What is Depression? A Q&A with Stella Chan

Depression Detectives is up and running, and we’ve kicked off our weekly online Q&As! These are a chance for the group members, with lived experience of depression, to quiz scientists and experts who work on depression or related topics. This week we were joined by clinical psychologist and researcher Stella Chan, and this is the transcript of that conversation. We’ve removed names and any identifying information to keep the contributions anonymous.

Q&A

Hi Stella!

Stella: Hi all, I am a clinical psychologist based at the University of Reading. I have been doing research on depression for some years. My current focus is on adolescent depression. Hello to you all.

 

Depression Detectives member A (DD A): 

Thanks for taking the time to be here today. I’m a bit confused about (apparently) conflicting views on depression and medication. Some GPs have said that one should try and “come off” antidepressants after CBT practice etc. is well established some have said there’s no rush and no long term issues with medication, so don’t rock the boat. Is depression seen as a temporary illness which you can “think” your way out of, or a chemical imbalance (that might be inherited), which taking long term medication for (like diabetics take insulin) is expected. I’m simplifying the views I’ve heard but hope you can give us your opinion.

Stella: It’s difficult to say. There have been mixed research findings. The common view is that depression is caused by multiple factors – biology (e.g. genetics, brain functions etc), psychology (thinking and feeling) and social (environmental and relationships etc). But of course the cause for each individual is different. Regardless of what causes depression, one finding that is quite established is that depression itself tends to be ‘episodic’ – meaning that it’s like a TV episode, it comes and goes. Some people experience one-off episode but some experience recurrent episodes over time.

Advice on treatment also seem to vary across different professionals. My own advice is that there are a lot of individual differences – the advantage of CBT (and other psychological treatments) is that individuals are given help to learn more about themselves – to develop their own coping strategies, versus medication is more passive. So, psychological treatments give people a better chance to prevent the next episode if they feel able to implement the coping strategies. That said, I know people who really benefit from ‘maintenance medication’ i.e. continue taking medication after you have recovered for a little while to consolidate recovery.

People really vary so the best is to work closely with the clinicians who look after you to determine the best strategy – but also be prepared to ask questions and don’t feel you have to accept whatever treatments offered to you.

 

DD I: Are there different types of depression?

Stella: This is a big research question actually. Research on depression has generally been rather slow, with little breakthrough in the field compared with other conditions like anxiety. Some researchers have proposed that depression may have different subtypes which we have not identified yet – and that’s why treatments don’t always work because treatment offering isn’t tailored to subtypes. One example is that some people experience ahedonia (i.e. lose pleasure of things they usually enjoy) but some don’t (instead they feel sad). It’s common to lose sleep in depression and yet some experience the opposite (sleep too much).

DD N: I’m curious whether this may link in some way to some depression being a result of other mental health issues or neurodivergences that haven’t been properly diagnosed or treated? Because living with these other issues has caused a situational depression therefore there’s a variance in how it presents to depression that is mainly biological?

DD N: I have also done some reading around physical causes of depression, has much research been done into this? From a female point of view, the impact of monthly hormonal changes and how this can impact mood? It seems like this regularly gets dismissed by GPs, but can have a massive impact on daily life when you have 1 week a month when you experience symptoms of severe depression

Stella: Yes I totally agree. there are many layers here actually – depressive experiences/ symptoms could be different when people have other mental health difficulties or neurodiversity. This may lead to clinicians having overlooked / missed some of them. We are developing a new screening tool for depression for children and young people with autism for exactly this reason. I also think that sometimes clinicians may not be paying enough attention to signs of depression when there are other mental health problems present that have ‘distracted’ their attention. Same for family and friends and other professionals such as teachers and support services. Not saying people are careless or anything like that, but real life clinical work is not like textbook and things are often unclear.

DD N: Thanks Stella, that makes sense – it’s such a complex issue because we all have very different experiences. Do you think in some respects ‘textbook’ definitions of depression can be a hindrance in diagnosis and treatment because they frame it in isolation from other issues?

Stella: My short answer to that question is that yes – i think textbook definition may need to be revised following research. It is also important to understand that depression is not a label but a subjective experience. The bottomline is that if you are experiencing a hard time, feeling low and depressed, you don’t (and shouldn’t) need to tick all the boxes to justify that you need help. If you feel you are not coping then help should be offered. It is also important to balance between theoretical/ medical perspectives and practical everyday aspects. Sometimes the solution involves more than changing the way you think and feel, but it may be about some practical changes in environment. I have once helped a young person who was referred to me for depression but after a few sessions I think what they needed was some time off having some fun (as the young person was a carer for a family member). In the end instead of psychotherapy I referred them to young carer charity’s support and it did a whole lot of good.

DD S: Depression pertaining to psychology is a persistent low mood that affects a persons a persons behaviour, their thoughts, feelings, motivation and their sense of wellbeing and is marked by such features as sadness, low self-worth, lack of concentration and clear thinking and an inability to enjoy life. During a person’s experiences of depression a person may encounter the following symptoms: The feelings of deep sadness, dejection, hopelessness, a pessimistic outlook, low self esteem, an increase or decrease in appetite, altered sleeping patterns, a reduction in energy levels, altered reaction times, a decrease in the ability to take pleasure in the ordinary things of life and suicidal tendencies.

Stella: Yes – though it’s important to stress that you don’t need all the symptoms to be diagnosed. This means that individuals who have depression could have different symptom patterns, which may suggest different subtypes but research hasn’t been very clear yet on this point.

This is true of most of mental health illnesses, there is a lot of research but the causes are hard to define or know what are the root causes. Each person is different and as you have already mentioned it could be due to a number of different causes which contributes to a person’s symptoms.

Also because most research is cross sectional (i.e. one time point) – and these results can only tell us what factors are ‘associated’ with each other but can’t tell us which causes which. For example, people with depression often have sleep problems, but it’s difficult to say whether sleep deprivation causes depression (it’s possible as we all know how crap we feel when we haven’t slept well) or whether depression keeps people awake (which is equally possible as we all have nights that we lie in bed ruminating about our troubles). Longitudinal studies (i.e. studies that have multiple time points) are difficult to conduct – people often drop out (i.e. participants stop taking part) and it’s expensive to run.

DD S: There are different things that we know predispose someone to depression – e.g. certain genes, adverse childhood experiences, etc. But why can two people have the same predisposing factors, but one person develops depression and another one doesn’t?

Stella: Yes that’s a very important question. I think one reasonable explanation is the stress diathesis model, which suggests that people have background vulnerability and when the background risk is triggered by stress then one may become unwell. So, level of stress, as well as the level of stress coping skills, and reactivity to stress, could make a fair bit of difference

Similarly, social support and relationship quality will also make a difference. In short, we all have risk and resilience factors and our chance of getting depression and our ability to bounce back/ recover is perhaps a balance between the two.

DD S: Are there things a person can do to improve their stress coping skills, and ward off future episodes of depression?

Stella: Yes, absolutely. Shirley Reynolds has published a few nice books on teenage depression (for young people and for parents I think). In general, I would suggest going back to basics: sleep well, eat well, regular exercise, connection with nature. These are all evidence based actually – though also sounds common sense. In terms of cognitive skills – I think avoid black and white thinking or jumping into conclusions; instead try to put things in perspective and ask yourself what would you say to your best friend if they have experienced this situation. I would also highly recommend having a look at self-compassion self help – self-compassion is different from self esteem; it is about showing kindness to yourself at times of disappointment and setbacks. It is closely associated with depression.

I would also recommend behavioural activation – this does not mean you keep yourself insanely busy, but to make sure that you engage in activities that you see value in them.

I think relationships and social support are really important. It doesn’t have to be romantic relationships at all – friendships, family, or even people you see in hobby groups.

 

DD S: Hi Stella what’s your view on “Lifestyle Management Courses” Like the one run by [removed for anonymity]?

Stella: I can’t comment on this particular course because I don’t know much about it. That said, the key is to see if the course is ‘evidence based’ (i.e. whether what is offered has been tested and evaluated to be effective).

DD S: I am a peer volunteer for a Lifestyle Management Course and facilitate on the course. the success rate of the course can be seen in the looks of fear and trepidation that are on the participants faces when they walk in on week one to the smiles they leave with at the end of week 10. LMC has four main components: 1. Relaxation/meditation 2. Weekly self-management education topic 3. Weekly solution focussed reflection 4. Gentle graded Movement.

A 10 week 3 hours per week course co facilitated by Practitioners and Peers.

 

DD S: Is it true that some people remain stuck in the cycle of depression because they have adopted poor habits of allowing those habits to control them and thinking that nothing can be done to help them out of the situation?

Stella: It’s rather difficult actually – when people are depressed, one of the classic symptoms is that they feel hopeless and they lose motivation. These symptoms make it very difficult for people to engage in therapy to change the way they think/ cope.

I also want to emphasise that it’s not all about individuals. Our environment is key as well – being placed in a supportive environment, good access to treatment and support, with supportive relationships etc go a long way in empowering people to develop new coping skills. Life is hard though and sometimes the lack of control is not purely psychological – things are often out of control. More integration between social support and individual therapy is important, in my opinion. We need to recognise the importance of the interaction between environment and ourselves

Also echoing one of the comments above about the possibility of subtypes of depression – it’s possible that some depression is more ‘chronic’ by nature due to its causes. We don’t have enough research findings to know whether this is exactly true, but I do think that from clinical observation, people with depression vary a great deal.

 

DD I: You mentioned adolescent depression in your intro. Can you say something more about that? Is it different from what adults experience or a precursor to it (or some other interaction?)

Stella: if you look at a diagnostic manual, the only one difference in terms of symptoms is that ‘irritability’ is listed as a symptom in children and young people but not in adults. Personally I am not sure if I am convinced that this is a key difference. I think irritability is a symptom across age groups (not for everyone of course).

Current treatments for children and young people with depression tend to be adapted from adults – and they are not very effective (their outcomes are poorer than that in adults). I think we need to develop better treatments that are based on our understanding of young people’s everyday experience and if possible involve young people using a co-production model. We are actually running a series of three workshops over the next half year to discuss adolescent depression.

 

DD A: The stereotypical portrayal of an adolescent is of someone going through rapid hormonally-influenced changes and so their behaviour is irrational, selfish, unpredictable etc. What do you think about these stereotypes and can they mask more serious mental health issues that adolescents might be experiencing?

Stella: yes I agree these stereotypes are rather unhelpful. We take time to grow up – and scientifically speaking, our brain is developing until around age 25 (yes!). Sometimes young people may seem to be inconsiderate but I do wonder if this is something to do with their high level cognitive functioning (e.g. perspective taking etc) being still developing. I think the stereotypical portrayal of ‘moodiness’ is indeed a key concern that masks mental health problems. Another concern, a serious one in fact, is that some young people with depression are misperceived as attention seeking or drama queen that sort of things – one of my MSc students have analysed lots of social media posts which reveal that this is indeed a widespread issue. These add to more stress and sometimes makes young people hesitate to seek help.

 

DD S: Hello, CAMHS psychologist here, you’ve talked a wee bit about secondary depression to other presentations such as anxiety or neurodevelopmental conditions. What are your thoughts on the order of treatment? You also mentioned about how the treatment options for young people are adapted for adult treatments and less effective. Are there any up and coming therapies that are looking promising?

Stella: In terms of order of treatment – i think it depends on individual cases. Once I had a case that was depression coupled with alcoholic use – the issue was that it was difficult to engage the service user in depression treatment when they were not sober. Hence the decision was made to help with alcohol use first. One way to decide is to open up the question to the service user and ask whether they feel one is driving the other or whether they feel if they feel more confident that one is more modifiable.

In terms of treatment – i think behavioural activation has shown quite good results with young people (because cognitive work is more effortful and difficult for young people).

 

DD J: I was wondering if your research includes ADHD? I’ve found personally, that the symptoms and results of ADHD greatly increased depression. I wish my doctors looked into ADHD first instead of just treating my depression and leaving an underlying factor unaddressed.

Stella: I have collaborated on work on ADHD (led by Sinead Rhodes) but it’s not something I have specific expertise in. I definitely think our understanding of depression in people with ADHD, Autism and other developmental conditions is not very good because most of the research has been on people without these conditions. I would encourage you to challenge clinicians’ views if necessary if you think they have overlooked anything.

 

DD N: If you’ve got time at the end Stella, it would be great to know if there’s anywhere you think there are gaps in depression research that should be looked at?

Stella: Too many gaps in research – I would prioritise involving the voice of young people in research. We have just launched a survey to ask young people what they think we are missing in research in depression. My own motto always is ‘ask the people you want to help’.

That’s all the questions we’ve got time for unfortunately! Stella thanks so much for coming, this has been extremely interesting to read.

Stella: Hope people have got something out of the hour. Take care – my goodnight message is to take it easy – life is hard, and we don’t have full control over what happens in our lives, nor can we always control how we react in situations. We feel as we do as humans. Take it easy, and be kind to yourself as you would to someone you love. Goodnight x

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