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.
In this episode, we'll be looking at the treatment of depression and how it has changed over the last few decades or so.
Mark, at the moment, one of the main ways of treating depression, well, there's two big approaches, physical treatments and psychological treatments.
Those are the main two approaches. But there are many psychological treatments are come to those in a moment of the physical treatments.
There are some that are fairly rarely used nowadays that used to be used a few decades ago, like ECD Electroconvulsive Therapy treatment.
But the main physical treatment is antidepressant medication. They're very, very widely used now all over the world and they work pretty well.
So antidepressant medication. They obviously affect brain chemistry.
How in detail do they work? Well, in the brain there are many, many different receptors sites.
For example, the way in which nerve cells work is an electrical impulse running down a nerve cell.
But then it comes to a junction and then the current, as it were, the impulse has to be transferred from one nerve cell to another.
And that's called the sign ups, the junction of these two things. And that's the point where chemicals come in because those neurotransmitters are
released from one end and are picked up at the receptor site of the other one.
And then they the transmission continues.
Now, there are millions and billions of these in the brain and so much of our functioning are eating our sleeping mood.
Everything is governed by the action of neurotransmitters in the brain.
And what we know is that when they get unbalanced, then depression can result.
There are many neurotransmitters, the two ones that are most thoroughly studied, noradrenaline and serotonin.
And what we know is that the antidepressants that work are often antidepressants
that effectively increase the availability of these substance in the brain.
They usually do so by blocking re uptake.
What that means is that usually when the neurotransmitter is released, if that sign up is going to be effective, it can't linger for very long.
So there's got to be mechanism for, as it were, gobbling up the neurotransmitter. So when the next impulse comes, you know, it can release.
And so that's called re uptake.
Now, if you have a really uptake blocker, that means that when neurotransmitter has been released, it stays around for longer.
That's one of the ways in which it works. Now, we know that it takes some time.
It takes a few days for most anti-depressants to, as it were, kick in and affect your mood.
In a notice and significant way that you actually notice it, although they start working straight away.
The fact that it takes a little time suggests that it's not just more neurotransmitter.
That's the critical thing, but it's actually changing the balance,
the the sort of changing the balance of sensitivity in the cells, the sort of sending and receiving sites.
So is depression caused by low levels of these chemicals in the brain such things as serotonin, or is it more complex than that?
It's probably more complex than that, because if it was, you could just give things to increase the levels and people would be instantly happier.
That doesn't happen. So what people think is that there might be something in some of the receptor sites, for example, they might be just insensitive.
Now, if you get a receptor sites insensitive, just increasing the amount of available neurotransmitter isn't going to work instantly.
So that might be something. We also know that the transporter gene, that's the the genetic, as it were,
messenger mechanics of getting the stuff available to the brain that might also be effective.
And there's quite a lot of interesting work now at the frontier of this science, looking at serotonin transporter genes, for example.
How effective are these drugs? Are they all similarly effective? Well, they seem to be.
I mean, the drugs that were introduced in 1950s and 60s, what called tricyclic antidepressants, are pretty effective.
The new generation of antidepressants are about as effective.
The major aspect of them is they're less toxic in overdose, for example.
They're safer. They don't have so many side effects. And, of course, side effects are always an individual interaction between the profile,
the biological profile of the individual taking them and the biological profile of the medication.
And therefore, it's impossible to predict exactly what side effects come with each antidepressant.
So very often a physician will will try a personal one antidepressant and then say,
come back and tell me if this suits you and try another one of the same or a different class.
If it doesn't. So there is a part of of this which is experimental and it's always a of discovery for
the physician and the person themselves in discussion to decide what works for them.
But if you ask whether they work well, it's pretty controversial.
It looks as if about 60 percent of people in most studies after you know, if you go on for a year, you'll get remission or recovery.
That's depression really going down to bearable levels and a premature babies, only one or two symptoms around any in any one week.
Instead of these crushing weight depression,
about 60 percent will or recover later data from things like the Big Star D trial I was referring to in Episode
one that suggested after 12 weeks on one form of medication and then about 30 percent respond to that.
If he then changed to another antidepressant, a further 19 percent will respond to that.
If you then change to another of those who haven't actually responded to either of those first two, then another 14 percent will respond to a third.
Now, that cumulative rate of about 47 percent over one year is slightly more pessimistic than than many would have hoped.
And there's new evidence all the time on the effectiveness of antidepressants and some of the big meta analysis.
That's when people get all the data.
All the studies together are beginning to suggest that for mild depression or perhaps even some moderate depression,
antidepressants don't work much better than the placebo, a sugar pill. But for this as vier depression, which caused the greatest amount of problem,
then you do see clear blue water between the antidepressant and a placebo.
Now, having said all that, of course, your doctor, if you go to the doctor, will never give you a sugar pill.
Well, if you're not part of a research trial where you've got consent to do that,
and therefore the fact that you get both a placebo effect and a therapeutic effect can be, for many people, a lifesaver, as it were.
It does change lives. It does change moods.
And so nothing about the psychology or the new psychology or depression means that these are now irrelevant or should be substituted for psychology.
For many people, they're a lifesaver. But probably the best estimate is 50 to 60 percent of people responding.
And of course, one of the things that emerges from that is, well, what about the other 40 percent?
And also, what about the people who are respond to one or the other? And of course, some people don't want to stay on antidepressants for a long time.
The major problem with antidepressants is this, that when you stop taking them,
let's say you take them for six to nine months or a year and it deals with depression and then you feel stable.
If you then come off antidepressants, then your risk of getting depressed again returns to the risk that you had before you started taking them.
That means if you've had three episodes of depression, then your risk was 60 to 70 percent.
You can deal with that with antidepressants for, say, a year, two years.
When you come off them, your risk goes back to 60 to 70 percent. If you've had five depressions in the past, then your risk is 90 percent.
When you come off antidepressants, your risk goes back. Now, you might not become depressed immediately.
But a recurrence is. Of course, a very, very damaging and disappointing thing to happen when you thought you'd coped with it.
And therefore, many physicians are saying, well, why not go on antidepressants and stay on them if they suit you?
Treat it like diabetes, you know, like it's a permanent lifetime thing.
You've got free with diabetes. But the trouble is that many people don't want to be on drugs for the rest of their life.
Some people naturally come off. So in that long term study from I was telling you that started 1970s,
virtually everybody after a year had spontaneously come off their antidepressant.
We know from recent data that 30 percent of people don't even go back for their repeat prescription.
So there's a large sort of weight of evidence that people naturally come off despite their doctor's advice.
They come off antidepressants and then, of course, they are at risk of getting depressed again.
Is that risk a withdrawal symptom or is it just that returning back to normality and, you know, the world hasn't changed?
It's a good question. If it was just a withdrawal system, then you'd expect the Depression to come back quite quickly.
And that does indeed happen. When you come off your antidepressants, say, within three months, four months, five and six months.
And when you think about it, imagine that a depression is going to last for five or six months.
Naturally, we know that depression naturally gets better if you don't do anything with it.
It tends to be episodic. That means it comes it's crushing when it happens, but then you get over it.
Now, if you take antidepressants for an episode of depression, then if you take your antidepressants for a few weeks,
the depression is, as it were, still there underneath the biological processes, still at work.
If you come off prematurely, the depression comes back pretty quickly.
That's what's called a relapse. And that's where you get these sort of a kick back effect.
However, if you've taken antidepressants for six, nine months a year, that has covered that episode of depression.
And when you come off, you'll be OK for a while, probably.
But then there's what we call a recurrence as opposed to relapse, which is that within a year or two, the depression tends to start again.
So it's probably not just a kick back effect, a withdrawal, although scientist patients are harder to come off than others.
And and some I mean, you always, of course, need your doctor's advice.
If you think you're coming off antidepressants, you always go and see the physician who's given you them,
who is prescribed them and ask their advice and they'll help you because some are easy to come off.
Others are much more difficult than you can get a lot of other symptoms of flu like symptoms from some, for example.
And you need to have a doctor's reassurance that these are recognisable and that to help you get through that so you can get out to the other side.
So does this mean the only long term solution to depression is a psychological approach?
Well, yes, in a sense it is. Now, if it's true that just by carrying on taking your antidepressants, you can reduce the risk of depression,
that will work for some people and for those who've been advised by their doctor, that's to do that.
If they're happy with that and it doesn't cause great side effects, then there's no reason why they should suddenly stop their antidepressants.
Of course, there's still a bit of a risk of relapse coming,
even if you carry on with antidepressants and that's where you can supplement them with psychological skills and psychological therapies as well.
But we do know and this is in a sense turning to our second major strategy, that there are psychological.
There are psychological approaches that help and that when they help, they actually also protect against relapse and recurrence.
So let's come to psychological treatments. What are the main psychological treatments at the moment?
There are five or six psychological treatments that work well in dealing with acute episodes of depression.
The one that's got most evidence for it is cognitive therapy. So I come back to that.
But it's true to say that there's something called behavioural activation, which is getting people moving, as it were, in their behaviour.
There's something called interpersonal psychotherapy,
which is as effective as cognitive therapy in trials which deal with the things that happen, you know, interpersonal life.
I mean, it's an individual therapy. It deals with things like guilt, with real transitions, with interpersonal effectiveness, these sort of things.
In the early days, people thought that psychodynamic psychotherapy, sort of Freudian, more analytic psychotherapies would be good.
And there wasn't much evidence for that. But then there wasn't much evidence collected.
So there wasn't there weren't many scientific studies.
And indeed, as people began to make those approaches, more psychoanalytic approaches, more structured and shorter, then, for example,
there's something called psychodynamic interpersonal psychotherapy, which they got it down to 15 sessions, just like other psychotherapies.
And they found. It worked pretty well. This problem solving therapy, which works, works pretty well.
That's for mild depression, certainly an exercise. We know exercise works pretty well for milder depressions.
So there's a whole range of things that we can do to to deal with acute depression.
But probably the main one is the one with the biggest evidence base is cognitive therapy.
And the history of cognitive therapy is really interesting. One of the puzzles about the psychology of depression was that in the 1970s,
people didn't actually think that depression was treatable with psychological means.
They thought perhaps the new antidepressants were one way because it was a biological thing.
And there were people on the analytic side talking about psychoanalysis, but without any much evidence.
But certainly there was accumulating evidence that depression could be treated with antidepressant medication and that although in the 1950s and 60s,
people had many psychological treatments for anxiety and phobias.
Nobody thought that depression was the sort of thing that you could treat with with this approach.
Did people once think that you could treat depression by correcting irrational ways of thinking?
Well, it seems obvious now, but actually, no, they didn't. I mean, obviously in history, throughout history, people had a go at night.
It's obvious that irrational thoughts and negative thinking is a very important part of depression.
But people thought that it was a symptom of depression, that you had to cure the underlying thing.
If you think about what antidepressants are doing,
you're treating the underlying biological problem and you expect the thoughts to clear up by themselves.
And in psychodynamic psychology, you're in a sense doing a similar thing.
You're going for the underlying, say, interest, psychic conflict, whatever it is,
and hoping that the thoughts themselves would sort themselves out when you got to the underlying problem,
both biological and dynamic models have this in common.
Go for the underlying source of the problem and negative thinking and so on would would naturally just dissolve.
It wasn't until two major things happened in the late 60s and early 70s that we changed our mind.
A psychologist about this. First of all, there was a big emphasis within animal learning theory on what was called learnt helplessness.
There was a professor in the United States called Martin Seligman,
who found almost by accident that when he had animals and experiments that had been subject to uncontrollable stresses,
electric shocks, noise, this sort of thing,
that if they were then put used in another experiment in the days when you did this sort of animal experimentation
in another experiment where they could actually escape the stress they were going to be put under.
He found that two thirds of them didn't escape.
It was almost they learnt to be, as he described it, helpless that they learnt there was nothing they can do.
He called it response, outcome, independence. And they will learn that, well, there's nothing I can do.
And he said, you know, this could be it a model for depression. And he started to look at human laboratory experiments and invited ordinary people.
Well, students, anyway, to come to the laboratory and to be subject to stress that they couldn't control
or anagrams they couldn't do or little Problem-Solving they couldn't do.
And then he began to wonder if they can't do one, what's their effect on the next thing they do?
That's where I started my HD studies. I mean, my interest in depression started in 1975, 1976, when I started to research.
Why do some people who fail then expect to fail on the next task, whereas other people who expect to fail, it galvanises them for the next task.
And that had been what Seligman was interested. It was what my colleague John Teesdale, who is my Ph.D. supervisor, originally was interested in.
And so that's what I worked on for my doctoral studies.
Now, the interesting thing about learnt helplessness is that it works right through the animal kingdom.
And it suggested that when you have human depression, you have to discover what it is that makes humans begin to,
as it were, learnt from one event, something which may not be true of the next event.
You know, I've just failed. Does it mean I'm going to be a failure in the future? Inasmuch as you believe that then you're going to have problems.
You know, you're not going to know if you think I'm not going to enjoy this party. Therefore, there's no point in going.
You're making an inference about the next event based on your experience.
And therefore, you begin to reduce what you do in your life. But Seligman didn't have any treatment.
He had a great theory which then started to be picked up by undergraduates and graduate students all over the world taught in.
Medical schools all over the world, very famous theory of depression, but no treatment.
So people started to come out of medical school, come out of psychology, come out of clinical psychology training,
say we've got a theory, but what can we actually do and offer to our patients?
And then there was somebody called Tim Beck, Aaron Beck, who'd been working in Pennsylvania on something he called cognitive therapy.
Now, this of course, this is a great deal of interest because cognitive psychology was the designed guised within experimental psychology.
The term had been coined by Dick Neisser in 1967, by 1970, 72.
Every the world was abuzz in psychology about cognition, about thinking, about memory, about attention.
How is deployed? Here was a psychiatrist, Tim Beck, trained as a psychoanalyst.
He'd worked with Korean veterans coming back from the Korean War.
He'd noticed how they were often depressed as a result of the trauma they'd been through and how often thoughts about worthlessness,
helplessness, about not being good enough, how how much their thoughts were going round and round and round.
As an analyst, he'd thought, right. I need to get underneath this to find out what's it about as a biological psychiatrist,
because he is a psychiatrist who could treat it with antidepressants. But his amazing insight was to say, what would it be like?
What would a theory look like if the thinking that's going on in their mind was actually part of the cause of the depression?
And if not, the cause? Part of what was maintaining the depression.
And that one insight led him to start asking his patients, why did every time you feel down.
Just catch. What went through your mind just the moment before?
And he started to notice that people began to be able to catch their negative thinking that there was often a flash.
It might be very fast. It might be slow of a negative thought.
And he started to get people to write them down and then say, look, what if this is the depression speaking?
What about seeing whether depression is telling the truth or not?
Let's take these ideas about how useless you are, how much you've always failed and so on.
Let's write them down and let's actually be a bit of a scientist here.
Let's look at them. Look at the evidence for the evidence against. And soon he began to find this was liberating huge swathes of his patients without
having to do long psychoanalysis and without having to do biological treatments.
And in 1977, he and his colleagues, Gary Emery, Brian Shaw,
John Rush and him published the first randomised clinical trial where they compared antidepressants for properly diagnosed,
depressed patients with this new what called cognitive therapy.
And it was astonishing. Not only did it as well.
There was some suggesting it could do better with this ability to test out your thoughts and change your behaviour in these interesting ways.
And that was the major, major change in depression in the last 50 years.
I think presumably this insight was revolutionary. It was.
And like most revolutionary insights after the fact, it just seems so obvious.
I remember in the mid 70s when I started to read Beck's work thinking that it was trivial and I
don't really even need to read very much because it's so obvious that when people are depressed,
they get negative thoughts.
We need to go underneath the problem just to deal with negative thoughts was was was a trivial way of approaching a really hard problem.
But now when you look at the work by Chris Diski and Dennis Greenberger that their book,
Mind Over Mood is an incredible bestseller for obvious reasons because people can do this by themselves.
David Berns, the feeling good,
the new mood therapy and work that Beck himself has continued to do and his colleagues has revolutionised the study of depression.
I mean, one of the other indications is that my colleague, John Teesdale,
when he was a psychologist and due to move to Oxford to start off one of the first
laboratory programmes in the psychology depression anywhere in the world in 1975,
that he was advised by his colleagues there that this would be a waste of time.
Everybody knew, they said that depression was a biological problem or needed some long term analysis.
But as a biological problem, what's the point in dealing with psychology? Psychology is epiphenomenon.
Psychology is the epiphenomenon.
You can't treat depression by dealing with something which is just a surface happy phenomenon and how wrong they were,
because today's work has turned out to be the most influential work together with Tim Beck, I think, in the last 40 or 50 years.
You are a student and I was his student. I was very lucky to be his student.
Just to put your terminology, really. What's the difference between CBT, cognitive behavioural therapy and CTE?
Mesotherapy that actually no difference at all. S.T. tends to be used in the United States cognitive therapy.
But there was a long history of behaviour therapy in Britain and Europe before cognitive therapy came along.
And therefore, cognitive therapy was sort of seen as an add on to behaviour therapy.
And therefore, cognitive behaviour therapy is the word coined in Britain and Europe.
But actually, it refers to the same set of procedures.
So it's impossible to tell which patients are going to respond most favourably to the likes of antidepressant medication or S.T.
It's really interesting that you ask that question because one of the earliest studies asked exactly that question.
And what they did was they gave people a scale which they call learnt, resourceful, the scale.
And it measured basically how much you tend to take an active approach to your Problem-Solving or how much you
prefer a passive approach where people do something for you and to you rather than you take an active approach.
And what these early studies found was that people that tend to like to take an active approach, their problem, really respond to cognitive therapy,
but don't do too well with antidepressants, whereas people that tend to be passive do pretty well with antidepressants.
But actually they don't do too well with cognitive therapy. Now, how do we how can we cheque that out?
Well, one way of checking it out is giving people safe.
If somebody comes for cognitive therapy,
it's been found that if you give people a little leaflet six page log at the first session and you say to people,
in fact, it's one of the first things that John Teesdale did with with my colleague Melanie Fennell, who's still workless here in Oxford.
And then you say part of your homework for this week is to read this and see whether you like it or not.
You know, tick down the what you think of it. This is what we're going to be doing together.
And I'd be interested in your response when they came back in session, too.
And how did you get on this question with this with this leaflet? And some people said, oh, it's it was just describing me.
I felt I was the person referred to there. And it was exactly what I think I need.
And other people said are, you know, I didn't I didn't get on with all this business about taking an active approach,
you know, is it I've got a biological depression or, you know, I'm not sure about this at all.
Now, if you transcribe that and put it on a seven point scale from plus three through zero to minus three,
they found that that scale predicted outcomes after twelve weeks.
Just about as well as anything else. And the people who took to it in those early days actually worked hard, did the homework that they had to do.
They got a lot of benefit. Those people were saying, I don't know. They were they they didn't make very much progress in the first few weeks.
They didn't make very much progress in the last few weeks either. So there are ways of telling.
It's a matching process between what people think is plausible for them.
You know what they think they by the model of their illnesses.
And if you get a meshing between people's own feelings about what's going wrong and what you're offering to help do about it,
then you get that sort of gelling, you get that enthusiasm and you get a lot of progress.
Are these underlying character traits that determine this or is a character of the depression that they're suffering from?
It's quite possibly both so that we don't.
And actually, the truth is we don't know. So that there are underlying traits in how passive and active people are.
Whether it's a character trait, as it were, like there from birth, we don't know.
It may just be your experiences over a lifetime. You're learning history, as it were, has set you up to be passive or to be active.
So it's not really a character trait in the sense of biologically determined.
However, you're quite right that there are different sorts of depressions as well,
and that some people do respond some sort of depression to respond better than others.
And when we come later, in later episodes to talk about mindfulness and mindless based cognitive therapy,
we'll be able to describe ways in which we can begin to learn who is responsive to what aspect of treatment,
because that turns out to be very important. Well, thank you very much for that.
In this programme, we were looking at the treatment of depression,
and in the next episode we'll be looking at why people relapse despite their best efforts and
the best drugs available for further information about the issues raised in this programme.
You can read The Mind four Way Through Depression by Professor Mark Williams and his co-workers.
Well, you could read our book, Mindfulness Finding Peace in a Frantic World by Mark Williams and me, Danny Penman, where you could visit our Web site.
Frantic World Dot.com. If you'd like to support further research in this area, you could visit Oxford mindfulness dot org.
That's all one word. And follow the links to the development campaign.