2.3 Consolidating your understanding of depression

Dr Danny Penman:

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 tides of these mental health problems?

Mark, what exactly is depression?

Professor Mark Williams:

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 out of bed in 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 diagnosed with depression.

So there are other symptoms as well, and any combination−four of five of these other symptoms−are often considered necessary for a diagnosis of clinical depression. And they are things like changes in appetite, perhaps even weight loss or sometimes people eat too much and 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, you know, feeling that you, you know, you want endless sleep. But generally, with depression it’s not sleeping, it’s insomnia.

And then there are things like feeling guilty, lack in concentration, feeling agitated or very slowed 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 their family. Now 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 of depression. At the point of which these things prevent you from living your life as you want to live. So it’s what might be called ‘functional impairment’. You can’t function and you can’t explain it in terms of illness, your physical illness. You can’t explain it in terms of a recent bereavement. This comes and stays and you don’t seem to be able to get rid of it.

Dr Danny Penman:

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?

Professor Mark Williams:

Well they’re very closely related so you very rarely get depression without having other things like high anxiety at the same time. Depression is often characterised by, you know, 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.

Psychiatrists and psychologists 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 too big a separation between anxiety, stress, depression, exhaustion isn’t quite what is going on in the world.

Dr Danny Penman:

Are things like anger, irritability, road rage, you know, typical explosions that you see, we all see every day. Are they related to depression at all?

Professor Mark Williams:

They can be. I mean, 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 groups, so, for example, in adolescent depression there can be quite a lot of anger, 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 an appetite change, sleep change and that sort of thing.

Dr Danny Penman:

Depression is increasing worldwide. Is it increasing predominantly in the developed world or it is also increasing in the third world?

Professor Mark Williams:

Well, what we now know is that depression is rapidly becoming one of the biggest reasons for people to have, basically, lose years of their effective life through disability. So the World Health Organisation publishes data decade by decade over that and about two decades ago they recognised that depression is becoming a big problem. Well, it’s now arrived. They have a statistic of the years’ 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 very low-income countries it’s still in the top ten of years lost to disability.

Dr Danny Penman:

So depression actually exacts a bigger toll on society than cancer and heart disease and other things like osteoarthritis?

Professor Mark Williams:

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 staying 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.

Dr Danny Penman:

Can you give us some figures as to the prevalence of depression both in the developed world and the developing world?

Professor Mark Williams:

So, in high income countries, for example, depressive disorders, which is what we’ve been talking about, account for about 14% of the years’ life lost to disability. And putting that in proportion, if you look at Alzheimer’s and other dementias that’s about 5% of the years lost to disability. If you look at osteoarthritis it’s 4%. If you look at chronic obstructive pulmonary disease that’s about 3%. So 14% is huge compared with that.

And then if you look at low- and middle-income countries, then depression is about 10% of that and the next in line for the years’ life lost to disability are eye problems, what’s called ‘refractive errors’ and that’s about half that, about 4.7%. So again, in terms of the years' life lost to disability, it’s huge.

What epidemiologists seem to find wherever they look is about one in 20 of a population are depressed at any one time, and about 20% of the population at some point will get very depressed and that’s a major problem.

Dr Danny Penman:

Every time I hear these figures I’m just completely stunned. What’s the fundamental driving force behind the increase in depression?

Professor Mark Williams:

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 the Hebrew Old Testament, as it were, and you see people expressing, you know, sadness and depression and anger and irritability and this sort of thing. If you go back way in to the beginning of something like Buddhism, for example, 500 BC and you have people needing to learn to meditate, and to deal with the problems of the mind. The problem of the entanglement of the mind, as it were. So I think it’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 were beginning to report, from about people born in the 1950s onwards, when they were assessed towards the end of the 20^th 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 the first part of the 20^th 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 1980s and 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 ‘ST’, the beginning of STAR*D, it means ‘Sequenced Treatment’. So it was a big trial to look at what treatments provide, one treatment after the other, after the other. So they had 4,000 people who volunteered to take part, and as part of that trial they 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 actually the most common age in which people started to get depressed was between 13 and 15 years old. And that is an astonishing new development.

Dr Danny Penman:

Is the same true for, kind of, anxiety and stress and irritability and ...?

Professor Mark Williams:

We weren’t clear about that until about the 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 the 30 years from the 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 and young people had become, in a sense, the whole bell shaped curve had shifted towards greater anxiety. And by about one standard deviation which means that whole swathes of children and young people who hadn’t been anxious in the 1950s, as it were, if they were born in the 1980s, then they were likely to show anxiety which had been virtually at clinical levels 30 or 40 years ago.

Dr Danny Penman:

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 miss understand that, because that’s quite an astonishing figure?

Professor Mark Williams:

That’s true in anxiety. And now that we know the same is true of depression. That is that 50 years ago people would live out most of their life without getting these crashing depressions. But now that, you know, 35, 36% get depressed before the age of 18, 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 the cases. And once you’ve been depressed twice then the chances go up even further.

Dr Danny Penman:

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?

Professor Mark Williams:

Well, one of the inferences we can make from these big changes being so rapid and recent is 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 have driven that. I mean, clearly it could be that people are just recognising depression that was always there, but now they’re recognising more. But the fact that both clinical studies and epidemiological studies show up the same thing argues that it’s not just that people are recognising it better, because you control for the sort of questions you can ask and check that the questions asked are the same over those decades.

But the other thing is that 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 suicide rate which to some extent mimic 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 have been affected by this change in pattern of depression I think shows that something is 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 seem to be some almost unavoidable changes in the gaps between rich and poor.

We know that in the countries that have the least gaps between rich and poor, then the levels of stress, the levels of trust even within the communities are higher. The levels of ‘hope’ are higher, and people tend to live longer in those 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 and approaches which can now deal with this depression epidemic.

Dr Danny Penman:

If you had to choose fundamental driving forces behind depression, what would they be?

Professor Mark Williams:

Well, at the individual level they’re 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, and the standards 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 do things, the targets it sets for us and so on. And when society sets us targets 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 that you’ve done a good job because of your work, you know, if 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 is think 'Ah,thank goodness that I’ve met my targets', you know?

So suddenly it turns the possibility 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 can work for a while, you know, but gradually it can eat away. I think. at you in ways that are a bit pernicious.

Dr Danny Penman:

So how could you, for example, you know, if you’re an omnipotent dictator, how could you change society or, you know, perhaps if you’re running a company how could you change the culture of that company or of that society to actually promote mental health and wellbeing?

Professor Mark Williams:

Well. people talk about ‘work-life balance’ don’t they? And that’s really important. It’s 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’s run on just target lines and so on, in this stressful way, that actually people. in order to meet their targets. they feel very stressed. They put in more hours, but they aren’t necessarily 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 see the whole picture, then 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.

Dr Danny Penman:

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 get over it, you dust yourself down and carry on with the rest of your life. Is that possible or does it tend to return?

Professor Mark Williams:

OK. Depression can be a one-off, so it’s not inevitable that it will return. So it’s a bit of a message of hope. If we’d 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 − the sort 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, you’re not necessarily 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 stressor, 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 and by the end of the day you’re feeling very depressed.

So the statistics suggest that about 50% of people might have a one-off episode and then it doesn’t bother them again. But if they’ve been depressed twice, the chances they’ll get depressed again are much higher. Three times, the rate’s at about 70 to 80%. And in our studies we find, for example, if we follow people up for about twelve months without offering any treatment to them, then if they’ve had three depressions in the past before they come to see us, then between 60 and 80% of them will get depressed again in those next twelve months.

Dr Danny Penman:

People who become repeatedly depressed year after year, what proportion of their lives do they actually spend in that depressed state?

Professor Mark Williams:

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 the NIMH, that’s the National Institute for Mental Health. They started a study in 1975, and because they’re able to keep in touch with this large number of people that started then, they’ve been able 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% 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.

Dr Danny Penman:

That’s a really disturbing statistic. What proportion of people then go on to begin self-harm or even commit suicide?

Professor Mark Williams:

There are changing rates of self-harm and suicidal behaviour, and the definitions vary, so self-harm sometimes 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 suicide in people who’ve been seriously depressed are elevated compared with the general population.

Now, about 1% of the population die by suicide anyway. If you’ve been depressed in the past, that’s likely to be higher, about 4 or 5%. If you’ve been depressed and been an in-patient at some point in your life and been hospitalised for depression, it can be as high as 10 to 15%. So one in six, one in seven people die by suicide if they’ve been an in-patient, 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 happens for the family left behind, and for the friends and colleagues of the person.

Dr Danny Penman:

Is suicide always linked with depression?

Professor Mark Williams:

It’s the most closely linked problem. 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 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 people become at greater risk of suicide whatever the condition it is. It’s the occurrence of depression that accounts for that.

Dr Danny Penman:

Do 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’re in the teeth of a depression?

Professor Mark Williams:

There’s quite a lot of clinical evidence for that. It’s never been proven by research. It’s a very difficult thing 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 a 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, 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’s 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%, because of the very close association. People don’t tend to be suicidal outside an episode of depression. Depression is the thing that, 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 those core 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 help.

Dr Danny Penman:

So what exactly does a full-blown depression feel like?

Professor Mark Williams:

It’s a combination of experiences of a distortion as, 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 you’re thoughts are dominated by that.

That becomes habit. So that although many of us might think like that for, you know, 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 and 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 could imagine somebody standing behind you all day saying how useless you were, then sooner or later you’d feel sad, irritable, run-down, 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. 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 in to your sense of fatigue and slowness, lack of energy. Either being in some cases very agitated, in some cases being very slowed down.

And if you look at the way people walk when they’re depressed, for example, their gait is very different. Not, as it were, walking upright, walking slouched and going from side to side instead of actually more steady on their feet.

And lastly your behaviour is affected. Either you feel suicidal, but also you feel like withdrawing from the world and that sense of withdrawal, of not wanting to see things. Now once again most of us have had times in our life when the phone rang and we said 'Oh no, 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, you know, quite sort of withdrawn. But that goes on relentlessly. 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 is just to act, or your behavioural tendency is 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.

Dr Danny Penman:

So is there any one thing that drives people or tips people over the edge from normal ‘run-of-the-mill’ sadnesses, or periods of rumination or reflection, into a period of full-blooded depression?

Professor Mark Williams:

There are, and actually I’d like to tackle that in greater 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’ll be able to go in to detail in future episodes.

Dr Danny Penman:

So that implies it is possible to stop a depression, or rather 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 a clinical depression?

Professor Mark Williams:

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.

Dr Danny Penman:

And that must have huge clinical relevance?

Professor Mark Williams:

It’s got huge clinical relevance because if we could find and I’ll describe that in the later episodes. If we can find that this is actually as useful as antidepressants or as other treatments, it’s of global significance because it doesn’t depend on medications which in some contexts are just too expensive for people to purchase.

Dr Danny Penman:

Thanks very much for that, Mark. In this episode we were 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 Mindful Way through Depression’ by Professor Mark Williams and his co-workers, or you can read our book ‘Mindfulness: Finding Peace in a Frantic World’ by Mark Williams and me, Danny Penman. Or you could visit our website: franticworld.com

If you’d like to support further research in this area you could visit: oxfordmindfulness.org and follow the links to the development campaign.