Hello and welcome to the new psychology of Depression.
A series of programmes with me, Dr. Danny Penman and Professor Mark Williams of Oxford University.
We live in a world filled with material wealth. We have never had so much political and economic freedom.
We live longer and healthier lives. And yet anxiety, stress, unhappiness and depression have never been more common.
Why is this? Or perhaps more importantly, what can we do to stem the rising tide of these mental health problems?
Mark, why exactly is depression? Well, depression is a syndrome.
It's a combination of symptoms that occur at the same time.
So most people know what sadness is. Most people know sometimes how difficult it is to get up out of bed, out of the morning.
This sort of thing. Depression is different from that. It's low mood, feeling hopeless, feeling very sad and listless.
But also it can be lack of energy and enthusiasm for things that you used to actually quite enjoy.
And those are the core symptoms of depression.
But even then, if you get those for a couple of weeks and they go on and on and on, that's not enough to get you a diagnosis of depression.
So there are other symptoms as well.
And any combination, four or five of these other symptoms are often considered necessary for a diagnosis of a clinical depression.
And there are things like changes in appetite, perhaps even weight loss, or sometimes people eat too much in weight gain, changes in sleep.
So that some people don't get to sleep at night or they can't sleep in the middle of the night or they wake up very early in the morning occasionally,
especially with something called seasonal affective disorder. It's sleeping too much and not feeling that, you know, you want endless sleep.
But generally with depression, it's not sleeping. It's it's insomnia.
And then there are things like feeling guilty, lacking concentration, feeling agitated or very slow down, feeling tired all the time.
And even many people get suicidal ideas, ideas they'd rather be dead, that they're just a burden to the family.
That's what depression is. Is these symptoms coming together most days for at least two weeks.
In general, however, they go on for months and that's when you'd get a diagnosis,
depression at the point at which these things prevent you from living your life as you want to live.
So it's it's what might be called functional impairment. You can't function and you can't explain it in terms of illness or physical illness.
You can't explain it in terms of a recent bereavement. This comes and stays and you don't seem to have to get rid of it.
So how does it interrelate with other problems that we all suffer from from time to time,
such as anxiety, stress and, you know, things like mental exhaustion?
Well, they're very closely related. So you very rarely get a depression without having other things like high anxiety at the same time.
Depression is often characterised by dwelling on the past a lot,
but you hardly ever get that without people also worrying about the future and being anxious about the future.
Psychiatrist or psychologist usually put anxiety and depression in separate camps,
but the new genetic evidence is suggesting they're much more dimensional, they're much more mixed.
And also the treatments that work for depression tend to work for anxiety as well.
So there's quite a lot of evidence that actually to make a two biggest separation between anxiety,
stress, depression, exhaustion isn't quite what is going on in the world.
Things like anger, irritability, road rage, you know, typical explosion's that you see we all say everyday.
Are they related to depression at all? They can be.
I mean, that they're more likely to be related to stress because you often get in high chronic stress.
You get people showing a lot of anger. But also and it depends on the age group.
So, for example, in adolescent depression, that can be quite a lot of anger and irritability and hostility,
which is how often within that age group, a lot of sadness is expressed.
But you couldn't get a diagnosis just from being angry all the time.
You'd need some of these other things like weight loss or appetite change, sleep change and that sort of thing.
Depression is increasing worldwide. Is it increasing predominantly in the developed world or is it also increasing in the Third World?
Well, what we now know is that depression is is rapidly becoming one of the biggest reasons
for people to have basically lose years of their affective life through disability.
So the World Health Organisation publishes data a decade by decade over that.
And about two decades ago, they recognised that depression was becoming a big problem.
Well, it's now arrived. So in the end, they have a statistic of the year's life lost to disability and in high and middle income countries,
depression is the top of the list for that. So it's higher than the disability caused by heart disease, for example,
cerebrovascular disease, road traffic accidents and even in low income countries.
And rayland and it's still in the top 10 of years lost to disability.
So depression actually exacts a bigger toll on society than cancer and heart disease and other things like osteoarthritis.
Indeed, in terms of its global impact, of course, there's the suicide impact as well.
Nearly a million people die prematurely by suicide each year.
Across the world. But also, there's the more hidden cost as well as the big cost of things like suicide.
People feeling like they can't function, feeling like stay in bed rather than getting up, which is not just laziness.
This is depression, as it were, that's doing this to them.
It affects the ability to be a breadwinner for your family, the ability to look after your family.
And that's why it's such a burden right across the globe.
Can you give us some figures as to the prevalence of depression, both in the developed world and the developing world?
So in high income countries, for example, depressive disorders, which is what we've been talking about,
account for about 14 percent of the year's life lost to disability and putting that in proportion.
If you look at Alzheimer's and other dementias, that's about five percent of the year's lost disability.
If you look at osteoarthritis, it's four percent. If you look at chronic obstructive pulmonary disease, that's about three percent.
So 14 percent is huge compared compared with that.
Then if you look at low and middle income countries and then depression is about 10 percent of that and the next the next in line for their years,
lifelong disability are eye problems, what's called refractive errors. And that's about half that, about four point seven percent.
So, again, in terms of the years life lost disability, it's huge.
What epidemiologists seem to find wherever they look is about one in 20 of the population are depressed.
Any one time. And about 20 percent of the population at some point will get very depressed.
And that's a major problem. Every time I hear these figures, I'm just completely stunned.
What's the fundamental driving force behind the increase in depression?
I think there's always been a proportion of the population that has felt depressed as far as we can go back in history.
You can look in the Psalms, in Hebrew, the Old Testament is the word.
And you see people expressing sadness and depression and anger and mutability and this sort of thing.
You go back way into the beginning of something like Buddhism, for example, 500 years BCE,
and you have people needing to learn to meditate, to deal with the problems of the mind problem, the entanglements of the mind, as it were.
So I think he's been around a long time.
One of the things, however, that's new is over the last 50 years in the Western world, the age of onset of depression has changed.
It's become earlier and earlier and earlier. And that's one of the major discoveries.
It started to emerge from epidemiology where big surveys started to pick up that people
would begin to report from about people born in the 1950s onwards when they were assessed.
Towards the end of the 20th century, they started to report that their depression had started a bit younger than we had previously thought.
It was previously thought that depression was a bit of a late life problem, late 50s, early 60s,
and indeed the evidence that people born in their first part of the 20th century seemed to verify that.
But decade by decade, from about 1950 or 60 onwards, the age of onset got younger and younger.
And so by the late 1980s, 90s, people were beginning to get depressed in their 20s.
And there's been a striking confirmation of that in the last few years.
One of the biggest clinical studies ever conducted was done in America. It was called the Star D trial.
And it was S t the beginning of starting means sequence treatment.
So it was a big trial to look at what treatment to provide one treatment after the other, after the other.
So they have 4000 people who volunteered to take part.
And as part of that trial were asking them, when did you first get depressed?
And they found that the mean age of onset in this sample was about 26.
But. The most common age in which people's jobs get depressed was between 13 and 15 years old.
And that is an astonishing new development, is the same Truffaut kind of anxiety and stress and irritability.
And we weren't clear about that until about year 2000, where somebody published a big paper in one of the big journals in America.
They'd traced the anxiety level of children and young people over 30 years from the night early 1950s, all the way through to the mid 1980s.
And they found exactly the same thing, that it looked as if the anxiety pattern in children, young people had become that in a sense,
a whole bell shaped curve had shifted towards greater anxiety by about one standard deviation,
which means that whole swathes of children, young people who hadn't been anxious in the 1950s as a Fairborn in the 1980s,
then they were likely to show anxiety, which had been virtually clinical levels 30 or 40 years ago.
I think earlier you said that what we regard as normal levels of anxiety and stress
would have been regarded as a clinical level anxiety and stress 50 years ago.
Is that true? Did I misunderstand that? Because that's quite an astonishing figure.
That's true in anxiety. And now that we know the same is true of depression, that is that 50 years ago,
people would would live out most of their life without getting these crushing depressions.
But now that, you know, 35, 36 percent get depressed before the age of 18 and then there's a whole life ahead of them,
which is the biggest challenge, a whole life ahead of them, where they might actually get another depression.
Because one of the things we now know is if you've been depressed once, you tend to get depressed again,
at least in half, half the cases and once you've been depressed twice, then the chances go up even further.
So does this suggest that depression is really a problem of how we deal with the world the way we think,
rather than a chemical imbalance in the way our brains are actually working?
Well, one of the inferences we can make from these big changes being so rapid and recent is that it can't be genetic changes,
it can't be driven by our basic biological makeup. So there must be something else happening and it must be environmental changes that are driven
that I clearly it could be that people are just recognising depression that was always there,
but now they're recognising it more.
But the fact that both clinical studies and epidemiological studies show up the same thing argues that it's not just that people recognising
it better because you control for the sorts of questions you can ask and cheque that the questions asked are the same over those decades.
But the other thing is we know that after about 1977, you got increases in changing rates of suicide as well, especially in young men.
Right the way over the Western world, you got increases in the suicide rate,
which to some extent mimicked this younger and younger depression hitting.
Now, that's stabilised over the last few years.
But the fact that you get really confirmation from another area that we know is likely to be affected by this changing pattern of depression,
I think shows that something's going on here. It's very difficult to understand exactly what the causes are, changing patterns of society.
The increase in the gap between rich and poor.
The fact that when economies develop rapidly, often there are seem to be some almost unavoidable changes in that in the gaps between rich and poor.
We know that in the countries that have the least gap between rich and poor,
then the levels of stress, the levels of trust, even within the communities are higher.
The levels were hope are higher and people tend to live longer their societies.
So there are little bits of evidence that people are beginning to put together to suggest what the changes might have been.
But what we're working on are treatments that approaches which can now deal with depression epidemic.
If you had to choose a fundamental driving forces behind depression, what what would what would they be?
Well, at the individual level, that the way we think about life.
So where we feel we are, as it were, in relation to other people, in relation to our own standards, understand that other people set for us.
So one of the ways in which society is changing is the way in which it expects us to to do things, the targets it sets for us.
And so on. And when society sets us target.
And says, meet those or else. Then the best you can hope for from your work is relief when you've met your targets.
In other words, if you could do a good job and feel pleased, you've done a good job because of your work.
I know you're a heart surgeon and you've saved, you know, several lives this week.
Then that must be a really good sense of worth about what you've done.
But what happens if you've got a target to save six lives this week? All you do is when you've saved six lives.
Thing off often couldn't staff met my targets.
So suddenly it turns the possibility of of satisfaction with a job well done into relief that you haven't made a mistake.
So you've turned potentially something really enjoyable about life into a thing that isn't going to, as it were, give you the motivation.
So gradually that that can work for a while, you know. But gradually it can eat away.
I think to you in ways that are a bit pernicious. So how could you for example, you know, if you're omnipotent dictator, how could you change society?
Or, you know, perhaps if you were running a company,
how could you change the culture of that company or of that society to actually promote mental health and wellbeing?
I think it's what people talk about work life balance, don't they? And that's really important.
It also to recognise that productivity needs engagement and engagement needs a sense of control, a sense of choices.
So as you go down companies, traditionally you get people having less and less choice about what they do.
And if you can find a way to increase the choice, then you naturally increase the creativity.
We know that when a company is run on just target lines and so on in this stress stressful way,
that actually people in order to meet their targets, they feel very stressed.
They put in more hours, but they artlessly more productive because they're not seeing the whole picture.
And if you want employers to see the whole picture and if we want us in our family life to the whole
picture that you have to learn to attend and you have to learn to see the whole picture by reducing stress.
And there are things we can do about that.
And mindfulness, which is what I've spent much of my life researching over the last 20 years, is one of the answers to that.
Does depression inevitably return or, you know, is it possible to just have one episode of depression and,
you know, that's it for the rest of your life. You go over it, you dust yourself down and carry on with the rest of your life.
Is that possible? Or does it tend to return? Okay. Depression can be a one off.
And so it doesn't it's not inevitable return. So it's a bit of a message of hope.
If we said, oh, it's always going to return, then it's a counsel of despair for many people.
On the other hand, if you've been depressed once, you do have a slightly increased threshold and it rather depends why you got depressed.
If you got depressed because of a big life event, for example, bereavement,
unemployment, separation and the sorts of reasons that would make any of us low then.
So long as you don't have a repeat of those sort of events, then you don't necessarily not really going to get depressed again.
But the problem is that if you get depressed, the threshold for you getting depressed again is slightly altered.
And if then you get depressed for a second time, what we know is the triggers of a third depression are less.
So, for example, you might need bereavement or unemployment the first time you get depressed,
the second time it might be something slightly less of a stress or but then the third, fourth time, then you may not need a stressor at all.
By the time actually you've had three, four, five depression, it may be that you just wake up one morning feeling a bit low.
By the end of the day, you're feeling very depressed.
So the statistics suggest that about 50 percent of people might have a one off episode and then it doesn't bother them again.
But if they'd been depressed twice, the chances to get depressed again are much higher.
Three times the rates at about 70 to 80 percent.
And yet our studies, we find, for example, that if we follow people up for about 12 months without offering any treatment to them,
then if they've had three depressions in the past before they've come to see us,
then between 60 and 80 percent of them will get depressed again in those next 12 months.
People who become repeatedly depressed year after year.
What proportion of their lives do they actually spend in that depressed state?
Well, we didn't know the answer to this question until fairly recently.
And there's some researchers in the states who've done a long term follow up of a study called.
And IMH, that's the National Institute for Mental Health. They started a study in 1975.
And because they were able to keep in touch with this large number of people that started, then they went to look at,
you know, how much time do people actually spend depressed if they've been repeatedly depressed?
And the figures are staggering. What they found was, and it's just been published in the last couple of years,
is that people on average spend 32 percent of their time in episode over a 20 year period.
So on average, four months a year are spent in episodes of depression, which I mean, considering the burden that we talked about earlier.
It's an incredible statistic and some pretty disturbing statistic. What proportion of people then go on to begin self-harm or even commit suicide?
There are changing rates of self-harm and suicidal behaviour. And the definitions vary.
So self-harm sometimes, I mean people who harm themselves, physically, cutting themselves and so on.
Deliberate self-harm is sometimes broader than that, people that take overdoses and so on.
And we know that the rates of of suicide in people who been severely depressed are elevated compared with the general population.
Now, about one percent of the population die by suicide anyway.
If you've been depressed in the past, that's likely to be higher about four or five percent.
If you've been depressed and been an inpatient at some point in your life and been hospitalised for depression, it can be as high as 10 to 15 percent.
So one in six, one in seven people die by suicide if they've been in inpatient, hospitalised for depression.
But, of course, it's not inevitable. Most people don't die in this way.
But it's always a tragedy when it when it happens for the further family left behind.
For the for the friends and colleagues of the person. Is suicide always linked with depression?
It's the most closely linked problem so that even.
I mean, you get elevated risk of suicide in other mental health problems like schizophrenia, for example, or bipolar disorder.
But it's the depressive aspect of schizophrenia.
So many people can can survive, as it were, having serious mental health problems in an amazingly courageous way.
But depression takes away that hope.
And it's when hopelessness comes, which tends to come with depression, that as people become at greater risk of suicide,
whatever the condition it is, it's the it's the occurrence of depression that accounts for for that.
Do you people tend to kill themselves as they come out of a depression rather than when they actually
have the kind of hopelessness and the lack of energy when they are in the teeth of a depression?
This is a quite of clinical evidence for that. It's never been proven by research.
It's a very difficult thing to to to prove. But many people have said that they thought that the person was actually feeling happier now.
And the natural inference is exactly as you suggest, that people, when they're very, very depressed,
actually have very little energy and that it's when the energy starts to come back.
But the mood has not yet improved. That is a very dangerous time.
It's also true to say that some of the big studies that Lewis Appleby and others have done in the
United Kingdom have found that the most vulnerable time is a time just after discharge from hospital,
for example, after a change in medication which reflected very often reflected the fact that their physician thought they were feeling better.
So that's also indications that when people are on the mend and people around them think they can stand on their own two feet,
that that almost that transition is a very difficult time for people.
You were mentioning about the close links between depression and suicide and asking about that.
And somebody is calculated actually how much of the suicide risk in the world could be eliminated if we could eliminate depression.
And it turns out to be about 80 percent because of the very close association.
People don't tend to be suicidal outside an episode of depression.
Depression is the thing that is the, as it were, the final common pathway, depression and hopelessness.
And one of the interesting things that's emerged in the last few years is that when you get repeated depressions,
you can get depressed again and again, but different symptoms can be there each time.
So that always there's cause symptoms seem to be there, like low mood and lack of interest.
But the other things like weight loss, sleep, loss, guilt, they may or may not be there.
But our research in Oxford has found that of all the symptoms that recur when depression recurs, suicidal feelings are the most recurrent.
And of course,
that's important clinically to realise because it means that often doctors will ask somebody who's depressed whether they feel suicidal.
Well, that's an important question to ask, but it's more important to ask, did you feel suicidal when you were last depressed?
Because if people felt suicidal at their worst ever time,
then there's some chances that during this episode, at some point they're going to feel suicidal.
So clinically, it's important.
And research wise, it's important to get to the bottom of what are the characteristics of recurrence so we can begin to begin to help.
So why exactly does a full blown depression feel like?
It's a combination of experiences, of distortions, you might say, in the way you think, the way you feel, the body and your impulses.
So if you take each in turn, your thoughts are dominated by ideas of helplessness,
rejection, being a failure, not being good enough, not being worth your space in the world.
You feel like the lowest of the low and that nobody wants you.
Nobody likes you. And that even if they do like you, that's because they haven't found out the truth about you.
You're just a fraud. And as soon as they find out what you're really like, they'll reject you.
So your your thoughts are dominated by that. That becomes a habit.
So that although many of us might think like that for, you know what,
at once or twice a day or a week or a month in depression, it just like comes all the time.
I mean, many of us know what it's like to wake up in the middle of the night, for example, and not be able to get back to sleep.
Our thoughts go round and round and round. We just ruminate and brood. Well, depression is like that sort of middle of the night thinking.
But it happens during the day as well. Secondly, your feelings get bombarded.
There's feelings of sadness, of hopelessness, of worthlessness.
And they're very closely tied in with your thoughts. If you can imagine somebody standing behind you all day saying how useless you were then.
Sooner or later, you would feel sad, irritable, rundown, exhausted and a miserable failure.
And that's the way in which the feelings reflect those thoughts.
It's not just a mental thing. Your body slows down. You lack energy.
You your body fails to work in an efficient way.
So you don't sleep well. You don't eat well. And this itself feeds back into your sense of fatigue and slowness, lack of energy,
either being in some cases very agitated, in some Caples cases being very, very slow down.
And so that's the way the blame. If you look at the way people walk when they're depressed, for example, the gate is very different.
Not as if we're walking upright, walking slouched, go from side to side instead of actually more steady on their feet.
And lastly, your behaviour is affected. You don't either.
You feel like you feel suicidal, but also you feel like withdrawing from the world and that sense of withdrawal,
of not wanting to see things that once again, most of us have had times in our life when the phone rang with.
Oh, do I have to answer that? Or when we didn't want to get up in the morning and anybody could have seen, we were quite so withdrawn.
But that goes on relentlessly. It a fear. It feels like it goes on relentlessly in depression.
And when you put these together, the thoughts, the feelings,
these body changes and your impulse to act or your behaviour or tendencies to withdraw, then that is what drags you down.
It's not surprising then that people feel the burden and can't function when they've got all of this going on in their life.
So is there any one thing that drives people or tip people over the edge from a normal run of the
mill sadnesses or periods of rumination or reflection into a period of full blooded depression?
There are. And actually, I'd like to tackle that in great detail in later episodes,
because it's exactly what tips people into other episodes that the research is most exciting over the last 20 or 30 years.
And out of that comes the interest in mindfulness research. So that's something that I think we'd be able to go into detail in future episodes.
So that implies it is possible to stop a depression from or other normal feelings of unhappiness that we all experience from day to day.
It's possible to stop that and prevent it from tipping over the edge into into clinical depression.
That's the most exciting development in the last 20 years. And the way in which mindfulness is able to help people to notice when the tipping point is
coming and allow you to deal with what you've got then without going down into the depths is,
I think, one of the major things. And that's must have huge clinical relevance.
It's got huge political relevance, because if we could find and I'll describe that in the later episode,
if we can find that this is actually as useful as antidepressants or as other treatments.
It's it's it's a global significance because it doesn't depend on medications, which in some context are just too expensive for people to purchase.
Thanks very much for that, Mark. In this episode, we're talking about the new psychology of depression and what exactly depression is.
And in the next episode, we'll be talking about the major treatments for depression and how they've changed over the last century or so.
For further information about the issues raised in this programme,
you can read The Mind four Way Through Depression by Professor Mark Williams and his co-workers.
Or you could read our book, Mindfulness. Finding Peace in a Frantic World by Mark Williams and me, Danny Penman, where you could visit our Web site.
Frantic World Dot.com. If you'd like to support further research in this area, you could visit Oxford mindfulness dot org.
That's all one word. And follow the links to the development campaign.