Designing our research: A Q&A with Mark Adams, Alex Kwong and Matthew Iveson

To help us refine our final question into a small piece of research, yesterday we held a Q&A with three researchers from the University of Edinburgh who study depression and work with cohort studies: Mark Adams, Alex Kwong and Matthew Iveson

Q&A

Hi all! 

Mark: Hi, everyone, I’m a statistical geneticist (meaning I use maths and computers to study genetics). I work on very large scale genetic studies of depression, comparing DNA between people with and without depression using data from countries all across the world. I’m also interested in how depression symptoms might or might not relate to each other.

Depression Detectives member I (DD I): Which cohorts do you work with /have access to for this project?

Mark: We could use UK Biobank, Generation Scotland, and (possibly) ALSPAC (Avon Longitudinal Study of Parents and Children)

DD S: What are the timescales of each of those? (Sorry I know you’ve posted links but I haven’t had as much time to read for this as I’d hoped). The longer the better if we’re looking at recurrence of depressive episodes over lifetime…

Alex: Do you mean the timescales for completing the research or how long the data has been collected for?

DD S: How long the data has been collected for

Mark: In Generation Scotland, our initial measurement was retrospective (asking people to recall past experiences) and they can be initially grouped based on that response. 10 years later we asked the participants again, so it would be possible to look at people who initially did not report an experience of depression, but did have an episode subsequently. UK Biobank is similar, with a 5 year gap to the follow-up. The other way to look at it would be using health records (hospital, GP, and prescribing).

Alex: So in UK biobank we have data collected at multiple waves across ~10/12 years. In that time people would have been asked to think back about how many episodes of depression they had (which can be problematic as you might imagine). In Generation Scotland there is a similar method where people have been followed up over time but have been asked this specifically. There is also the possibility of linking to health records as well which could provide further validation for these self reported measures.

 

Matthew: Hi all, I’m mid bedtime with my 3 year-old so apologies if I have to duck out. I’m a researcher in the Psychiatry department focussing on using routinely collected health data to examine life-course risk factors and mechanisms underlying depression.

DD S: Sorry! We found with my last project (with parents of small children) that we needed to put the Q&As quite late, or everyone was still doing bedtime. Baby books lie!

9pm is quite impressive for a three year old though.

DD C: I was just feeling proud of myself for extracting myself from my 7 year old’s bedroom in time to be here!

DD M: We managed 8.40pm with ours. Whoop!

DD S: My 7yo is still up, but he’s watching TV…

 

Alex: Hi everyone, I’m Alex and I’m a mental health researcher like Mark and Matthew. I normally work on data from young people and look to see how depression changes across adolescence and why there are different patterns of depression for some people and not others. I normally look at genetic and environmental factors like childhood trauma, bullying and relationships. But then more complex factors like parental depression which could be a mix of both genetics and the environment.

DD C: How do you even begin to untangle all of that?!

Alex: With great difficulty that’s for sure! We don’t tend to do all of it in the same piece of work. Normally we will have a specific question like how does parental depression impact on their children and try to examine that specifically.

DD C: Sounds like the only possible way! What research methods do you use to investigate these questions?

Alex: Excellent question. So there are multiple methods but my preferred method is to look at trajectories of people over time.

So let’s say someone completes several questionnaires about depression over time (maybe every year for 4 or 5 years), we then create a trajectory for that person. If you have 100 people then you have 100 trajectories and you can start to see how people differ and if these are specific characteristics for different groups of people.

So you may have something that looks like this image below.

More info here

DD C: I’d be really interested to see how you ask about depression. I know that my personal experience of depression is very different to the questionnaires I was supposed to use for screening when I worked as a medical doctor.

Alex: So each cohort is different and that is one challenge. But I have used this measure quite often – the short mood and feelings questionnaire. It was mainly aimed at looking at depression in children and adolescents, but can be assessed for older people as well. It’s definitely not perfect but on average those who score higher on this questionnaire are more likely to meet the criteria for depression assessed by a GP

DD C: Thank you for sharing that. It looks pretty standard. I really find it hard to reconcile these questions with my 40 years of experience of being depressed and would be interested to hear if others agree. For me, it went far deeper than that and this sort of questionnaire only scratched the surface. I am also prejudiced against it as I found many patients in elderly care medicine were labelled as being depressed on the basis of a questionnaire like this, whereas the truth was that it was perfectly rational and reasonable for them to feel low and hopeless when they were trapped in a hospital bed for months on end and the appropriate treatment was not to give them SSRIs!

Alex: Yes I can see your point. I think the questionnaires just scratch the surface as you say and there is a lot more detail that could be asked.

DD C: I guess the added detail would negate their use as a quick screening test though. On the other hand, I think there is a difference between the sort of depression which is encompassed by those questions and the sort which is more complex and this is relevant to treatment, given that some depression may be adequately treated by standard GP options, while other forms require years of talking therapy plus whatever else.

Alex: Yes it’s a double edged sword really and as you say there is like an academic version of depression (assessed through these quick fire questionnaires) and then the actual real life depression that people face on a day to day basis.

 

DD C: My biggest concern with this research question is how to recruit the single episode group. From the survey you did, we’re a bunch of long-haulers! How would we attract people who have had a single episode in the past and interest them in becoming part of our study? And how do we know that it’s only 1 episode and they won’t relapse again in the future?

DD E: Perhaps we need some kind of “survival analysis” for time to next episode?

Matthew: It’s totally possible to run -time-to-event’ studies with multiple events. It gets tricky depending on the variation in number of events, so an alternative is to break down ‘classes’ of trajectories – are those with 1 episode different to those with 2-3 episodes, and different to those with 4-8 episodes, etc.

DD C: That’s an interesting thought. I guess the only way we can know it’s a single episode is to follow them up until death, which isn’t exactly practical! Maybe what we need to look at is the difference between people who dip down occasionally and infrequently but are well between episodes versus those who are chronic?

DD E: Or have another endpoint, like 15 years worth of follow up. This is how things like cancer recurrence are studied. But i appreciate Matthew’s point about the scale/trajectory/frequency of depression mattering too.

DD E: There must a wealth of data in Medical Records at the Royal Ed of one-off receive episodes as well as CDD

Matthew: I think some of the GP and hospital records for Generation Scotland go back to the 1980s, though I can’t guarantee their quality or useability

DD C: Yes, I can see that a lot has changed in psychiatry since the ’80s, so that could be a very messy process to embark upon….

DD I: How do you define single episode? What does it look like in your data?

Mark: Defining a “single episode” is difficult. When does an episode “end”?

 

DD E: Do the data you study have groups of folks who have single episodes of depression and another with multiple episodes? My hunch would be most patients are in the latter category, but maybe the data can’t say so, or say otherwise.

Mark: We find in our data about an even split between people who only report a single episode and those that report more. It would be interesting to compare health records between the two groups.

DD N: Surprising (to me anyway)! Is that based on self-reporting or GP records?

 

DD S: I’m sorry, I didn’t see the papers you’d shared below until a few minutes ago. I’m just having a look now. Is chronic depression just being depressed forever (rather than it coming and going)?

Matthew: Chronic is generally having diagnosis-level symptoms for 2 years or more, affecting you for more days in a week than not.

 

DD I: Part of the question is about single episode vs chronic depression /multiple episodes.

What measures would capture that?

Matthew: It’s always worth thinking about “in an ideal world, how would we measure that”. The best way would be to follow people over time and ask them about symptoms of depression that they’ve recently (rather than having to recall an experience that may have happened years or decades ago). Unfortunately there are no large genetic studies with such short follow up intervals. ALSPAC probably comes the closest, followed by whatever information we can glean from health records in other cohorts.

DD I: Within ALSPAC did they ask both parents?

When the kids got old enough, did they get the depression questionnaires too?

 

DD I: We have had some discussions in the group about what is not captured by GP records (for various reasons).

You mentioned in the group that ALSPAC asks people to fill in depression questionnaires regularly.

Could these be compared to what is in GP records? Eg suspected depression from questionnaire data vs confirmed by gp

DD C: Are we able to get hold of their depression questionnaire to see what they ask? That could be a good starting point…

DD I: Is the questionnaire online?

DD M: There’s a standard depression questionnaire… GPs also use the depression forms. I think PHQ9 is the one I know

DD C: I’d be interested to know what other people in the group make of the standard GP questions as I found they were a very blunt tool and didn’t encompass my lived experience of depression at all. Maybe I just had a different form of depression to the standard version!

Alex: You could compare self reported depression from a questionnaire to GP records. But there are some things to bear in mind. Firstly, not everyone who has an episode of depression will go to their GP. So you may be missing information there. The opposite could also be true in that someone may go to their GP when they’re depressed, but may not fill in a questionnaire because the survey wasn’t asked at that time.

DD C: Are GPs supposed to carry out the standard questionnaire and put the result in the records or do they just use their clinical judgement? If the latter, then is the diagnostic process powerful enough for it to be included in serious systematic research? It’s been a long time since I bothered going to the GP with a depressive episode, but when I did I was never formally assessed. The first time, the GP took great pains to differentiate between whether I would walk out of the way of an oncoming bus or whether I would step into the path of said bus etc etc, but I have never been asked the standard questions such as I learnt at medical school. My understanding of clinical research (I also used to be a researcher, but that was cellular and molecular so very different) is that you need to standardise the diagnostic process.

DD M: In my experience it varies

Alex: So I think GPs can put scores from a questionnaire on health records. This is actually quite common for those with perinatal depression. That said, my understanding from talking to a lot of GPs is that it’s a bit time consuming to run these questionnaires and it’s better done by primary or secondary specialist care.

DD M: Interesting 🤔 I think PHQ9 is really quick, but maybe not for the first time

DD C: Fair point, but does that mean that GP records are less valuable as a means of research data if the diagnostic process is, how shall I put it, non-standardised!

DD M: Could we not look at prescription data in that case?

It would be skewed slightly by use for other conditions though. And we’d have to be v cautious re amitriptyline as its also used for certain types of pain relief

DD C: Only if we are only investigating depression which has been treated by medication. I stopped taking anti-depressants a long time ago but had several episodes which I managed without drugs and without seeking help from my totally useless GPs.

Matthew: Prescribing data also covers therapies and social prescribing (as long as they were prescribed)

DD C: But only if prescribed by the GP. This assumes that everyone’s treatment is being coordinated by the GP or another NHS professional. We don’t know how many people give up on their GP after years of ineffective treatment and go off and sort themselves out, like I did. I would never want my GP records to be used in serious research because they would give such an incomplete picture.

 

DD S: One basic question is, as far as the research literature goes, what proportion of people do you think have one single episode, vs have several episodes?

And is there a typical pattern to that? (Like, age of first episode, frequency of episodes, etc)

Matthew: There’s a bit of a problem in terms of how you define an episode, generally. A person with chronic depression could look like they are having one long episode (2years+), and are very different to the typical ‘episode’ of depression in major depressive disorder. If you look at health records (e.g., prescriptions) you can estimate episode numbers and lengths, but it’s only ever an approximation

DD C: In what way do you think we could best define or operationalise the term “episode”?

Matthew: I think taking it literally is best. An episode can be any length (though the DSM criteria is min of 2 weeks), but when that length gets above 2years then we should be calling it chronic

DD S: When you say chronic depression, does this include dysthymia, or is it a chronic version of more severe depression? And do you think these differ qualitatively, or only by degree?

DD M: What’s the difference between major depressive disorder and chronic please?

Matthew: I’ll preface this by saying I’m not a medical professional. My understanding is that major depressive episodes are sufficient depressive symptoms lasting 2weeks+, major depressive disorder is having 2 or more episodes, and chronic depressive disorder is having symptoms for over 2 years. Dysthymic disorder is a little confusing, as it is often lumped in with chronic, but many consider the symptoms to be lesser in dysthymic disorder

Mark: Major depressive disorder includes somatic and cognitive changes as well (extreme changes in sleep, diet or weight, or lack of energy and concentration) whereas chronic depression could occur with only the symptoms of low mood and lack of interest in activities.

DD M: Aha, that’s really interesting. Thanks

DD S: That’s interesting, ‘chronic’ by that definition does sound more like dysthymia. It also raises the question of whether there are qualitative differences in the pathophysiology, between people with the somatic and cognitive changes too, and people with only mood issues – any thoughts on that?

Mark: Yes, the non-mood symptoms all implicate circadian rhythms.

I think somatic and cognitive changes are a bit different because they are more liable to snowball (poor sleep leads to fatigue, which causes concentration problems, etc)

Sarah: Hard to tease out cause and effect as you could argue ways that all 3 types of symptoms affect the others…apparently the cognitive ones often don’t fully remit between episodes, despite mood improvement (to allowing normal fluctuations within ‘healthy/normal’ range) so are they independent to at least some degree?

 

DD E: I hope this is an appropriate question – Where does Bipolar Depression rank in Long term depression?”

DD L: Bipolar is often considered separately in research studies, so it would depend on the study but often a study on long term depression wouldn’t look at bipolar.

 

DD N: Something that’s come up in talking about this question is how you measure how many episodes of depression someone has had, since not everyone will go to the doctor every time they have an episode – do you know if there’s any existing data on how those things compare?

DD M: Plus I think relying on self reporting will be unreliable

Alex: Yep self-reporting isn’t very reliable, but it could give more depth than the questionnaires – it can pick up on things the questionnaire designer hasn’t thought of. Plus even knowing that there is a difference between what’s recorded and how people perceive their medical history is in itself interesting (just doesn’t tell you the cause of the discrepancy)

DD S: This is what I am wondering. If ALSPAC is giving people a depression questionnaire once a year, that could pick up episodes of depression that people don’t go to the doctor with (and therefore would be invisible to electronic health records). Has anyone done that analysis? Comparing depression according-to-the-questionnaire to depression-according-to-health-records for the same population, and seeing how they differ?

Alex: Nobody has looked at this yet but this would be an interesting option and something that could be done.

DD S: I wonder what depression questionnaire they use – does it cover the last year, or only how participants are feeling at that moment?

Alex: In ALSPAC, depression is measured using the short mood and feelings questionnaire when assessing depression in young people and then the Edinburgh Postnatal Depression Scale in the young people’s parents. Even though it says postnatal, it can still be used when people are not pregnant. These are self reported questionnaires and can be completed quickly. There is diagnosis data from more advanced screening measures as well but these are the most commonly assessed in this cohort.

In Generation Scotland, a different measure called the GHQ28 is used whilst in UK Biobank, the PHQ4 and PHQ9 are used.

DD S: So just at that time then – could miss any depressive symptoms that occur between the yearly questionnaires?

DD N: Do you think it might be possible to extrapolate from that to an idea of the total number, including people who had a depression episode at other times of the year?

Alex: In regards to timing, most questionnaires will only capture the last 2 weeks or the last month. So this poses some problems like what if you catch someone on a bad day? This is an example of measurement error which is a really common problem we have in mental health research

DD M: Catching someone on a bad day would be better than on a good day though?

Alex: I think it extends both ways and both ways are potentially a problem depending on your point of view. Good news for the person if they’re having a long episode of depression and have a good day (hopefully the start of more good days) but bad from a researcher point of view if it’s just a good day in isolation and an anomaly with regards to the data.

But essentially yes, this is a problem sometimes.

 

DD L: Is there any existing research on predictors of chronic depression or dysthymia? Just found this article – are we thinking of doing something along these lines?

Matthew: There’s also a recent paper from a Brazilian cohort (all middle-aged civil servants, only 2 waves) that shows education and female sex predict persistance

DD S: Well we definitely aren’t going to be able to follow people for 11 years! We’ve got, like, two weeks… But we do have access to the data several cohort studies have been collecting, so we can ask questions of their database…

 

DD I: With our question as the starting point, what question would you ask the data?

Mark: I’d start by seeing if we can use health data to differentiate people who reported (retrospectively) having single versus recurrent depression to see how closely that data matches what people remember.

Health data is what we call “prospective” because data collection started before the event you want to capture occurs. This will not be totally true because health records only go back in time so far, but there are some statistical methods we might be able to apply to get around that.

Alex:  I would agree with Mark. If there is the possibility of using self reported data AND health records, then you can verify if the two are correlated and be more confident in your data.

DD S:  I thought we have the (anonymised) records from the cohort studies, but there’d be no way to identify and ask those specific individuals about their perception?

Matthew: I think once we’re happy to use health records to estimate episodes and that it’s reasonably accurate, then a simple question would be something like “what does a life of episodes look like? How are they spread out, when (in life/year) do they occur more frequently?” and also “What risk factors predict more episodes?”

DD S: My concern with looking at the pattern alone, is whether it would add anything novel, although I’d be very interested in the result! But if we look at patterns in combination with risk factors, or treatments, that might be useful? I’m just not sure what’s been done already. That said, being in the UK might be novel (healthcare system different from other countries), also the combination with risk factors / protective factors / treatments that worked or didn’t, might add useful information?

Matthew: I think Mark Adams is talking about comparing the questionnaire responses that the cohorts have already completed (including several waves of depression questionnaires) to the health records we have for them. If someone reports a depressive episode in the last 12 months can we see this in their health records?

 

DD I: Our question speaks to biological, psychological, behavioural and history eg. trauma.

This is pretty wide.

What do you think might be the key to the difference between single episode and multiple/chronic. (Even just a hunch)

What measures do you have within the cohort studies that might speak to that?

Mark: Based on what we know from family data, my hunch is that single episodes of depression are more situational.

DD L: Yes, I would expect people with higher early life stress to have more chronic depression, with single episodes linked to a stressful experience in adulthood but less early life stress.

 

DD E: I would like to ask what method of study will the survey take, qualitative or quantitative?

DD L: It depends on what the specific research question is. Pretty much everything the panel talked about tonight would be quantitative because it would be using large amounts of numerical data.

 

DD S: From the Generation Scotland paper you linked to, “We found that the heritability of recurrent Major Depressive Disorder illness course was significantly greater than the heritability of single MDD illness course.” Do you think that means that a single episode of depression is almost a thing that could happen to anyone if the right (wrong!) circumstances come together. Whereas recurrent depression is more to do with people having a genetic vulnerability to it?

Mark: Yes, that’s a good conclusion. Also about 75% of the genetic risk is shared between single and recurrent, meaning that the genetic vulnerability is very similar.

Alex: I remember reading a paper which I think said that multiple episodes of depression had a stronger genetic basis compared to those who had only one episode. I think it was a paper by Kenneth Kendler using some data on twins.

DD S: When discussing our question, one big reason for people wanting to know the answer is the hope that if there were ways to predict at first episode which people would have a one-off and which would be likely to have repeated episodes, then maybe those groups could be treated differently.

Do you know if GPs or psychiatrists ask people if they have family members who’ve experienced depression, when they are diagnosing them?

Matthew: There is certainly a READ code (one of the codes GPs use when entering a record) that is for family history of depression, but whether it’s used (due to time limits) or accurate, who knows. It would be possible to check accuracy by comparing to cohort questionnaire data, as Mark Adams suggested above

 

DD C: I’m beginning to wonder whether our research could be to do interviews with people who have a history (current or past) of depression and see whether their experiences are adequately assessed by the standard questionnaires!!! I’m not being completely flippant here, since I think the relative triviality of the questions reflects the lack of adequate treatment options….

Matthew: The problem with that approach is that clinicians and researchers really do need standardised questionnaires. They may not be the best, and they may not suit all cases, but they allow us to compare between studies/populations/countries.

DD N: I guess perhaps the question is then whether the standard questionnaires could be improved! I’d be interested to know how long ago the current ones were created

DD C: I know. I guess I’m just a bit cynical because I don’t feel it applies to me and because I have witnessed so much inappropriate use of them….

DD S: Also, in practical terms, that would probably need a new ethics application and we probably can’t do that in time.

DD C: Do you think it would be interesting to have feedback from our group on these questionnaires?

Matthew: I think that would be great: most of the questionnaires were designed by clinicians. I would say constructing a more patient-led questionnaire is fantastic, but would take a while – probably more time than you have here. Something to come back to, though!

DD C: I’d certainly be up for it if you ever wanted to attempt it!

DD C: Maybe we could pick out some questions , even if it’s not the full questionnaire…

 

DD N: I’m afraid that’s our hour and we’ll have to let the researchers go now – thanks so much for coming Alex, Mark and Matthew

Alex: Thanks for having us! Really interesting to talk to you and discuss these ideas!

DD S: No. Lock the doors. Stop them from leaving.

(OK, I’m joking.)

Thank you for coming Mark, Matthew and Alex, it’s been fantastic and so useful.

DD C: Thank you all so much! It’s been really enlightening

Matthew: Thanks everyone, it’s been great. It’s tough to nail down a research question – happy to come back to this and any other questions another time.

 

 

Our final research question

Over the last couple of weeks, the members of Depression Detectives discussed the top 10 questions we chose from our list of 59 possible research questions, then voted to choose the one question we’ll be using to design a small piece of research which will be done by the group.

The winning question is…

How does ‌chronic‌ depression/dysphoria‌ differ ‌from,‌ ‌say‌ ‌a‌ ‌single‌ ‌episode,‌ or‌ ‌discrete‌ ‌episodes‌ ‌of‌ ‌reactive‌ ‌depression? Are there markers (biological, psychological, behavioural, and current or in a person’s history e.g. trauma) that distinguish them?

The next step is to narrow down this quite broad question to something it’s possible to try and answer in a small piece of research happening over a short time. That’s what we’ll be doing over the next two weeks.

Trauma and Depression: A Q&A with Karen Goodall, Hope Christie and Rachel Happer

As part of Depression Detectives, we’re holding weekly Q&As with scientists and experts who work on depression or related topics. Our Q&A last week was with three researchers from the University of Edinburgh who study trauma – Karen Goodall, Hope Christie and Rachel Happer.

Q&A

Hi all!

Karen: Hi everyone! I am Karen Goodall. I am a senior Lecturer at the University of Edinburgh. My research is focused on childhood adversity attachment and wellbeing and mental health in adulthood.

It’s really great to be here – we are looking forward to chatting with you!

Hope: Hi everyone! Thanks for coming along this evening 🙂 my name is Dr Hope Christie, I am a Global Challenges Research Fellow at the University of Edinburgh, which is a long winded way of saying I do a lot of work with people in different countries – mainly South Africa.

My work focuses on parents who have experienced something traumatic and may have developed post traumatic stress disorder (PTSD) as a result. I’m interested in how parents feel their trauma and PTSD has affected them, their parenting and their family dynamic.

I’m also excited to be here chatting with everyone this evening!

Rachel: Hi everyone. I’m Dr Rachel Happer. I’m a Clinical Psychologist. I’ve spent the last twenty years working with children, young people and adults who have experienced trauma, particularly trauma that has occurred within interpersonal relationships. My research interests are compassion, shame and institutional roles in abuse.

 

Depression Detectives member S (DD S): Hello, thank you so much for coming!

For starters, what are the ‘headlines’ of the relationship between trauma and depression?

Rachel: Depression is often the outward symptoms that someone might see, trauma is the body’s response to experiences that are difficult to manage.

Karen: There are a large number of studies that point to a relationship between trauma and depression. Particularly trauma in childhood seems to be relevant.

It’s also worth mentioning that depression is one outcome but there are other outcomes linked to trauma such as anxiety disorder or substance use. But it is important to say that not everyone who has experienced trauma will become depressed and vice versa.

DD C: would you say this is mainly connected with attachment or other factors?

Karen: That’s a really interesting question. We tend to think of attachment relationships as risk or protective factors. Trauma seems to be more potent if it is interpersonal, especially if it is related to a parent. On the other hand a secure relationship with another person can protect against the stress of trauma.

I think I should also mention that insecure attachment relationships might play a role in developing depression. However, in children and young people there is evidence that the extreme stress of trauma can lead to impacts on the neurodevelopmental system.

It is also important to mention that we tend to think of trauma as ‘an event’. In fact trauma can be the absence of something, such as good parental care.

DD A: In the context of childhood traumas from parental care (or lack thereof), and given that these have a huge impact on mental health, what approaches could be taken to intervene at this stage? As children may not be able to identify that something wrong/bad is going on!

Hope: Just to add onto the great answers Karen and Rachel have given, it is most often the case that mental health difficulties such as depression and anxiety are often co-morbid or share similar symptoms to post trauma symptoms as well. This can sometimes lead to trauma symptoms being overlooked if you are going to your GP for example.

DD S: Does everyone who’s experienced trauma experience depression at some point? If not, why do some and not others?

Rachel: Each person’s journey through trauma is unique. Whether or how some experiences the impact of trauma will depend on many things including the supports they have around them, the response someone receives to disclosure of trauma, how quickly someone receives the right help, the other resources in their life, the scale and impact of trauma.

 

DD N: Does depression that stems from trauma present differently in any ways to other causes of depression?

Rachel: I would always see someone’s experiences as unique to them. Depression has some key features that have quite a biological underpinning and PTSD type trauma also has some key features such as flashbacks and nightmares.

However, trauma, particularly unresolved, can have a lifelong impact. Both trauma and depression can be impacted upon by the quality of a person’s relationships.

Hope: Great question! I would say that no, that there is no difference in the way that depression presents. Typically what we see is that depression comes second to the trauma. Depression and trauma do share similar symptoms to each other in terms of low mood, withdrawing from relationships or social situations, etc. But there are differences as well, in terms of the root causes of each and how we may treat them

DD N: Thanks for both of those responses. That makes sense. Does that then have implications for treatment of depression? For example making it more complex to get to the underlying issues. And what are the strategies that could be used to help get a diagnosis that reflects causes of depression as well as the depression itself?

Karen: This is quite a complex question. Generally, depression may have multiple causes but typically it will be the symptoms that are treated. I’m not sure that it would be too easy to get an alternative diagnosis but certainly having the space to be able to talk to someone about what happened to you would be the first step in starting to address core issues. Antidepressants can play a role and can support someone who is undertaking other types of therapies but you would also want to be thinking ideally about a therapy that addresses the core issues.

 

DD A: Can you give us a summary of what current literature tells us about childhood attachment and trauma related mental health issues in adulthood?

Karen: Great question! There is a very big literature on insecure attachment and mental health which shows that people who are insecurely attached are more prone to mental health conditions in general. This is because through attachment relationships we learn lots of skills such as how to regulate emotions, what we think of ourselves and the world and how we can trust other people. In this way, people who have a secure attachment may be a bit more resistant to stress, but if we haven’t had those experiences, we can be more prone to finding things stressful. This is one of the ways in which people can become depressed – through stress.

 

DD I: As part of our Top 10 questions in the group (as we try to narrow in on our 1 research question) we have:

How does ‌chronic‌ depression/dysphoria‌ differ ‌from,‌ ‌say‌ ‌a‌ ‌single‌ ‌episode,‌ or‌ ‌discrete‌ ‌episodes‌ ‌of‌ ‌reactive‌ ‌depression? Are there markers (biological, psychological, behavioural, and current or in a person’s history e.g. trauma) that distinguish them?

Can you say anything that might speak to that question eg. research that has been published or gaps that still exist?

Rachel: Big question! Trauma is really about what has happened to someone, either in recent years and in childhood. Chronic depression, reactive depression and single episode all could have a trajectory that arises from trauma, particularly if trauma is not resolved. People often take many years to reach the most effective trauma focused psychological work.

DD I: We know. We are just exploring/trying to narrow things down in the group just now.

Do you know of any markers of trauma (other than the person remembering themselves).

What if it happened very young?

Karen:  That is a very good question indeed because we tend to think that what we don’t remember can hurt us. However it is clear from the research that trauma in early life has a very pervasive effect. In terms of markers, I don’t think you could point to any specific presenting factor and say that it is related to trauma with certainty. What you might expect though is the usual symptoms of difficulties relating to others, making sense of oneself, being prone to anxiety and difficulties in regulating emotions.

DD E: Would these symptoms necessarily be flagged as trauma-related if the individual didn’t feel able to disclose? And separately, since things like struggling to make sense of your identity are often attributed to adolescence or just a part of growing up – at what point is that distinguishable?

Karen: On the whole, I think the impact of trauma tends to be under-rated. For example, when a person goes to a GP with depression, there is not usually the time to ask about what happened to that person in the past or currently and the symptoms of depression are just treated. It is very difficult for people to disclose a history of trauma and often they might not even see it as relevant to their current symptoms. But no, in general practice I don’t think they would be immediately recognised as trauma related. There is a big push currently to ask more about histories but it is tricky.

DD C: I’d add to this that someone may not define their experiences as trauma. It took me many years of therapy before I accepted that I had a traumatic childhood (disorganised attachment, no safe person or safe places….) and it’s only since accepting this term that I’ve been able to reframe things enough to recover. I guess what I’m saying is that it’s easier to define depression, since that’s a bunch of well-defined symptoms, than trauma, which relies on an account of what happened in the past. I wonder how this affects the ability to research trauma-related depression – who defines the existence of trauma in the history?

DD E: I have been in the same boat – I’d be really curious to hear the response to this one!

Karen: I couldn’t agree more. It is much easier to diagnose depression than recognise trauma. In terms of research, many questionnaires will not ask directly ‘did you experience trauma’ but instead might ask about more subtle things such as ‘did you fear either of your parents’. This type of trauma tends to be additive. From my own perspective, I am very interested in emotional abuse because some of the behaviours are ‘normal’ behaviours that happen in all families, such as swearing, shouting etc. It only becomes emotional abuse when it is at the higher end or carries on for a long time.

I also whole-heartedly agree that many people may not define their own childhood as traumatic as we tend to think it is normal. Recognising that you weren’t supported or you were exposed to potentially dangerous situations etc. can be a first step in understanding responses such as chronic loneliness, unmanageable fear or depression.

DD C: “some of the behaviours are ‘normal’ behaviours that happen in all families” and also we only have experience of our own families so we have no clue what it is like to be a child of parents who are less abusive. Another reason we can’t recognise our own trauma. So how does the brain know that it is being traumatised when the person is reacting to what is essentially a normal situation for them? I didn’t know that other families didn’t treat their children like that until I became part of my husband’s family in my 30s!

Oops, we were typing at the same time and you have answered me! 🙂

DD C: How would you address this issue of recognised/undiagnosed trauma? If people present to their GP and all they are offered is anti-depressants or 6 sessions of counselling, then no one will get to the root of the problem and yet another person is failed by the system….

 

DD E: Hello Can you explain what the impact is on the brain when trauma is experienced and does it contribute to dementia in later life?

Karen: I am not an expert on dementia. However, it is clear that when extreme stress is experienced through trauma, it increases what is called allostatic load – wear and tear on the brain and stress regulation systems. Trauma and multiple adverse experiences in childhood such as loss have been linked to physical health such as heart disease and diabetes. It would not surprise me if it were related to dementia but I have to admit that I don’t know this literature in much detail 🙂

 

DD I: Possibly slightly off topic (if so just ignore)

In our Top 10 we also have a couple of questions about parenting, if you are able to speak to those at all?

a) What‌ ‌are‌ ‌the‌ ‌specific‌ ‌problems‌ ‌that‌ emerge‌ ‌from‌ ‌having‌ ‌a‌ ‌parent‌ ‌with‌ ‌depression,‌ ‌and‌ ‌what‌ ‌can‌ ‌be‌ ‌done‌ ‌to‌ help‌ ‌counter‌ ‌these‌ ‌effects?‌ ‌

b) Can‌ ‌parents‌ ‌learn‌ ‌and‌ ‌teach‌ ‌healthy‌ ‌emotional‌ ‌behaviours‌ ‌and‌ ‌positive‌ ‌strategies‌ ‌(e.g.‌ ‌through‌ ‌therapy),‌ ‌even‌ ‌if‌ ‌they‌ ‌can’t‌ ‌always‌ ‌do‌ them‌ ‌themselves?‌ ‌

Hope: Good questions!

I think we can all agree that being a parent is a really difficult job and most of the time parents are really doing the best they can with the tools they have.

a) There is an extensive amount of literature covering depression and parenting. Pointing to parents (mostly mothers – as they have been most studied in regards to this topic) experiencing a number of impairments in their parenting particularly around the parent-child relationship/bonding, as well as being more withdrawn or irritable with the child. In terms of counteracting these effects, there isn’t a one-size-fits-all solution, but social support/support from friends and family is consistently found to be a good protective factor.

b) Again, parents work with what they have. If they themselves were never modelled healthy behaviours, positive coping strategies and emotion regulation in their own childhood, then it is unfair to expect them to be able to model that perfectly for their child. I would also like to add that perhaps depression/trauma/anxiety may impair certain parenting behaviours, but this does not mean that people are bad parents. They will still be trying their hardest and will want the best for their child. Therapy can help parents reflect on their own behaviours for them to model this for their child, but their child may also pick up these things from other family and friends around them as well.

Hope this answers your questions! 😊

 

DD E: This is somewhat of a broader question (and less in the specific scope of depression), but as complex trauma and C-PTSD was mentioned in the Depression Detectives group earlier – I’m wondering what your stances are on that topic? Specifically that effects of complex trauma can present in less “classical” ways (i.e. emotional dysregulation as opposed to flashbacks) and symptoms such as this emotional dysregulation and associated SI/DSH behaviour can end up being labelled as borderline personality disorder. Do you think that they are separate conditions, or just different names for the same thing? If too big a question feel free to ignore this!

DD C: I’m really interested in this, too, thanks for asking. I find it difficult to tell the difference between borderline and complex PTSD… I think, to me, it seems that borderline seems to mostly have underlying complex PTSD? Would love to hear the experts’ views on this…

DD E: This is especially interesting too due to the stigma commonly associated with personality disorder – whereas complex PTSD seems to carry less stigma!

Rachel: I would never want to ignore this question. This is what I have spent my working life talking about, learning about and trying to get people to understand.

Complex trauma is an organisation framework that brings together a set of responses that include emotional dysregulation, difficulties around trust in relationships and a fragmented sense of self. It is most often associated with trauma that has occurred in close, care giving relations, especially in childhood. When children are hurt by those that are meant to care they not only experience the trauma itself and the associated violations but they also have no refuge from the fear. In addition they miss out on the safe relationships where children learn about regulation, who they are, and how to build trusting, safe relationships. If you look at Borderline personality disorder against the context of what individuals have experienced many of the symptoms rare about managing unmanageable situations, feelings and experiences.

DD E: In this vein then, would you say taking a trauma-led approach to BPD is a valuable one? As therapies currently tend to take a behavioural approach (I’m thinking DBT and the like).

Rachel:  I would say a trauma-led approach should be essential in any approach to working with someone who has received a diagnosis of BPD. I would like to see a much stronger emphasis on trauma around work with these individuals. BPD is often associated with a lot of trauma in relationships both in childhood and adulthood, trauma that has occured at developmentally vulnerable times and from someone in a position of trust. The trauma is not always event based, it can also be about what someone has not received such as with neglect. That is not to say interventions like DBT don’t work but they treat emotional regulations and support alternative coping strategies to coping such as self-harm. I think it is also important to know what has happened to someone so they can make sense of how they are feeling and seeing the world and themselves. More self-compassion is key.

 

DD E: Are there treatments available to help those affected by trauma. Ive heard of EMDR – is this something that would help traumatisation? Im thinking psychological treatments

DD E: Not an expert here (so may be overstepping, sorry!) but as someone currently going through EMDR it can be really really effective for processing traumatic memories. The way it was described to me is that traumatic memories get “stuck” and cause lasting distress as they haven’t been processed, and EMDR is a way to un-stick them.

DD A: I’m really interested to hear the answer to this too. I found EMDR very helpful and curious to know others’ experiences.

Rachel: EMDR is an exposure based intervention and so is particularly helpful for processing fear based symptoms such as flash-backs and nightmares. It can be helpful for the right person. The shame that is so often attached to trauma, especially interpersonal trauma often takes longer to shift and need time, a safe relationship and the opportunity to explore beliefs about self, others and the world. Survivors of trauma carry a lot of blame and I take a compassion focused approach.

So good to hear about people getting access to trauma-specific interventions. This is so important. EMDR is one of these, glad it was helpful. So many get other aspects treated first i.e. substance use, low mood, self-harm. And it takes so long for someone to ask “what happened to you?”.

 

DD E: Is EMDR available on the NHS and if so is there a long waiting list? Or even a recommendation of private therapy?

Rachel: EMDR is available in many NHS psychological services especially trauma specific services. What is available and how long the wait will depend on the NHS Health Board. EMDR has a UK Association that can recommend therapists.

DD A: at the end of my CBT sessions my NHS therapist asked if I wanted to try some sessions of EMDR (she was doing a course in it for her job).

 

DD S: The link one of you shared earlier, about ACEs, listed big traumatic events, like child abuse, violence, etc. But what about ‘normal’ traumas, that almost everyone experiences at some point – e.g. the end of a serious relationship. And then ordinary stressful events – losing your wallet, missing a train, failing an exam – which can feel like a big deal at the time.

What is the difference between stressful life events and trauma? Is it just the size or number that makes them different?

Rachel: Interesting question and one that is often asked. There are a number of ways in which the experience of trauma can affect individuals that can have an impact of better or poorer outcomes. These include the direct impact of the trauma/s, whether the trauma impacts on an individuals ability to cope and whether it impacts on relationships. The impact of stressful life events is often cumulative, little things chip away and impact on resilience. Trauma is often experienced as threatening and leads people to believe that the world is threatening and unsafe place. This can lead people to avoid relationships and experienced hat might help.

Hope: Hi, that is a good question! We tend not to look at traumas as ‘big’ or ‘small’ etc, because as you said, everyone’s experience is different and what feels like a big deal to someone, might not feel like much at all to someone else.

Typically when someone has experienced a traumatic event, there is about a four week period the the trauma taking place and perhaps traumatic symptoms starting to develop. This four week period is important, because as you quite rightly pointed out, it may have felt like a big deal in the moment, but as time goes on you are able to carry about your normal life and it doesn’t really bother you. However, there are perhaps other traumas that happen in your life, that will tend to stick with you a bit more. You may find that you start experiencing flashbacks or nightmares, you might start actively avoiding reminders of the trauma, or feeling like you are constantly on edge or feeling jumpy all the time. If these symptoms start developing in that four-week window and continue to get persistent or make it difficult for you to function in your daily life then you may need to seek additional professional support for this experience.

Hope this answers your question 😊

DD S: Thank you both. Yes, that is useful.

 

DD E: Do siblings (one male, one female from the same family) react differently to a severe traumatic accident?

DD M: I would say this is all tied up with the culture they are growing up in. Because there are no significant differences for male/female brains

Hope: A good question here and an interesting one! It is difficult to say, are you suggesting here that both the siblings experienced the same trauma? Or maybe one did and one didn’t?

Either way, you can develop PTSD either through directly experiencing an event, or through witnessing an event taking place.

There is evidence to suggest that females are more vulnerable to developing PTSD post-trauma, but there are also a variety of other factors such as poor social support, and previous experiences of trauma.

I’m not sure I can answer your question specifically, as there are a lot of other factors to consider, but it may be the case that siblings from the same family would react differently to a traumatic experience, as they themselves are different as people.

Karen: There is evidence that females tend to be depressed more than males and they tend to be exposed to trauma more often. However, in terms of siblings, and the same event, it would depend very much on the individuals involved as siblings have different genetic make-ups, personalities, support circles and so on.

 

DD S: I’m interested in your point that trauma might not be ‘an event’. I’ve often imagined that the ongoing experience of growing up, eg, in a violent and unpredictable home, and having no real place of safety, would be much worse than the ‘one-off’ trauma of experiencing a terrorist attack, or another act of violence. Is this what you see in the research? How does continuous and prolonged trauma differ from a one-off event?

Karen: Great point. A ‘one-off’ event is of course extremely stressful but even high levels of stress can be managed if people have developed good self regulation skills and have support. For children and young people, whose brains and stress regulation systems are still developing, ongoing chronic trauma through neglect or abuse or loss can put an intolerable load on a young person who has not yet developed these skills. This continuing stress can actually start to affect the way the brain and other body systems function, making that person potentially more vulnerable to stress, depression and PTSD in the future.

Always important to add, however, that this is not inevitable and people can recover from trauma.

I also wanted to add that living in poverty is traumatic, as is neglect which can feel life threatening to a young person. Of the different types of trauma, a recent meta analysis showed that emotional abuse is more strongly linked to depression than other types of abuse. We tend not to think about the impact of emotional abuse too much but it can be very pervasive and potentially damaging to a child.

DD S: What about if both the imaginary people are adults? I mean, eg, the stress of living in an abusive relationship vs a one-off traumatic event?

Karen: It is very difficult to categorise the effects of trauma. I see what you mean that a one-off traumatic event may present less chronic stress in some cases than ongoing fear-related events (such as an abusive relationship). However, people respond to trauma in different ways that reflect their past, their relationships etc. so for one person something might lead to mental health impacts, where it doesn’t for another person. That said, abusive relationships are particularly toxic due to the constant exposure to fear.

 

DD I: What research methods do you use? (We are just considering what methods to use in our group)

Karen: It depends really on what your question is 😉 We use survey methods a lot to collect data on variables that are likely to be contributory. Other methods might include stress tests, observations of interactions etc. What specifically are you trying to research?

Hope: In my work I use a mixture of both quantitative approaches (e.g., questionnaires) and qualitative approaches (e.g., interviews). I think using a mixture of both is really helpful when trying to address a topic like mental health and parenting. For example, I had one mum talk to me about some questionnaires I had given her asking about the level of communication she had with her child. The questions asked things like “my child looks at me when I say their name or am talking to them”, “my child does what their told the first time they are asked”, “when I speak I feel like my child is listening”, etc. She said to me during her interview she was concerned about those questions, because her child was autistic. So her child didn’t always listen to her first time, and didn’t always look at her when she was speaking to them, but not because their communication as mother and child was poor, but because of her child’s autism. Something like this wouldn’t have been captured via the questionnaire alone, but was discussed during the interview. So I think it is always beneficial to use both where possible 😊

Karen: To add to this, there are a lot of questionnaires on trauma or Adverse Childhood Experiences (ACES – which you might have heard of). These can be very triggering to some people however so need to be used very cautiously.

 

DD E: Is there much in the way of support groups for trauma/ACEs? I only know of one!

Rachel: Scotland has a National Trauma Strategy which you can read about on the web. There is a strong drive to get as many people as possible to be trauma informed. Organisations like Health in Mind can run helpful groups.

 

DD E: I am interested in trauma experiences in different places/cultures. Are some cultures more likely to be protective or induce depression? I was interested in the South African context and someone mentioned before about poverty being traumatic and the UK has a big problem with that.

Hope: Yes, you are correct that lower socioeconomic status can make people more vulnerable to trauma exposure and subsequent PTSD development. This has a lot to do with the context that you live in as well. You may be more at risk to being exposed to dangerous situations. In South Africa, it is an interesting one (I’ll try and not go on forever about it, although I really could!), you’re right that culture plays a significant role. With the parents that I have specifically worked with they were Black African parents, who culturally believed that you dealt with trauma within the family and you did not speak about the trauma as you would bring shame on the family if you did. They also lived in a really unsafe environment where their exposure to trauma was continuous, which was also difficult. In addition, a lot of the South African parents I worked with didn’t really understand what their trauma symptoms were, or didn’t make the connection between their trauma and then having nightmares for example. So you’re right, culture and context has a huge influence.

DD E:  Very interesting. So people recognising trauma and that some of their feelings are a result of trauma will help them to cope/recover better?

Hope: It can do in certain cases, yes. It gives you a bit more of a sense of control and an understanding of where these symptoms are coming from.

 

DD N: That’s all we’ve got time for I’m afraid! Rachel, Hope and Karen, thanks so much for coming and answering our questions, this has been great

Karen: Thank you so much for inviting us. We’ve really been kept on our toes with these insightful questions. It was a real pleasure!

Rachel: It is really important for all of those who have experienced trauma to be given understanding, support and the right access to psychological approaches. Many symptoms are coping strategies that were essential at the time. Survivors of trauma carry so much self blame. they need our compassion not our judgement.

Hope: Thank you so much everyone for all your interesting questions, this has been great 😃

DD C: Thank you so much! I wish we could meet and chat things through properly as this format is really hard to keep up with (especially when my 7 year old daughter had a massive meltdown and needed soothing so I was very late!!)

Mental health, pregnancy and childbirth in history: A Q&A with Morag Allan Campbell

As part of Depression Detectives, we’re holding weekly Q&As with scientists and experts who work on depression or related topics. Our Q&A last week was with Morag Allan Campbell, a historian specialising in mental illness in pregnancy and childbirth, particularly in Scotland between 1820 and 1930. 

Q&A

Hi Morag!

Morag: Hi, thank you so much for the invitation, I’m very pleased to be joining you here tonight.

I’ve recently finished my PhD in Modern History at the University of St Andrews, and my research focuses on postpartum mental illness in nineteenth century and early twentieth century Scotland, looking not only at what doctors thought and what treatment they used, but also at what families and communities understood and how they dealt with mental illness during pregnancy and following childbirth.

Depression Detectives member I (DD I): For those that are not quite sure (like me who just looked this up!), Morag looked at the years 1820-1930. 

Morag used records from the chartered asylums at Montrose and Dundee, court and prison records, and newspaper accounts, to explore how childbearing-related mental illness was recognised, accepted and supported by families, neighbours, friends and authorities.

 

DD N: I’m interested in the family and community aspect – were people supportive of mothers experiencing mental illness in that time or not so much?

Morag: That varied a lot from case to case, but, on the whole, yes, it seemed to be something that families and communities seemed to expect. Most of my work is based on asylum records and it’s difficult to know much about what they did before women were admitted, but we can piece together stories of how families tried their best to look after women until they could no longer cope.

 

DD S: You looked partly at how attitudes and treatment differed by class and social group. Could you tell us a bit about what you found out?

Morag: They looked for different behaviours and values in private and pauper patients – willingness to work was seen in pauper patients as a sign of recovery, while the private patients exhibited self control and engaged themselves in genteel activities. They foregrounded different attributes in the patients also. But basically, they judged the poorer patients according to middle class values, which were often difficult or impossible for them to achieve.

 

DD A: Your thesis sounds really interesting Morag. Congratulations for completing! I’m interested in how how mental health issues would be diagnosed in women after childbirth before the NHS. Did they have midwives? Was there much aftercare? Would they go to a doctor?

Morag: Thank you! Yes, there would be midwives, but they weren’t like professionals at that time. Families would usually begin to notice symptoms, changes in behaviour etc, and most would just struggle on until the woman’s condition improved – most of this is undocumented, so it’s hard to know what really went on. Doctors would be called in if they really couldn’t cope. There wasn’t really any official after care.

 

DD C: Have you looked at comparisons/ differences between what is diagnosed as postnatal depression or postnatal psychosis today, and what women experienced in the period you studied?

Morag: Yes – there are definite similarities across the different time periods, but in the nineteenth century, the symptoms reported were different – one researcher who did a comparison said that nineteenth century symptoms were ‘more florid’. But the condition tended to be measured much more in moral terms than we would do today.

DD C: What does this mean, in more moral terms? What kind of effects did being unwell have for women?

Morag: They defined mental illness in terms of adherence to appropriate norms of behaviour and assumptions about what was appropriate for each gender.

DD S: What does ‘more florid’ mean?

Morag: I think he meant more extravagant and varied

DD N: Would that mean some people who were diagnosed as mentally ill would be considered not to be unwell by today’s standards? Or is it more that the effects on behaviour were caused by mental illness, but the behaviour changes were what was considered important?

Morag: Good question! What we regard as mental illness differs according to time, culture and society – so yes, it’s a bit of both.

 

DD I: How did people get out of asylums?

Morag: They were discharged when doctors felt they were fit to leave, and this was usually negotiated with the family. Often, at the asylums I was looking at, they would be sent home on a trial basis. There’s lots of stories about people being ‘put away’ for years, but asylum care was actually quite expensive. I came across more incidences of families trying to get their family members discharged before the doctor thought they were cured. Generally, I felt the doctors were really trying their best to help their patients and were often deeply saddened if they felt the patient had left the asylum before they were restored to health.

 

DD S: You studied the period from 1820 to 1930. How did attitudes and experiences change over that time?

Morag: Early in the nineteenth century, the dominant idea and treatment was what they called ‘moral treatment’ – it was a new age for treatment of the mentally ill, and they believed they could cure mental illness with the right treatment. Moral treatment revolved around middle class family values and the importance of work in maintaining good mental health. The 1800s saw a big rise in asylum care – with the intention of cure – but by the end of the century, ideas had gone over much more to the idea of the hereditary nature of madness, and they were less confident about cure.

In terms of postnatal mental health, in the 1800s it was all about what they called ‘puerperal insanity’ – they saw this as a distinct condition that they could cure – this also went out of favour by the end of the century, and in the early 20C the diagnosis disappeared. They no longer regarded it as a separate condition and in fact postnatal mental illness also became invisible in the first half of the 20C (making it very difficult to research!).

DD S: “the importance of work in maintaining good mental health”. Sounds a bit like the workhouse! Were women forced to scrub laundry and so on?

“Moral treatment”, were they being read extracts from the bible and things like that?

Morag: That’s an interesting comparison! The work ethic was very much part of the treatment, so yes, they were made to work, but only when they were fit to do so, and they did various things. The doctors thought that work occupied the mind and kept dark thoughts at bay. Women did work in the laundry, but also in spinning and weaving, and helping out on the wards. There were also cases of women being employed as nurses/attendants after they were discharged. Later in the century, most asylums would usually have farms, and patients would work in these to grow and produce food, for consumption in the asylum and outwith. It was seen as a collective thing, and many of the patients took pride in it. I expect they were read lots of things out of the bible (Sunday worship was a big thing, but then it was outside of the asylum too at that time); but moral treatment really meant training the patient to behave according to strict moral values, and recovering the patient’s reason through encouraging appropriate behaviours and attitudes.

 

DD S: What did Victorians think the *causes* of postnatal depression were? And what kind of treatments did they use?

Morag: There was lots of debate about this, and ideas about what actually caused it varied enormously. But at the root of it, they believed that women’s reproductive organs and cycles were pretty much the cause of all a woman’s mental health problems, and puberty, childbirth and menopause were seen as particularly dangerous times.

Having said that, treatment was pretty much the same for any patient, as they had little useful medication to give. Treatment usually started with the bowels – they were very keen on purging! There was also some bleeding and cupping (blistering). But mostly, they concentrated on giving women a good diet and a rest. Many of the women I looked at were living in poverty, and their stay in the asylum gave them a regular decent diet, and they would also get treatment for ongoing health conditions, such as piles. Improving the patient’s physical health had positive consequences for their mental health.

DD S: So they thought of what we would now call PND as a completely separate thing from other forms of depression?

Morag: Yes, though again there was much debate about this, and not all doctors agreed that it was separate.

DD N: You mentioned asylum care was expensive – how were women living in poverty/their families paying for it? or was it ever subsidised?

DD S: In Scotland, most asylum care was provided by large charitable institutions, funded through public donations and fees. There were very few private asylums in Scotland, and the big asylums catered for private and public patients. The fees for the private patients were paid by their families, and the pauper (public) patients had their fees paid for by the parish they belonged to – local authorities were basically church-based.

 

DD N: And that’s all we’ve got time for! Thanks so much for coming Morag, this has been super interesting

Morag: I hope all that made sense – those were some really good questions! 😃

 

Top 10 research questions

Our Depression Detectives have come up with 59 possible research questions and voted on their top ten.  We are now discussing, narrowing and finetuning them, and finding ways how they could be researched. Every day, we are looking at one of the top ten questions. Then we will then have another vote to decide on the final favourite question, which will be the basis of our study.

THE TOP TEN

  1. Do people with depression feel that they predominantly receive help to treat their “symptoms“ vs “origins”? How could this be changed?
  2. What is the effectiveness of treatments on offer from GPs on the NHS (mainly anti-depressants and short-term counselling) and what proportion of patients recover with just this, what proportion go on to have a major crisis which enables them to access more in-depth treatment, and what proportion end up self-funding something which actually works in the long-term?
  3. How do people who say that they have recovered from depression describe their recovery: Do they think they are “cured” or just “coping better”, “able to spot triggers better”, etc.?
  4. How does ‌chronic‌ depression/dysphoria‌ differ ‌from,‌ ‌say‌ ‌a‌ ‌single‌ ‌episode,‌ or‌ ‌discrete‌ ‌episodes‌ ‌of‌ ‌reactive‌ ‌depression? Are there markers (biological, psychological, behavioural, and current or in a person’s history e.g. trauma) that distinguish them?
  5. What would need to happen to make a wider range of support available, including more time-intensive interventions? How could access to psychological therapies be improved?
  6. What is the‌ ‌link‌ ‌between‌ ‌autism‌ ‌and‌ ‌depression? Misdiagnosis‌ ‌–‌ are ‘symptoms’‌ ‌of‌ ‌depression‌ ‌are‌ ‌actually‌ ‌’traits’‌ ‌of‌ ‌autism‌ ‌(being‌ ‌quiet,‌ withdrawn‌ ‌and‌ ‌needing‌ ‌to‌ ‌shut‌ ‌yourself‌ ‌away‌ ‌from‌ ‌the‌ ‌stimulus‌ ‌of‌ ‌ people‌ ‌and‌ ‌the‌ ‌outside‌ ‌world)‌ ‌which‌ ‌would‌ ‌explain‌ ‌why‌ ‌trying‌ ‌to‌ ‌get‌ ‌someone‌ ‌out‌ ‌and‌ ‌mixing‌ ‌with‌ ‌people‌ ‌as‌ ‌a‌ ‌way‌ ‌out‌ ‌of‌ ‌depression‌ ‌would‌ ‌not‌ ‌work‌ ‌and‌ ‌in‌ ‌fact‌ ‌make‌ ‌things‌ ‌100x‌ ‌worse‌?
  7. How can others best support family members or friends with depression? What do people with depression find most helpful?
  8. What‌ ‌are‌ ‌the‌ ‌specific‌ ‌problems‌ ‌that‌ emerge‌ ‌from‌ ‌having‌ ‌a‌ ‌parent‌ ‌with‌ ‌depression,‌ ‌and‌ ‌what‌ ‌can‌ ‌be‌ ‌done‌ ‌to‌ help‌ ‌counter‌ ‌these‌ ‌effects?‌ ‌
  9. Can‌ ‌parents‌ ‌learn‌ ‌and‌ ‌teach‌ ‌healthy‌ ‌emotional‌ ‌behaviours‌ ‌and‌ ‌positive‌ ‌strategies‌ ‌(e.g.‌ ‌through‌ ‌therapy),‌ ‌even‌ ‌if‌ ‌they‌ ‌can’t‌ ‌always‌ ‌do‌ them‌ ‌themselves?‌ ‌
  10. Can we ask GPs what training they received in mental health, whether they think it was adequate to prepare them for GP consultations, what more they would like to learn and what services do they wish they could refer patients to? Doing 6 months in inpatient psychiatry as an optional part of a rotation doesn’t really prepare you for dealing with the majority of mental health issues in the community.

Sleep and Depression: A Q&A with Daniel Smith

As part of Depression Detectives, we’re holding weekly Q&As with scientists and experts who work on depression or related topics. Our Q&A last week was with Daniel Smith, a psychiatrist from the University of Edinburgh who is part of a sleep research project called SCRAMS  (Sleep, circadian rhythms and mental health in schools). We were also joined by Heather Whalley, who works with Daniel on SCRAMS and led our Q&A on brain imaging.

Q&A

Hi Daniel!

Daniel: Evening everyone. I’m a psychiatrist and researcher with a special interest in bipolar disorder. My interest in the connection between disturbed sleep/circadian rhythms and mood disorders includes research on the genetic overlap, research on sleep and depression in young people and more recently an interest in ‘chronotherapies’ such as bright light therapy for bipolar depression

Depression Detectives member N (DD N): Could you tell us what the genetic overlap is?

Daniel: This is about common genetic variants that slightly increase our risk of sleep disruption also being associated with increased risk of mood disorders. It’s due to many of these variants combined, rather than single genes

 

DD E: So change in sleep pattern can trigger depression in bipolar?

Daniel: Yes – sleep deprivation is a common trigger for mania. I should add that this is also about disrupted rhythms of rest/activity, not just sleep per se

There is some evidence that genetic factors that predispose us to sleep problems are shared with genetic factors for depression and bipolar disorder, and traits such as mood instability

DD E: Oh interesting so it plays a role in the highs and lows of mood?

Daniel: I think anyone will have changes in their mood the day after a bad night’s sleep but people who are vulnerable to depression and bipolar disorder are probably more sensitive to this and less able to compensate. A classic example is that crossing time-zones in air travel can really disrupt our circadian rhythms (and gives most people jet lag) but people with bipolar disorder can become much more unwell

DD E: does melatonin treatment help with bipolar the same way some people use it for jet lag?

Daniel: The evidence for melatonin in bipolar disorder is pretty weak – it sees that people with bipolar disorder need a more robust way to regulate their sleep patterns

 

DD S: I’ve heard that sleep deprivation can help depression. For example see this article. My question is, does this apply to everyone, or to a subgroup of people with depression – notably, does it apply only to people who oversleep when depressed? And is there consensus on what ‘sleep deprivation for depression treatment’ should consist of e.g. one 24h without sleep? A longer period with an hour or two less each night? It seems like it would be worth trying…but are there risks? (if you’re undiagnosed bipolar I would think this could trigger mania, for instance)

Daniel: The idea of using sleep deprivation as a treatment for severe depression has been around a long time and it’s good to see some more recent studies. Overall, it can be effective for some people but I think it’s fair to say that the effects are often short-lived and this is not an easy treatment to deliver (it needs lots of staff time and resources, for example)

DD E: staff time to keep the patients awake? And can people do sleep therapy by themselves?

Daniel: So it need quite intensive nursing to ensure sleep deprivation

 

DD N: Sleep is often mentioned as a symptom/factor in depression, but it seems people go either towards sleeping way more than usual or struggling to sleep at all. Is there any indication as to why people experience different effects on their sleep?

Daniel: In general (but not always) depression is associated with worse sleep and bipolar depression with more sleep

Heather: That’s a really good point, and some of the difficulties in depression research (I work with Daniel) – people experience different and sometimes opposite symptoms, like increased or decreased sleep, and increased or decreased weight for example. We are only just starting to tease these things apart.

DD S: Do you think it’s because actually people are experiencing different types of depression? Or that different people respond differently to the same thing? Or that there’s almost a biological or behavioural coin toss somewhere, and the same person could go either way?

Daniel: Very good question – obviously it’s complicated, mostly because depression is not a single disorder – more likely a collection of slightly different disorders with some common symptoms

Heather: I’d like to say we know, but we don’t as far as I’m aware. There have been genetic studies trying to tease these things apart (to see if these might be different subtypes based on the type and direction of symptoms, and different underlying causes ), but we’ve only recently had sample sizes to do this kind of analysis, and I’m not aware of anything convincing as yet, tho Daniel might know more….

DD S: How would you even study that then? What kind of experiments would you do?

Heather: there are v big studies like one called UK Biobank which has genetic data and some information on depressive symptoms, but often because of the scale (0.5 million people) some of the nuanced symptom data is lost – but its a place to start…So essentially looking to see what large datasets there are with the right sort of information.

 

DD C: Could you tell us a bit more about how chronotherapy works? And is this suitable only for some people or for everyone who has depression and has sleep problems?

Daniel: Light boxes in the winter can help most people with mild seasonal depression or lack of energy in winter and bright light in the morning is now being seriously investigated for bipolar depression

 

DD A: Hi Daniel, is there much research about starting school at a later time for teenaged children because they are unable to sleep long enough when school starts at 9am?

Daniel: Our SCRAMS group are reviewing the literature on this but overall it looks likely that even a small delay in schools start times is beneficial for teenagers, who are not programmed to wake up properly until about 11am

DD S: Teenage me feels vindicated here!

DD C: Not just teenage me. All my life I’ve had this problem. I wonder if it’s related to poor quality sleep in adulthood, say because of sleep apnoea?

Daniel: yes – all sorts of causes

Heather: There is increasing research here I think, and discussions not just about later start times, but thinking about the content/subjects for the earliest lessons

Daniel: Also, we shouldn’t be expecting teenagers to go to sleep at 9 or 10pm when their body is telling them 11pm or midnight

DD N: This makes me wonder whether teenagers who are living in situations without artificial light have the same difference in sleep schedule as teenagers living in electric-lit houses!

Daniel: Too much light at night for teenagers is a very bad thing!

DD N: Is too much light at night worse for teenagers than adults?

Daniel: Yes – I think this is very likely true

Heather: interesting 🤔!

 

Heather: Someone posted during the week about if we know what comes first, the sleep problems, or the depression. Do we have any info here Daniel?

Daniel: Not sure – sleep problems are a trigger and a symptom, so hard to untangle this

DD N: Do you have any thoughts on what kind of research would be needed to figure it out?

Daniel: I think we need very carefully designed prospective follow up studies of large numbers of young people and collecting objective data on sleep and mood to see what comes first and then what happens after a depressive episode

 

DD S: From a discussion thread in this group, it seemed like a lot of us were natural ‘owls’. Is there any research on chronotypes and depression? Are naturally late-rising people more prone to depression? (Either because there is some connection between the causes, or because late-rising people are more likely to experience sleep deprivation, in ‘9-5’ jobs/schools?).

Daniel: Sorry to say that night owls are more likely to have a range of adverse health outcomes, including more depression. Evening chronotype makes it more likely to experience circadian disruption

DD S: Do we know why the worse health outcomes?

Daniel: Because the circadian system controls all of our biology – from eating to immune response to hormone release – it affects all sorts of functions

DD S: So you’re saying evening people have worse health outcomes because their circadian rhythms are more likely to be disrupted. But is that BECAUSE school and office hours, etc, are set to suit morning people? ie it’s the social setting that causes the health outcomes effects, rather than the chronotype per se?

Daniel: I think some people cope well with our (very unnatural) 24 hour modern living – these people are more often morning larks, so yes modern society suits larks.

DD S: I’m now wondering if there’s any research looking at this during the pandemic? I mean, a lot of people have been working from home, and more easily able to have a sleep schedule that suits them. Have owls found this has improved some aspects of their health?

(I realise it’s probably difficult to separate the sleep schedule from everything else that’s been going on….)

Daniel: I’ve seen a fair bit on sleep during the pandemic, eg, everyone is having more vivid dreams (because they are sleeping more naturally without alarm clocks and are more likely to wake up during a dream)

DD S: We’ll that is fascinating! I’d always assumed we naturally wake up at the end of a dream. Is that not the case?

Daniel: we dream about 5-6 times per night, during REM sleep which cycles veery 90 minutes but we dream more at the end of the night

DD S: And our brain doesn’t ‘wait’ to wake us up after the dream has finished? But just kind of wakes us up as it’s still going on? (Now I’ve typed that, I’m wondering what it would mean to finish a dream. It’s not like it’s a film, with a narrative arc…)

Daniel: it’s just that sleep becomes lighter as the night progresses and we are more likely to wake towards the morning

DD S: What wakes us then? If it’s not the dreaming brain? Who/what decides it’s time to wake?

Daniel: It’s a natural biological cycle of deep and light sleep that recurs 6 times per night

DD S: hence waking between 3 and 4 am being quite common?

 

DD C: Is the chronotype completely fixed or could a night owl turn into a lark?

Daniel: young people are morning larks, then teenagers are evening owls, then older people are morning larks again, so it changes through life and can be modified by training

DD A: My children (8 and 4) are natural night owls, like me. They will sleep reliably around 10pm and struggle to wake up. Should/could I be actively training them to sleep and wake earlier?

Daniel: I don’t think so – probably best to respect their natural rhythms as far as possible – they will change as they get older

 

DD E: People who regularly change their sleep pattern, e.g. to do day and night shifts on rota, are they more likely to get mental health problems doing that?

Daniel: yes, I think it has been shown to be not good for health generally, fighting natural circadian rhythms. In general shift work is very bad for our long term mental health and people with mood disorders should probably avoid shift work if possible

 

DD L: Is the quality of sleep different in people with depression? E.g., less deep sleep.

Daniel: In general yes – less deep sleep, more waking etc

 

DD E: Reading your answer on bipolar sleeping later in the morning resonates with me and I find I can go to sleep fairly easily in quite a good settled mood, but wake in the morning feeling down and depressed. Is this typical for bipolar disorder?

DD M: I’m not bipolar but can also experience this

Daniel:  Yes – in bipolar depression (and more severe unipolar depression) people have more diurnal variation in mood , usually feeling much worse in the mornign and better as the day goes on

DD M: how would one determine ‘more severe unipolar depression’ please?

Daniel: Just more severe symptoms, more debilitating fatigue, loss of appetite, weight loss, preoccupations with dying etc

 

DD E: During times of depression are dreams on more of a depressed theme?

Daniel: I’m not a Freudian (much) but I think that could be true for many people!

DD M: lots of mine are anxiety dreams. If I remember them

 

DD L: Does lack of sleep play a role in the development of post natal depression?

Daniel: Yes indeed – an important factor among many

 

DD E: One more question – does depression medication affect quality of sleep in a therapeutic way? Or does it interfere/block sleep quality

Daniel: It depends on the medication I think – some drugs, eg, benzodiazepines do provide good sleep and others, eg, SSRIs might help sleep but it can be a bit more superficial/less satisfying

DD C: I can certainly affirm that SSRIs gave me incredibly lucid dreams, especially ones where I was flying. I was also often aware in the dream that I was in fact dreaming and could to some extent take control eg I think I’ll fly over there now. Unfortunately it was shortly afterwards that I would wake up.

 

DD N: Do you think there are any major gaps in the research in this area?

Daniel: In general I think psychiatry has not paid enough attention to how manipulating sleep patterns can be therapeutic, eg, using light and other chronotherapies – part of the reason is that there is very little money in this for drug companies

 

DD S: Ooo, I had one more question. I find that if I walk outdoors each day (my usual form of exercise), then my sleep is much better. We know that exercise is good for depression. But do we know if the exercise directly helps the depression? Or is it because the exercise makes your sleep better, and that helps with the depression?

Daniel: My strong view (as yet unproven) is that outdoor exercise helps our mental health via an indirect effect on better sleep caused by morning light exposure

 

Heather: Just posting a link here as one output from Daniels group- a comic type explanation of sleep, biology and mood aimed at teens 

 

DD N: That’s all we’ve got time for! Thanks so much for coming Daniel, this has been really great

Daniel: Thanks everyone – sleep well!