,900 --> 00:13:10,740 You fill in the form and you can get access to evidence-based treatments. 119 00:13:10,740 --> 00:13:16,470 Tremendous piece of work to make mental health accessible in the UK. If suicidal, 120 00:13:16,470 --> 00:13:27,480 The Samaritans or NHS emergency services are always available. And more and more people are looking at kind of social ways of working - gardens, 121 00:13:27,480 --> 00:13:33,000 parks, getting out to nature, connecting with others, talking and listening. 122 00:13:33,000 --> 00:13:39,780 Being with people that we know. Give us joy. Have our back. Make us feel better about ourselves. 123 00:13:39,780 --> 00:13:46,080 So, as I say, it's a lifelong puzzle. It's a way of actually figuring out for ourselves what supports our mood, 124 00:13:46,080 --> 00:13:51,870 what we can do when we become depressed, and what actually supports our well-being in the long term. 125 00:13:51,870 --> 00:13:58,560 So I have a good friend whom I WhatsApped yesterday and I know she suffers from seasonal affective disorder. 126 00:13:58,560 --> 00:14:04,880 And I asked her what she does. And she sent me this picture on WhatsApp. 127 00:14:04,880 --> 00:14:12,020 My solution to low mood is cinnamon buns, based partly on the following exchange with her teenage daughter. 128 00:14:12,020 --> 00:14:17,300 Mum, you should make these more often made. Yes. They taste nice. But then we'd be as big as houses. 129 00:14:17,300 --> 00:14:22,520 A teenage daughter. Yes, but we'd be happy houses. So is my considered answer. 130 00:14:22,520 --> 00:14:26,930 And you're welcome. So I'm not trying to be trite here, 131 00:14:26,930 --> 00:14:33,050 because what's interesting about this example is the very cruel thing about depression is 132 00:14:33,050 --> 00:14:38,450 it destroys our motivation and it makes us feel like this might actually go on forever, 133 00:14:38,450 --> 00:14:47,340 forever. And we are actually the only one who's suffering from this, that actually keeping a sense of doing the right thing and being patient, 134 00:14:47,340 --> 00:14:50,360 and this, too, shall pass, is really important. 135 00:14:50,360 --> 00:15:01,080 So the making of these cinnamon buns, even when one feels like not doing it, I think is kind of part of what this person was trying to communicate. 136 00:15:01,080 --> 00:15:08,790 So I'll just finish again with Matthew Johnston and I Had a Black Dog. Matthew Johnson is somebody who suffered from recurrent depression, 137 00:15:08,790 --> 00:15:15,790 and you can see in the second slide towards the end of his book, his illustrated book, he's sitting, and he's doing a whole range of things, 138 00:15:15,790 --> 00:15:20,640 so he described the whole range of different things that he does at different times. 139 00:15:20,640 --> 00:15:25,260 What I think is important about this slide is that the black dog is still there in the window. 140 00:15:25,260 --> 00:15:32,040 I think with recurrent depression, this sort of propensity to low mood and maybe some of the negative thinking never quite fully goes away. 141 00:15:32,040 --> 00:15:42,940 But he's found a way of living with it that is tolerable, but actually still has meaning and well-being in his life. 142 00:15:42,940 --> 00:15:56,380 So just by way of conclusion. These are some resources that I would highly recommend the book that has been sent round on email to all the delegates. 143 00:15:56,380 --> 00:16:00,190 Then there is also Matthew Johnson's partner, Ainsley Johnston, 144 00:16:00,190 --> 00:16:06,940 who's, quite a few of the people I know who are interested in this talk, are living with somebody who suffers from depression. 145 00:16:06,940 --> 00:16:12,640 She provides her perspective on how to support somebody with depression in living with a black dog. 146 00:16:12,640 --> 00:16:18,070 And then this NHS Web site, the web link just here, has some fantastic resources. 147 00:16:18,070 --> 00:16:22,360 So I'm going to hand over to the panellists now and just finish my talk. But just before doing that 148 00:16:22,360 --> 00:16:32,200 I just want to thank the people who support my work, which is the Wellcome Trust, the Oxford Mindfulness Centre and the Riblat Family Foundation. 149 00:16:32,200 --> 00:16:36,770 Thank you. Great. Thank you very much indeed, Willem. 150 00:16:36,770 --> 00:16:44,970 And I know that we've got lots of questions that will allow us to discuss some of those themes that you've raised in more detail as well. 151 00:16:44,970 --> 00:16:50,700 So we look forward to further discussion with you shortly. And I just want to also say before we move on here, 152 00:16:50,700 --> 00:16:54,570 Thank you, Willem, for sharing so many useful resources. 153 00:16:54,570 --> 00:17:02,050 Some of those have already gone out to delegates and others and others will be sent out tomorrow in an email, as I mentioned, so huge 154 00:17:02,050 --> 00:17:09,630 thanks for sharing that. I'm sure they'll be really appreciated. I'd now like to introduce the other two members of our panel. 155 00:17:09,630 --> 00:17:17,910 So we're delighted to be joined by Professor Cath Harmer, who is a Professor of Cognitive Neuroscience in the Department of Psychiatry here in Oxford. 156 00:17:17,910 --> 00:17:26,970 Cath is the director of the Psychopharmacology and Emotional Research Lab, Perl, and is also a research fellow at Corpus Christi College. 157 00:17:26,970 --> 00:17:33,920 And I'd also like to introduce you to Professor Andrea Cipriani, who's a Professor of Psychiatry in the Department of Psychiatry. 158 00:17:33,920 --> 00:17:40,110 He's an NIHR research professor and is also director of the clinical research facility at the Warneford Hospital, 159 00:17:40,110 --> 00:17:45,270 associate director for R&D for Oxford Health and NHS Foundation Foundation Trust, 160 00:17:45,270 --> 00:17:50,490 and also an honorary consultant psychiatrist in Oxford Health NHS Foundation Trust. 161 00:17:50,490 --> 00:17:55,800 So I'm sure you'll agree we've got a really fantastic panel to speak to you today. 162 00:17:55,800 --> 00:18:04,270 And so we'd like to do is just start by asking a question which picks up on some of the things that Willem's already mentioned. 163 00:18:04,270 --> 00:18:09,570 So this really reflects a question that many people raised, particularly in the current time, which, 164 00:18:09,570 --> 00:18:16,080 as Willem said, you know, it is challenging and unusual and presents many difficulties for many people. 165 00:18:16,080 --> 00:18:20,640 And this is really that everyone, of course, feels low from time to time. 166 00:18:20,640 --> 00:18:25,240 And so how do we discriminate low mood from a clinical problem? 167 00:18:25,240 --> 00:18:29,550 And I think people did raise it in relation to, for example, the current situation of the pandemic, 168 00:18:29,550 --> 00:18:36,320 but also following a bereavement or in the context of physical health problems that cause discomfort and pain. 169 00:18:36,320 --> 00:18:42,450 How do we know when we should be concerned, when we should consider this to be a problem? 170 00:18:42,450 --> 00:18:47,600 So, Andrea, if I could get to you first. Sure. 171 00:18:47,600 --> 00:18:51,350 Yes. This is a key point to address. 172 00:18:51,350 --> 00:18:57,920 And it's a very frequently asked question from from patients, but also for carers, 173 00:18:57,920 --> 00:19:03,890 because it's crucial to be able to discriminate something that is called low mood. 174 00:19:03,890 --> 00:19:12,590 And as Willem said, is part of our live normal life from something which is a clinical problem. In clinical settings 175 00:19:12,590 --> 00:19:17,300 we tend to consider two important things, that I will to summarise. 176 00:19:17,300 --> 00:19:25,770 One is the low mood. It is itself is not a problem, is how consistently it is low. 177 00:19:25,770 --> 00:19:32,450 We'll mention the duration of symptoms over a longer period of time, weeks. 178 00:19:32,450 --> 00:19:39,470 And also, it's not reactive to normal things that usually cheer up people or may oh, 179 00:19:39,470 --> 00:19:44,060 we consider pleasurable things and people don't get pleasure from these things. 180 00:19:44,060 --> 00:19:48,800 So the duration of symptoms, not just the intensity, but the duration. 181 00:19:48,800 --> 00:19:56,530 And the second thing we consider to discriminate when is a clinical problem is the impact on personal life, 182 00:19:56,530 --> 00:20:04,220 the working life, and also whether people around the person notice that this has been a change. 183 00:20:04,220 --> 00:20:10,760 So these are usually the key pillars to distinguish what is normal low mood or as a normal 184 00:20:10,760 --> 00:20:17,500 reaction within the normal range, to something which is a clinical problem and deserves more attention. 185 00:20:17,500 --> 00:20:21,900 Right. Thank you very much. Willem, do you want to add anything on that point? 186 00:20:21,900 --> 00:20:29,510 Thanks. Thank you. So there was also a lot of questions about what people can do themselves, 187 00:20:29,510 --> 00:20:34,070 particularly thinking about before we get to a point where we feel we need professional help. 188 00:20:34,070 --> 00:20:39,960 What can we do to offset low mood? So Cath, it would be great to hear your thoughts about that. 189 00:20:39,960 --> 00:20:46,760 Yeah. And I think this is a great question, and I agree with some of the suggestions that Willem gave in his talk. 190 00:20:46,760 --> 00:20:52,670 I think there's lots of things that we can all do to try and offset low mood before seeking outside help. 191 00:20:52,670 --> 00:21:00,290 Perhaps the most important thing, although it sounds a bit trite is just to get to know yourself and try and find out what works for you. 192 00:21:00,290 --> 00:21:05,300 There's a huge amount of good advice out there, and we know that some things are very helpful, 193 00:21:05,300 --> 00:21:13,580 such as increasing levels of exercise, having a good daily and sleep rhythme, eating well, spending time with others. 194 00:21:13,580 --> 00:21:18,380 And all of these things can be very helpful. But they will work better for different people. 195 00:21:18,380 --> 00:21:23,840 And it can sometimes seem overwhelming if you see this long list of things that that you should try, 196 00:21:23,840 --> 00:21:27,860 if you try to do them all at once, especially if you feeling a bit low. 197 00:21:27,860 --> 00:21:33,620 So I think taking small steps and thinking about what's most important to you is a good start. 198 00:21:33,620 --> 00:21:39,800 We did a recent study online during the first lockdown and we found that there were a couple of things that really 199 00:21:39,800 --> 00:21:50,190 stood out across a group as being useful and being related to better mood and lower risk of subsequent depression. 200 00:21:50,190 --> 00:21:54,820 And there were two two main things. One of them was spending time outside each day. 201 00:21:54,820 --> 00:22:03,080 This is very important. And this, I think, is maybe particularly important now when we naturally spend a bit less time outside 202 00:22:03,080 --> 00:22:08,690 during lockdown and also having a high level of what's called behaviour activation. 203 00:22:08,690 --> 00:22:15,530 And Willem touched on some of these in his talk. It refers to a number of interlinked things. 204 00:22:15,530 --> 00:22:21,260 It's having a good structure in your day, seeking out, doing things that you find enjoyable. 205 00:22:21,260 --> 00:22:27,540 Trying not to put off things that you find unpleasant, but you have to do and they can hang over you. 206 00:22:27,540 --> 00:22:32,270 These are getting things out of the way. I also think it's really important to be kind to yourself. 207 00:22:32,270 --> 00:22:35,720 And sometimes we can be our own worst critic. 208 00:22:35,720 --> 00:22:40,970 Certainly, I would never speak to other people, think about other people the way I would berate myself sometimes. 209 00:22:40,970 --> 00:22:48,070 And I think it's important to kind of try to tune in to that, to recognise that you're doing it and then try and overcome that 210 00:22:48,070 --> 00:22:58,400 that tendency by giving yourself some praise and reward. And the more you do it, the more habitual it becomes, the easier, easier it becomes. 211 00:22:58,400 --> 00:23:05,860 And so I think it's very important just to start with small steps of the things that seem most valuable or meaningful to you and go from there. 212 00:23:05,860 --> 00:23:10,910 Remembering that we're all individuals and some of us will be relevant to different people in different ways 213 00:23:10,910 --> 00:23:17,060 and we have to find our own path to things which can help us offset these difficult times 214 00:23:17,060 --> 00:23:20,900 and they happen in our own life. Right. Thank you very much. 215 00:23:20,900 --> 00:23:24,980 And you mentioned sleep there, so just to take the opportunity again, just to mention that, sir, 216 00:23:24,980 --> 00:23:31,760 in on our YouTube channel, you'll find the last session that we did, which was on overcoming difficulties with sleep. 217 00:23:31,760 --> 00:23:39,400 So please do take a look at that. And Willem, would you like to add anything further on that point? 218 00:23:39,400 --> 00:23:50,010 Really, just to echo Cath's invitation to to make this a sort of kind self exploration I want instead of like hunting out all of this expert advice, 219 00:23:50,010 --> 00:23:53,400 actually just really treating ourselves as the expert. 220 00:23:53,400 --> 00:24:01,590 What do we know in a given moment, in a given day, in a given a week, what makes us feel a sense of aliveness, 221 00:24:01,590 --> 00:24:07,650 a sense of vitality and a sense of engagement with others and trusting ourselves in that. 222 00:24:07,650 --> 00:24:13,590 I think it's a kind of self exploration, which I think is really powerful and really interesting. 223 00:24:13,590 --> 00:24:17,350 So I just to echo I think what what Cath said. 224 00:24:17,350 --> 00:24:24,300 And I think some of these things like sleep something people say, yeah, I get that about sleep, but I don't know how to work with that. 225 00:24:24,300 --> 00:24:30,360 There are evidence based programmes. I mean, Colin's work with Sleepio is a fantastic result, 226 00:24:30,360 --> 00:24:35,690 but it takes the effort to go through the programme of the sort of diagnosis, if you like, of what, 227 00:24:35,690 --> 00:24:40,300 why am I having sleep problems? And then to kind of work through that kind of approach to that. 228 00:24:40,300 --> 00:24:47,160 So some of these things can feel as as as as as Catherine said, like a sort of insurmountable mountain. 229 00:24:47,160 --> 00:24:51,650 But we sort of break them down into small steps. What does it mean to exercise? 230 00:24:51,650 --> 00:24:56,260 I just mean just taking a 15 minute walk each day. What does it mean to sleep differently? 231 00:24:56,260 --> 00:25:02,510 Well, I'm just leaving our phone outside our bedroom. These are small but important steps. 232 00:25:02,510 --> 00:25:04,080 All right. Thanks very much. 233 00:25:04,080 --> 00:25:09,900 We had a lot of questions about antidepressant medication, and some people asked how long they might expect to be on them. 234 00:25:09,900 --> 00:25:16,060 What sort of side effects to expect. And also how likely they are to work for any any individual. 235 00:25:16,060 --> 00:25:22,070 Cath, can I go to you first with that? Yeah, sure. Again, I would say this relies very much on the individual. 236 00:25:22,070 --> 00:25:29,910 And there are lots of things which need to be taken into account when making a decision about whether to take an antidepressant drug treatment. 237 00:25:29,910 --> 00:25:37,260 As a general rule of thumb, if it's your first experience of depression, most people would take antidepressants for around six months or so, 238 00:25:37,260 --> 00:25:43,560 although it may vary a little bit between people. The side effects can also vary quite a bit. 239 00:25:43,560 --> 00:25:46,950 So in our research studies, when we look at different antidepressants, 240 00:25:46,950 --> 00:25:53,160 actually most people can't tell if they're taking the antidepressant or the placebo, 241 00:25:53,160 --> 00:26:00,030 but others will experience side effects. There are initial side effects, often like nausea or headaches. 242 00:26:00,030 --> 00:26:04,590 And this is usually just the first few days of treatment and it gets better. 243 00:26:04,590 --> 00:26:11,780 And I think it's important to recognise that anxiety can also get a little bit worse in the first few days or week. 244 00:26:11,780 --> 00:26:19,050 But again, this gets better over time and in general is also usually helped by anti-depressants. 245 00:26:19,050 --> 00:26:23,700 Perhaps the side effect, which is the most problematic, are the sexual side effects. 246 00:26:23,700 --> 00:26:30,330 Again, not affecting everyone, but, of course, can be very distressing. So things like decreased libido, interest in sex. 247 00:26:30,330 --> 00:26:37,170 But again, there are differences between different people and also probably between different antidepressants as well. 248 00:26:37,170 --> 00:26:39,770 The third part is how likely they are to work. 249 00:26:39,770 --> 00:26:47,550 So in our research studies, where we look at antidepressants, often in GP clinics on primary care, actually the response is pretty good. 250 00:26:47,550 --> 00:26:52,350 Around 60 to 70 percent of people feel quite a bit better. 251 00:26:52,350 --> 00:27:00,930 If you look at larger data sets across more diverse populations. One of the largest studies of this kind suggests that around 50 percent of people 252 00:27:00,930 --> 00:27:07,170 who go into treatment with an SSRI type of antidepressant will do quite well. 253 00:27:07,170 --> 00:27:13,320 And of those who don't respond to that, if they try second one, half of those again will respond. 254 00:27:13,320 --> 00:27:21,570 So anti-depressants are effective. They are a good treatment option, but they certainly don't work for everybody. 255 00:27:21,570 --> 00:27:28,470 And unfortunately, we don't have a good way of predicting who is most likely to get benefit from this in advance. 256 00:27:28,470 --> 00:27:35,550 And this is something which is very important for research to focus on. And it's actually a good link to our next panellist, Andrea, 257 00:27:35,550 --> 00:27:40,180 whose work focuses very much on this question. Absolutely. 258 00:27:40,180 --> 00:27:47,160 Yes. Can I go to you now? I totally agree with what Cath just said. 259 00:27:47,160 --> 00:27:54,630 It's crucial that the big challenge for for us now is to catch up with what medicine is doing in other fields. 260 00:27:54,630 --> 00:28:05,130 So ideally, to be able to personalise treatment, based on the clinical presentation and on people's need, but also people's preferences. 261 00:28:05,130 --> 00:28:13,740 And this is something I'd like to spend a few words on, because the big problem we have in psychiatry and if you want in medicine in general, 262 00:28:13,740 --> 00:28:21,780 is that everything tends to be clinician led while it should be person centred. 263 00:28:21,780 --> 00:28:29,370 And if we move to this paternalistic paradigm to something which is more shared decision making process, 264 00:28:29,370 --> 00:28:35,070 I think this will help tackling one of the most important things that Willem mentioned at the beginning, 265 00:28:35,070 --> 00:28:38,700 which is stigma towards mental health and 266 00:28:38,700 --> 00:28:42,960 especially towards anti-depressants, because sometimes people think, well, 267 00:28:42,960 --> 00:28:51,960 I should be able to do it myself without any help, but actually especially for people with severe symptoms, 268 00:28:51,960 --> 00:28:56,970 Antidepressants can really help in the majority of cases. 269 00:28:56,970 --> 00:29:03,660 And they should also be considered in combination with other treatments, including psychological treatments. 270 00:29:03,660 --> 00:29:11,130 In terms of what side effects to expect, if we have this shared decision making process and paradigm. 271 00:29:11,130 --> 00:29:16,740 I think it's crucial also to incorporate what people think about these specific adverse events, 272 00:29:16,740 --> 00:29:23,040 because what is upsetting for me may be less relevant for somebody else. 273 00:29:23,040 --> 00:29:27,870 The good thing is that when we present this information to patients and carers, 274 00:29:27,870 --> 00:29:33,600 we know that, for instance, some adverse events, like the gastrointestinal adverse events, 275 00:29:33,600 --> 00:29:39,560 nausea, diarrhoea, constipation for the most commonly prescribed antidepressant called SSRI, 276 00:29:39,560 --> 00:29:44,400 the certain emerged ones, they tend to disappear over a few days, a few weeks. 277 00:29:44,400 --> 00:29:50,820 Others, the ones that Cath mentioned, the sexual side effects, they tend to stay for longer. 278 00:29:50,820 --> 00:29:57,600 So this is also something to be factored in when we inform people about the side effect profile. 279 00:29:57,600 --> 00:30:03,690 And also, we should be aware, as Cath said, that not all antidepressants are the same 280 00:30:03,690 --> 00:30:15,240 so the side effect profile may may differ. The last thing about how long people may expect to be on antidepressants. 281 00:30:15,240 --> 00:30:22,890 Yes, we we have pretty strong data that if you continue taking the antidepressants, 282 00:30:22,890 --> 00:30:31,740 once the symptoms are over, you reduce more or less by 50 percent the chance to get a relapse. 283 00:30:31,740 --> 00:30:40,140 And as Cath said, it is an individual decision because we have people who may benefit for prolonged treatment 284 00:30:40,140 --> 00:30:45,840 and people who actually don't have any added value from this continuation treatment. 285 00:30:45,840 --> 00:30:48,600 So it's very important to have an open discussion. 286 00:30:48,600 --> 00:30:59,580 And what I'm trying to push is to have a discussion based on some numbers so people can quantify the expected benefit and have an informed decision. 287 00:30:59,580 --> 00:31:04,490 Thank you so much. And if Willem would got a follow up question for you both. 288 00:31:04,490 --> 00:31:06,930 So just a follow up to Cath and Andrea, which is OK. 289 00:31:06,930 --> 00:31:13,610 I think something's around for a lot of people who are on long term anti-depressants as sort of the questions and the issues they have 290 00:31:13,610 --> 00:31:23,450 about coming off their anti-depressants are to do with things like tapering and discontinuation and maybe discontinuation syndromes as well. 291 00:31:23,450 --> 00:31:33,040 Yeah, it did the how to taper off the medication is another thing very important to consider to avoid withdrawal symptoms. 292 00:31:33,040 --> 00:31:40,600 And this varies a lot because we have in the general population, people that we call fast metabolisers. 293 00:31:40,600 --> 00:31:47,470 They usually need higher doses of drugs because they eliminate the drug very fast. 294 00:31:47,470 --> 00:31:53,290 And there's also when you taper off and stop the medication, it has to be very gradual 295 00:31:53,290 --> 00:31:59,920 otherwise, you have a big jump in terms of levels of drugs in the body or on the other hand, 296 00:31:59,920 --> 00:32:06,090 we have this low metabolisers and then the tapering off is much, much easier. 297 00:32:06,090 --> 00:32:10,910 Thank you. Cath, do you want to add anything? No, I mean, I agree. 298 00:32:10,910 --> 00:32:16,250 I think there's been increasing focus on the withdrawal effects of coming off anti-depressants. 299 00:32:16,250 --> 00:32:25,430 And I agree it's a very important area, both for kind of clinical questions that have to come off it, but also what what's happening under the hood? 300 00:32:25,430 --> 00:32:30,510 What what kinds of things contribute to those kinds of people experiences? 301 00:32:30,510 --> 00:32:36,860 And if we knew that, then it might be possible to to support or target those same processes as well. 302 00:32:36,860 --> 00:32:42,620 So I think we are all aware of the growing importance of focussing on that stage. 303 00:32:42,620 --> 00:32:50,510 We need to know more about what's underlying it. And also how we can predict who's going to find it most difficult to come off anti-depressants. 304 00:32:50,510 --> 00:32:55,280 And also, does that place them at high risk of a relapse as well? 305 00:32:55,280 --> 00:33:02,480 So I think that there are research questions around that are very much ongoing. 306 00:33:02,480 --> 00:33:08,960 Thank you very much. So we had a lot of questions about how best to support other people who are struggling with low mood or depression. 307 00:33:08,960 --> 00:33:12,530 So we'd be really keen to hear what advice you would give. Andrea, 308 00:33:12,530 --> 00:33:17,610 can I go to you first of all? Sure. I'd like to go back to two 309 00:33:17,610 --> 00:33:26,670 two things that Willem said in his presentation. So how best to support people who are struggling with low mood and depression or depression? 310 00:33:26,670 --> 00:33:30,390 We all have low mood and we all can suffer from depression. 311 00:33:30,390 --> 00:33:39,570 So the first thing is not to be afraid of having a discussion and mention this because it can happen. 312 00:33:39,570 --> 00:33:47,550 So it's important for people who are suffering with those symptoms and low mood to be aware and have some feedback about these. 313 00:33:47,550 --> 00:33:53,640 And also go and have a word with a GP or a specialist. 314 00:33:53,640 --> 00:33:59,220 Because I think one of our roles as medics in the field is also to give feedback 315 00:33:59,220 --> 00:34:03,870 to patients and see that actually you're not suffering from depression. 316 00:34:03,870 --> 00:34:12,990 It's just low mood. So it's not automatic. Every time we see a patient to a person to assume it's a patient and prescribe medication. On the contrary, 317 00:34:12,990 --> 00:34:20,620 I spend a lot of time advising people and stopping the medication or not prescribe anything, of course. 318 00:34:20,620 --> 00:34:22,530 The other thing is about stigma. 319 00:34:22,530 --> 00:34:33,060 So sometimes having or actually often having a diagnosis helps, because diagnosis is not a label to have on the person. 320 00:34:33,060 --> 00:34:43,080 On the contrary, is a way for us to define a group of symptoms and have a treatment which is likely to be effective for this person. 321 00:34:43,080 --> 00:34:53,520 So it actually helps the process and be able to see whether we are above the threshold of something clinically significant or below is crucial 322 00:34:53,520 --> 00:34:58,280 also for treatment purposes. Thank you very much. Willem, 323 00:34:58,280 --> 00:35:09,360 can I go to you on that question too. One thing I would add is that two things. 324 00:35:09,360 --> 00:35:14,280 One is it takes a lot of patience because we've heard about the course of depression and that's been weeks and months. 325 00:35:14,280 --> 00:35:18,900 So it's not something that you can hurry or cajole someone through. 326 00:35:18,900 --> 00:35:22,230 So as a carer, it requires a lot of patience. 327 00:35:22,230 --> 00:35:31,680 And I think the thing I'd say then for people who are living with someone with depression is it's really important to take care of yourself. 328 00:35:31,680 --> 00:35:37,860 Because actually, to be able to support someone with depression, you yourself need to be in good shape. 329 00:35:37,860 --> 00:35:43,710 So if you have a teenager or a partner or a parent who is suffering from depression, 330 00:35:43,710 --> 00:35:46,740 maybe one of the best things you can do to support that person is to look after 331 00:35:46,740 --> 00:35:50,940 yourself so that you yourself are actually in good shape to be there for them. 332 00:35:50,940 --> 00:35:56,400 And can show that sense of patience and support through that depression. 333 00:35:56,400 --> 00:35:59,970 But again, I'd just point you to the book, Living with Black Dog. 334 00:35:59,970 --> 00:36:07,510 It's just, I think, a very vibrant example of her experience of living with someone with depression. 335 00:36:07,510 --> 00:36:13,780 If I could just ask a follow up question relating to this. I mean, as you well know, I work with children and young people. 336 00:36:13,780 --> 00:36:21,760 And one of the things that often comes up as a major symptom for low mood and depression in adolescents is high levels of irritability. 337 00:36:21,760 --> 00:36:29,620 And I know that's not unique to adolescents, but it does present some challenges in identifying depression, distinguishing it from normal experiences. 338 00:36:29,620 --> 00:36:37,120 And, you know, sometimes parents do reflect that sometimes they thought this was just adolescence. 339 00:36:37,120 --> 00:36:43,240 And, you know, later maybe it becomes clearer that the young person is struggling with depression. 340 00:36:43,240 --> 00:36:50,500 And irritability is potentially a particularly challenging thing for those living with people to be able to address. 341 00:36:50,500 --> 00:36:55,450 Because whilst we might like to have a nice conversation about the issues, 342 00:36:55,450 --> 00:36:59,440 maybe that's not going to go down quite so well if people are really struggling with irritability. 343 00:36:59,440 --> 00:37:04,970 So I was really keen to hear your thoughts on that. And any advice you would give? 344 00:37:04,970 --> 00:37:15,800 I don't know if anyone has a particular view. Cath, I'd like to I'd like to hear your view. 345 00:37:15,800 --> 00:37:21,190 But I guess what I'd say is I think this is where that example of looking after yourself is really important. 346 00:37:21,190 --> 00:37:24,740 And I think that for me personally, mindfulness is actually very helpful, 347 00:37:24,740 --> 00:37:29,390 because actually to be able to stay grounded and to be able to have some perspective, 348 00:37:29,390 --> 00:37:37,820 when someone or a child or an adolescent is irritable, helps us to realise that this is not about me. 349 00:37:37,820 --> 00:37:41,510 So that the eligibility might be directed at me. But this is not about me. This is about them. 350 00:37:41,510 --> 00:37:47,240 And how can I stay steady and support them? But, Cahty, I know you're being very even handed as the chair. 351 00:37:47,240 --> 00:37:52,010 But actually, I think probably the best person to answer this question would be you. 352 00:37:52,010 --> 00:37:58,560 Well, yeah. I mean, I think I'd very much reiterate what you've just said. I think I think the thing that we see happening is that when, you know, 353 00:37:58,560 --> 00:38:04,220 young people are struggling with irritability, it's very easy for that then to lead to conflicts. 354 00:38:04,220 --> 00:38:09,500 And because it's frustrating for parents. It feels disrespectful. 355 00:38:09,500 --> 00:38:16,520 It feels like they're being challenged and say parents may respond by fighting back. 356 00:38:16,520 --> 00:38:20,300 And then obviously then the young person feels they're being attacked, being targeted, 357 00:38:20,300 --> 00:38:26,540 and you get caught in a vicious cycle that sort of escalates the conflict and leaves everybody feeling pretty rubbish. 358 00:38:26,540 --> 00:38:37,220 So I think exactly what you have said is that sort of trying to maintain that patient ability to step back from it a bit and not take it personally, 359 00:38:37,220 --> 00:38:50,530 but instead just to be more curious and empathic and gentle in in response, but recognise it's very difficult to do. 360 00:38:50,530 --> 00:38:57,410 Thank you. So, Willem, you've already touched on the last question that we were going to get to. 361 00:38:57,410 --> 00:38:59,730 I don't know if you've got anything else you want to say about it. 362 00:38:59,730 --> 00:39:08,380 And that was really about exactly this, that where people are looking after a loved one or someone who is close to them who has depression, 363 00:39:08,380 --> 00:39:11,530 how can people also best after themselves? 364 00:39:11,530 --> 00:39:17,860 Andrea, you've commented on that as well, but we'll go to Cath first and then I'll come back and see if you've got anything else that you want to add. 365 00:39:17,860 --> 00:39:24,040 Cath, any thoughts on that? No, I mean, I agree with Willem. I think it's pretty important to look after yourself as well. 366 00:39:24,040 --> 00:39:30,590 I think it's it's like they say on the safety briefing on the aeroplane. Put your own oxygen mask on first. 367 00:39:30,590 --> 00:39:32,980 And this is really hard to do. 368 00:39:32,980 --> 00:39:41,020 But it's really important to do it, if you don't look after yourself and it becomes very difficult to talk to anyone else as well. 369 00:39:41,020 --> 00:39:44,320 So it's very important to invest in yourself. 370 00:39:44,320 --> 00:39:52,330 I mean, when I have this question, I was thinking of a time of my own life when perhaps I didn't follow this advice very well. 371 00:39:52,330 --> 00:40:04,300 When I had young twins to look after and a busy job and my sister was just diagnosed with cancer and I took the opposite advice to all of this. 372 00:40:04,300 --> 00:40:10,820 And I didn't invest any time myself in all these things had piled up and became very difficult. 373 00:40:10,820 --> 00:40:19,030 So I think I think my my advice with the benefit of hindsight is to set aside some time to look after yourself, doing some nice things, 374 00:40:19,030 --> 00:40:23,510 if you can, some essential things, some trivial things, 375 00:40:23,510 --> 00:40:31,940 but things that would otherwise mount up and come back. And also to try and seek the support and advice of people around you, 376 00:40:31,940 --> 00:40:34,970 even if it means telling them what they can do to help you. 377 00:40:34,970 --> 00:40:41,360 And I think we've all been in that situation on the other side of this barrier where we can see that somebody is having a very difficult time. 378 00:40:41,360 --> 00:40:45,530 But we don't really know what to do to help. And often then we don't really do anything. 379 00:40:45,530 --> 00:40:52,190 And I think most people are very happy to step in and help and to do some practical things if you need it. 380 00:40:52,190 --> 00:40:55,490 If you can tell them what you need and what would be helpful. 381 00:40:55,490 --> 00:41:01,790 And I think that this is it is really useful to try and gather some more social supports around you at those very difficult times, 382 00:41:01,790 --> 00:41:05,520 because it can be quite easy to become quite isolated, 383 00:41:05,520 --> 00:41:11,330 just focussing on looking after somebody else without the support networks that you normally rely on. 384 00:41:11,330 --> 00:41:18,950 And with things sort of mounting up, and you become in a sort of smaller and smaller space to actually deal with anything yourself. 385 00:41:18,950 --> 00:41:24,740 So I think it is hard to do in a situation where you're busy looking after somebody else. 386 00:41:24,740 --> 00:41:34,360 But I think if you can just set aside a little bit of time yourself every day to do those kinds of things, I think is is really important. 387 00:41:34,360 --> 00:41:38,350 All right. Thank you very much. Willem, Andrea, are there any final things here tonight. 388 00:41:38,350 --> 00:41:46,330 Come out on that point before we finish. I would like to come in if I may, and I think I'm just reflect on the poll that we did at the beginning. 389 00:41:46,330 --> 00:41:55,090 Ninety five percent of the people on this call have either suffered from depression themselves or know somebody who has in their immediate circle. 390 00:41:55,090 --> 00:42:05,830 So this is a very live issue. And I'm minded of the Wordsworth's, his words, "a deep distress have humanised my soul." 391 00:42:05,830 --> 00:42:12,030 And what he was describing was an experience of depression that actually had been somehow transformative. 392 00:42:12,030 --> 00:42:16,630 And many of the people I've described, I don't want to in any sense romanticise depression. 393 00:42:16,630 --> 00:42:24,040 It's not a romantic disorder. But actually standing alongside someone through depression, 394 00:42:24,040 --> 00:42:27,750 the beginning of the depression, and the aftermath of it, can be actually something. 395 00:42:27,750 --> 00:42:33,750 I've experienced this myself in my own life, as Cath's described, can actually deepen a friendship that can deepen a relationship. 396 00:42:33,750 --> 00:42:36,820 It can deepen a marriage. Yes, it feels difficult. 397 00:42:36,820 --> 00:42:45,380 But that teenager, Cathy, that you described, if you can be there for them through the irritability. 398 00:42:45,380 --> 00:42:54,030 And stand steady. You might find later that day when you're in a long car ride with them, they're disclosing something very personal to you. 399 00:42:54,030 --> 00:42:59,190 And I think that actually it's more than just can we survive living with someone? 400 00:42:59,190 --> 00:43:02,580 Depression with depression can actually be part of that relationship. 401 00:43:02,580 --> 00:43:07,590 Can it be something that actually enhances that relationship over the long, long haul? 402 00:43:07,590 --> 00:43:12,210 Because it's a part of life. And I just want to go back to where I started. If we talk about heart disease, 403 00:43:12,210 --> 00:43:16,230 we wouldn't have this kind of worry about it. I would say this is just part of life. 404 00:43:16,230 --> 00:43:20,790 This is part of the human condition. My hope is the same will be will be true here. 405 00:43:20,790 --> 00:43:22,980 This is what happens sometimes to people. 406 00:43:22,980 --> 00:43:29,540 And if we can find a way of navigating our way through it, then actually deepens and strengthens relationships sometimes. 407 00:43:29,540 --> 00:43:37,850 Thank you. And I think that's a really nice place to finish, so I'd just like to thank again our three panellists today. 408 00:43:37,850 --> 00:43:45,770 Wille, Cath and Andrea for a really fantastic session, which I hope will be useful for many people who are listening. 409 00:43:45,770 --> 00:43:51,840 It's really wonderful of them to give up their time to take part. And we really do appreciate it very much. 410 00:43:51,840 --> 00:43:53,700 I also would say huge thanks to Nicola Kaja and 411 00:43:53,700 --> 00:43:58,910 Halley, who've done enormous amounts work behind the scenes to make this series run as smoothly as possible. 412 00:43:58,910 --> 00:44:03,740 And also just to do a final plug for our YouTube channel where you can find the previous talks. 413 00:44:03,740 --> 00:44:11,180 You'll also be able to find this one here. And our next session, which is on overcoming mistrust and paranoia on the twenty eighth of January. 414 00:44:11,180 --> 00:44:17,790 And please do look out for the e-mail from us tomorrow where we'll be asking for some feedback, but also sharing some more resources. 415 00:44:17,790 --> 00:44:22,220 So thank you ever so much for joining us. And we hope you'll be able to join us again soon. 416 00:44:22,220 --> 00:44:33,214 Thank you.