This week on She Persisted. Self reflection is A2 edged
sword. It's good to be paying attention
to what's going on in your life. I think where people get stuck,
at least the folks we usually see clinically, they've gotten
into blaming themselves for things that have gone wrong.
I opposed to I didn't study hard enough for the test as opposed
to, you know, most relationships are practice relationships and
you get better with it with practice, etcetera.
We take it to heart and we blame ourselves.
We think we're unlovable or we think we're incompetent when
that's not the case. Hello, hello, and welcome back
to another episode if she persisted.
I'm so excited you guys are here today.
It's officially. Final season Yesterday was my
last day of class, so things are.
Busy. We're a little bit.
Stressed so many things on the calendar on a day-to-day basis
during final season. You guys know I'm really
sensitive with my sleep schedule.
It's like my number one non negotiable when it comes to my
mental health and I always like to take a proactive approach and
so I know during finals I have less flexibility with when I can
be sleeping. Not that I'm not getting enough
sleep, but it's definitely more limited than it is actually.
I don't have as much flexibility.
And that also means I have to be really cognizant about my
caffeine intake. Like I want to be drinking more
coffee because I feel a little bit more tired, but I also don't
want that recurring cycle of being exhausted drinking a bunch
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subscriptions. So in addition to finals, it has
been very busy because I just went to ABCT, which is also
known as the Association for Behavioral and Cognitive
Therapies. It is a huge convention.
This year it was in Philadelphia.
And so a ton of clinicians and researchers all gather to talk
about what's going on in the field, talk about new research.
I went to a bunch of panels on social media and mental health.
I went to a bunch of panels on depression.
It was really incredibly interesting, and I was so
excited because I had recorded with Doctor Holland, who's this
week's guest before ABCT. So I got to go meet him IRL and
hear him talk with a bunch of other really incredible
clinicians and build on this conversation that we had.
But if you're not familiar with ABCT or CBT or Doctor Holland's
research, Doctor Steven Holland is a professor at Vanderbilt.
He's at the forefront of depression research.
He's an extremely prominent researcher within the field and
his research is on how behavioral interventions can
treat depression. So how that can be an
alternative and sometimes even more effective than
antidepressants, which typically are like that frontline
approach, that first line intervention for depressive
symptoms. So to give you guys a little
overview, because this is a more research related episode, we're
going to talk about why Doctor Holland became interested in
this area of research. We talked about how many people
actually struggle with depression, like how much of the
general population actually gets depressed.
We talked about his perspective on how we should reviewing the
mental health crisis that we're in.
We talk about self reflecting on depression and what most people
get wrong. We then dive into the
evolutionary mechanisms behind our symptoms of depression, like
depression serves a purpose. Obviously we live in a very
different environment than the one that we evolved for, which
is like caveman days. So what is depression trying to
tell us That maybe the message isn't getting clear because we
live in a different context now. We talk about different
interventions other than antidepressants that are
effective treating depression and that the research shows that
they really work. We talked about how changing
your thoughts and behaviors through CBT can affect
depression. So your quick little TLDR on CBT
is that there's this cycle of thoughts, emotions, and
behaviors. And your emotions impact your
thoughts and your thoughts impact your behaviors.
And it's a continued cycle. And the idea is that when we
experience a lot of distress, when we're depressed, when we're
anxious, when we're not able to function in our day-to-day lives
effectively, something with the way that we're behaving or
thinking isn't going is actively as it could.
So how can we intervene and adjust that cycle?
And with CBT comes exposure therapy and behavioral
activation. And we'll get into some of those
in this episode, but that's your CBT is like the triangle.
And how can we change our thoughts and behaviors to shift
our emotions? Then Doctor Holland and I talk
about what makes some people more likely to get depressed
over and over again rather than just experience depression one
time. We talk about why adolescents
are more vulnerable to depression, which is really
interesting. One of my favorite topics to
touch on. We talk about two things you can
do to stop a depression episode. And lastly, we talked about
trusting adolescents to make positive changes for their
mental health. This was one of my favorite
episodes to date. Again, I'm giving you the
warning that it's a lot of research, but you guys are going
to enjoy it. And it's so relevant and
impactful. And I'm so grateful to Doctor
Holland for taking the time to sit down with me.
And it was great to get to meet him at ABCT.
So we hope you guys enjoyed this conversation.
I will be getting back to studying for finals and with
that I hope you guys have a great week.
I will see you on Monday for a mini episode.
As always, make sure to share with a friend or family member.
Post on social media, tag me, I'll make sure to repost.
I really appreciate you guys. We're almost at the end of the
year and we just did Spotify wrapped and it was so cool to
see how many new listeners we have here.
How many people from different areas of the world are tuning
in? What episodes you guys like the
best? So loved seeing that, so
appreciative you guys. And I'm going to stop yapping so
we can get into this conversation.
So let's dive in. Well, thank you.
So much for joining me today on Cheaper Assisted.
I'm so excited to have you on the podcast.
We know how many young adults struggle with mental health, but
there's this really, really big gap between the research that's
happening and what we know about depression and anxiety and then
what teens are aware of when they start struggling or when
they have a friend or family member going through it.
And so I'm hoping we can lift the curtain a little bit in an
accessible way. And I'm just really grateful
that you're taking the time for this conversation.
Please. Thank you.
So to give people a little bit of a background, if they're not
in undergrad studying psychology and really into reading all of
the literature, what made you want to study depression and
these different mechanisms and symptoms that are associated and
dig deeper? What drew your interest?
Yeah, for whatever reason, I've been interested in depression
for as long as I can remember. You never paid much attention to
the Bible, but the book of Job, I thought was interesting the
most of all men could be tormented by God.
And it just it it's kind of in the family.
It's I've had my own episodes of depression in the in the past,
but my father did and it was just always seemed interesting
to me. Lincoln, Churchill, some of my
favorite people have histories of depression.
Yeah. Yeah, yeah.
It's something that impacts so many people.
And I think what's also really interesting about it is like
when we think of those people and they come to mind, we don't
think the first thing about them is that they're depressed.
But when we're experiencing it ourselves, it's so different.
It often is like, that's the biggest part of my life, or this
is such a crucial part of my identity.
And so in so many aspects, there's that huge shovel
standard. Yes, very much.
Very true. Yeah.
So how I came across your work is I am a member of a lab at the
University of Michigan and the Pi actually came on the podcast
and he's doing research about how we think about depression.
It's like if we think about the chemical imbalance theory versus
it's a signal, how does that impact how much people engage in
treatment and then their outcomes?
And so we read your paper about what we got wrong about
depression and as a field, what maybe hasn't been as effective.
And I think, again, there's this gap.
So a lot of the things that you mentioned, maybe people aren't
seeing a difference yet when it comes to intervention or going
to therapy or getting support. And so I was wondering if you
could speak to us in your career, what you have noticed
1st about like things maybe we haven't gotten totally right.
And then also if there's things where you're like, I think
that's accurate. I think that's valid from the
research side. Yeah, sure.
Happy to do that. There are a couple things #1
depression, at least unipolar, non psychotic.
Unipolar depression is a lot more common than we were aware
of before. And if you do the retrospective
epidemiological studies, the estimates still make it a very
common clinical disorder. About 16% of the population, 20%
of women, 12% of men are going to have one or more major
episodes of major depression in their lifetime.
Again, non psychotic, a unipolar turns out that's that's about
three to five times lower than the actual base rates if you
follow so a cohort from birth on or across the course of
adolescence, which is where it usually kicks in for people.
And what you find is the rates are well over 50%.
For example, the Dineen cohort study, birth cohort study.
And folks are just in their 40s now, mid 40s.
And already more than half of the folks in the sample have had
depressions. And the other thing that we
weren't prepared for, we've always assumed the depression
was quite recurrent. If you have one depression,
you're going to have a series of of multiple episodes.
Turns out that's not true either.
It turns out for most folks, they're going to have one or two
episodes in their life in response to really bad things
that happened to them. You lose a loved 1, you lose a
job that you really cared about. You don't get to medical school,
whatever that may happen to be. But most folks aren't going to
have a lot of depressions. A smaller subset of people,
probably the 15 to 16%, are the ones that have multiple
episodes, and those are the ones that end up coming in for
treatment of. Those are the folks we've really
studied. So we've gotten a biased look at
what depression is really like. It's it's so common, you almost
talk about it as being species typical.
Anybody can get anxious, anybody get angry and virtually anybody
can get depressed. What are your thoughts on we are
like in the mental health crisis?
There's a lot of this messaging that that's a bad thing.
If that's this is species typical and that this is a shift
from like 50 years ago, 100 years ago.
Do you think it's really that non judgmental approach of like
this is something we struggle with and we can adapt
accordingly or you're like, we're on a bad trajectory.
This is an issue. We got a shift.
Well, I, I think, I think it's something that we can
understand. I think we can deal with.
I think it's actually, it's, I think it's almost a bit of a
growth experience. All that being said, I think the
last thing you want to do for people coming into adolescence
is cut them off from their friends. 1415 year olds ought to
be with the 1415 year olds not locked away on the Internet
because they can't go out in in public.
So I think, I think the notion that rates are up is true, but
that's the last thing you want to do to young teens.
And I think that's elevated the rates of depression.
But it's almost a sense of isolation.
I do think that if you don't take it the wrong way, if you
don't interpret as a sign of weakness as much as part of a
developmental process that ideally get a chance to go
through, then you don't take it as as quite as seriously.
Yeah, it also gives. You a lot of empathy for like
you mentioned, these big life experiences, whether it's grief
or being rejected, like we all have that happen.
And if we didn't, we wouldn't understand those intense large
emotions. And we know, like you mentioned,
relationships are so important for everything.
So having that emotional experience, although incredibly
uncomfortable, it in turn will strengthen those other
relationships down the line. I think you're absolutely right,
it's a miserable experience to go through.
On the other hand, anxiety keeps you safe, pain keeps you from
damaging already injured tissues, and depression keeps
you thinking carefully and seriously about the things that
are important in your life. And that's not a bad thing to
happen. Yeah, I'm sure this will get
into a little bit of the intervention and CBT side of
things, but ideally you would experience a down day, a couple
of days, maybe it's a couple of weeks and you'd be like, I have
to think about this. Something in my life isn't going
correctly. But I think a lot of people run
into a wall either. There's not that awareness, like
I'm depressed and not that you shouldn't feel that way, but
like, how can I shift my behaviors and emotions?
What do you do when people aren't having that self
reflection or they're not able to make those changes around
them? Yeah, I, I, I think, and again,
I could be wrong here, but I think that self reflection is A2
edged sword. It's good to be paying attention
to what's going on in your life. I think where people get stuck,
at least the folks we usually see clinically, they've gotten
into blaming themselves for things that have gone wrong.
Yeah, opposed to, I didn't study hard enough for the tester as
opposed to, you know, most relationships or practice
relationships and you get better with it, with practice,
etcetera. We take it to heart and we blame
ourselves. We think we're lovable or we
think we're incompetent when that's not the case.
What we try to do with somebody who's clinically depressed is
get them testing that out. Consider what kind of behavioral
experiments they could run. If you've had a bad experience
in a relationship, try other kind of relationships or other
additional relationships and see if it's really true that you're
lovable or we just went about the last one the wrong way.
If you're not getting what you want out of your profession or
job, career pursuits, etcetera, try a little harder.
Try something different. But it's usually not the case
that people are accurate when they make a global stable
internal attribution to some defect in the cells.
It's usually something in their behavior and they can work that
out. Yeah.
Do you think that's something that we are learning from a
societal perspective or do you think that's more internal?
I'm sure the CBT process is reinforcing it.
When we think about like the behaviors and the cognitions and
the thoughts we're having, it just becomes like a self
repeating cycle. But where do you think that
stems from for a? Specific.
I think we're wired up for that. OK.
Gotten very much interested in the evolutionary perspective,
and in particular this fellow Paul Andrews at McMaster.
He might find interest at some point, but no evolutionary
biologist would think about anxiety, pain, or depression as
being aberrations. They would think of this being
evolved adaptations that served a purpose.
And what they would do is follow the energy.
It's like in political scandals. You follow the money, they would
follow the energy. And if you've got an infection,
the energy goes to the immune system.
You don't want to date. You want to think you're not a
certain food. If you're starving, the energy
goes to foraging for food and preserving the vital organs.
If you're clinically depressed, the energy goes to the cortex
and the energy goes to really thinking long and hard and
carefully about whatever's going on in your life.
And that, again, that's probably not a bad thing to do from time
to time. You don't want to make a habit
of it, but it's not a bad thing to do.
What I think we do clinically in something like cognitive therapy
is help somebody get unstuck when they focused on some defect
in the self, which usually is not there as being the core
problem. And so that that's where I think
that goes. But I think we're wired up to
think carefully about things when we get depressed.
Yeah, We have these other really interesting mechanisms, like
we're motivated to withdraw even though being with people would
be more effective. You mentioned self reflection,
even though maybe a little bit less would be more beneficial.
There's all these other interesting you're eating more,
you're eating less, you're sleeping a lot, you're more
irritable and pushing people away.
Are there any other mechanisms of depression that potentially
have these evolutionary stems that offer a lot of validation
and compassion and like, OK, this is not crazy to people that
are struggling? Right, right.
Or that we, some of the things you just mentioned, for example,
the withdrawal, the loss of appetite, etcetera, predate
human beings. They predate cortex.
You get mollusks without much cortex that do those things.
That's part of our older immune response.
And probably what goes on to depression grew out of the way
we dealt with infections. So things that would conserve
energy, we're still there. What's new for human beings is
the cortex getting involved and really trying to solve problems.
So again, I don't, I hate to see folks get stuck.
I can remember a couple times in my life when I got stuck, but it
was usually when I was able to start thinking about what steps
I would take to arrive at a change, what was going on in my
life that I did. That's when I got unstuck.
And I think that's basically due and at least in a cognitive
behavioral approach to treating depression.
If people were going to get into all the things about CBT and why
that can be so effective, if people aren't working with the
CBT therapist, but this is their first exposure to that and
they're like, OK, I'm curious, I want to learn more.
What does that specific process look like to think less,
ruminate less, be in that cortex?
Less intensively, yeah. Yeah, that's a good question.
A couple things. There are self help manuals out
there. Dennis Greenberg and Chris
Podeski have one of the best, I think it's called Mind Over
Mood, and it lays out what you might do with the therapist
without the therapist. There are websites that you can
go to. You get a little cautious there
because it's like the Wild West. It's true.
You can do those kinds of things.
And it looks to be the case that there's not much you can do with
the therapist that you can't do on your own.
But especially if you have somebody working with a trainer
that you're accountable to. And you can do unguided
websites, but it works a little better if you have somebody that
you have to report back to, even if they're not necessarily
therapists. So there there are a lot of
options now that we have the thing that's mentioned is
cognitive therapy. Cognitive therapies are quite
generally pretty useful. They have long term enduring
effects. So they seem to reduce risk for
subsequent episodes, but they're not the only ones that work.
There's a simpler behavioral activation approach which
doesn't pay attention to cognition at all, but seems to
work out as well. It's not been tested as often,
but it's well, when it has been tested, it might have an
enduring effect in a personal psychotherapy works quite
nicely. The variety of psychological
logical interventions that do seem to work pretty regularly,
pretty reasonably. And the antidepressant
medications, they're much safer than what we had 20-30 years
ago. I have concerns about long term
reliance on medications because they don't have enduring
effects. And there's some reason to
think, and I go back to somebody like Andrew's in the
evolutionary perspective, that they might actually suppress
symptoms at the expense of leaving you at risk.
At any point you try to stop, you're going to be dropped right
back to the middle of an episode.
So long term, I would prefer to see people have other options.
A lot of these things work to take the edge off.
Yeah, well, you elaborate on behavioral activation and what
that looks like in the context of depression.
Yeah, what we would do in something like cognitive
therapy, which of course came out of Philadelphia, came out
of. But what we what we do in
cognitive therapy is to get people to use their own
behaviors to test the accuracy of their beliefs.
If, for example, you don't think you'd enjoy the party, go to the
party and find out. Now it turns out that most folks
enjoy the parties more than they thought they would.
Depression is, to use the phrases as a disease of
expectation and recollection. It lives in the future.
It lives in the past at the moment.
It's not that you can't enjoy, it's that you don't think you
will, and you remember it differently after the fact.
But we'll get people to run those kinds of experiments.
If you don't think that you can get into a school that you'd
like to go to, apply anyway and see what happens.
Apply to a bunch of schools and see what happens.
Sometimes you surprise yourself on somebody who's depressed
tends to turn a low probability into a no probability.
If I talked with an undergraduate about going on to
medical school or gradual say what the chances are about one
in 10, they're depressed. They think that means don't
apply as opposed to applying to 20.
And you get you pick. And then especially when it
comes down to things like the notion that you have a bad
relationship breakup and you think must be something about
me. You know, there may be things
you did that didn't work well, you want to pay attention to
that because you can change those.
But if the notion is somehow basically unlovable, try
additional relationships and they're not all going to work.
Some will, some won't, and it's a matter of taste.
Same thing with jobs. Same thing with careers.
How does that process evolve once you add in the thoughts
element? Yeah, and, and behavioral
activation or the behavioral activation component of CPT
don't wait to feel like doing something.
Do what you would do if you weren't depressed and see how it
turns out. And the cognitive element is
don't believe everything you think.
And what we'll do in cognitive therapy is try to encourage
people to check out how accurate the beliefs are.
There's like almost kind of a mantra where you're trying to
encourage people to lock away. And one is, what's my evidence
for that belief? Any alternative explanation than
the alumni I just came up with? And 3rd part of the real
implications. And usually one or more of those
three questions are going to help you sort out that.
I don't know exactly what it is yet.
Let me run an experiment and see where it's going to go.
You mentioned in the What We Got Wrong about Depression paper,
and you mentioned this in the beginning that there's some
people that maybe never experienced a depression.
There's some that maybe have an episode in response to a big
life event, and then there's others that are.
I don't know if more. Prone would be the right phrase,
but they have these multi episodes what make me feel more
likely to fit in that bucket. Well, maybe.
So the folks that we typically see in clinical settings have
multiple recurrences and most folks who get depressed don't
have multiple recurrences. That's one of the we're just
finding out. Then the question is what makes
the folks that have multiple recurrences different from the
folks that don't? And there are a host of things
that may be going on with the baby, some bit of genetics
involved. Although a unipolar depression
is not particularly heritable, it's less heritable than
political preference. Does mean that particularly
people have early onsets may have a little bit more of a
genetic loading that may be the people that have histories of
childhood trauma are a little more likely to get depressed.
There's a curious aspect here. In our evolutionary past,
depression seems to not show up much in pre adolescence, but it
kicks in in adolescence. So if somebody's going to have a
lifetime course of depression or even multiple recurrences, about
half or more of this folks going to have the first episode when
they're adolescents may not get treated, but it may be the kind
of thing that that they remember.
And in our evolutionary past, that's when our species became
reproductively capable, that's we had to worry about sex, the
other gender and, and getting pregnant.
And unipolar depression is twice as common in women as in men.
And when you start thinking about maybe what we're doing
here is having more cortical involvement to solve problems.
Nothing's more problematic to a young adolescent than
relationships. So it's exactly the time you
want to be able to think carefully about stuff that may
not be a bad thing. So that interesting period, not
necessarily pre adolescence, but adolescence potentially launches
really follows this pattern. Is there anything else about
that time frame or that time period that you think either
environmentally is that additional stressor or the way
we're thinking about things? Rejection is definitely
heightened. Any thoughts there?
That's when we outgrow our families.
My wife's, a developmental psychopathologist, works with
particular with adolescents. And that's about the time that
the reality becomes what your friends think it is.
And 11/12/13, nothing's more important to us than how we
think we fit in with our other friends, with our peers.
And you can sometimes get a little stuck, a little over
concerned about that. But this, there's a lot of drama
and, and understandably, but that's where, that's where
you're sorting out who you are, how you get along with other
people. And it's going to be, it's going
to be a time of testing your own independence.
Yeah. Yeah, I'd love your thoughts
right now. A big theory floating around
about why that period is tough is social media and phones have
exacerbated issues with regard to mental health, especially in
girls. Do you buy into that?
Do you have other thoughts? I, I don't know for sure rates
have gone up, and it's hard to say exactly why rates have gone
up, but they started going up even before the pandemic.
So the isolation of the pandemic made it even worse.
My understanding is that junior high school is a cruel time for
anybody. But if you can get unliked and
lie, I don't know all the things that happens on the Internet,
but a lot of stuff happens on the Internet.
And I've got two young granddaughters.
I kind of hope they get protected from that.
Right now they're just Disney Princess films, but God, things
are going to get worse in a couple of years.
Yeah, yeah, yeah. We were talking about thinking
about things too much. It's like the Internet feeds
into that because it's not like you see your friends at school
and you maybe you see them across the the lunchroom and
you're like, they're talking to that person or they're not
engaging with me. It's like they're not responding
to my Snapchat, but I know they're online and I see them on
Instagram. Dude, there's so much more
information. So much more information and
it's readily accessible, and I think it's easier to be cruel on
the Internet than it is in person.
I could be wrong. For people that have experienced
depression in adolescence and they're like, OK, maybe
potentially this might pop up again later in life, is there
anything that you would recommend they do at this point
in young adulthood to build that skill set?
Think about this differently. Again, the the the two major
things and once that the straight behavioral activation
component was just wait to feel like doing something.
If you would have done it, they can depress and do that anyway.
Make yourself do that and see where it goes.
You can get things moving more rapidly and then cognitively.
Don't believe everything you think.
Just because you think it's true, particularly if you're in
a bad mood, doesn't mean it is true.
Check those two things out. Interpersonal psychotherapy has
some really good strategies for building relationship, etcetera,
and I don't want, I don't want to short shrift them.
That's another very effective clinical intervention and all
good stuff, yeah. I'm curious to to get towards
the end of our conversation what you hope to see in the field of
depression research. What different areas you're
curious? About in the next 10. 20-30
years where you think we should be directing our energy or what
you think we need to. Understand more about.
Great question. I think focusing on just pre and
post adolescence is particularly part, again, my wife's
developmental psychopathologist and in her trials she can take
kids at elevated risk because they have parents with a history
of depression and cut the risk of initial onset in half.
And same kind of strategy we do for adults, but kids pick that
stuff up. Yeah, yeah.
What does that look like when she's working to decrease the
risk? Is it behavioral activation and
not trusting what you're thinking or any other
interventions? Exactly or where the two catch
phrases come from her. Oh, I love that.
Yeah. And she also trained at Penn
there with Marty Seligman that come from her basically, yeah,
adolescents can can do all of that stuff.
Yeah, no, I love that. I I took his class last
semester. It was incredible.
I got lucky because he hasn't taught undergrads in like 7
years and I happened to be here when he was teaching undergrads.
I was like, yeah, yeah, no, I think she's absolutely right.
And I think a lot of people underestimate how well
adolescents can internalize skills.
From a mental health perspective.
Like if you can learn how to think about those things
differently and how to manage your behaviors at that young
age, you really are setting yourself up for success in so
many ways. Because prior to that, it's like
you're environment and your schedule, which is largely
determined for you is doing a lot of the legwork.
You're not really building those mental health skills and so.
You have a lot of. Agency and capacity and I, I.
Don't know if we're trusting. Adolescents enough to be able to
like, remember, and internalize and implement these things.
I think you're exactly right. Our experience has been that
there's nothing an adult can do that an adolescent can't do.
The real change comes pre adolescents opposed to into
adolescents. From 11:12 on, that's just
miniature adults. Yeah, yeah, I love it.
Well, if people want to continue to keep up with your research,
where can they do that? I have a website at Vanderbilt
and we published periodically. When you took the class, was
that with the rupus or Seligman? We took it with Doctor Seligman.
He did the lectures for every single class and he had brought
in a bunch of MAP graduates at T as TA, so it was really
incredible. He was one of my, I think it was
one of my three mentors, along with Tim Beck and my wife's
primary mentor. Oh my gosh, that's incredible.
So he's that absolutely marvelous.
And he and Steve Mayer did a paper came out in 2016 where
essentially they said we got helplessness.
We're helplessness all wrong. Yeah, that marvelous thing.
And most scientists make their theories more complex when
they're conflicting data. This guy said no, we looked at
it and we had it. We turned upside down and and
you don't find many instances of that kind of courage in in the
sciences, but bless his heart for doing that.
You always used to say that in science, the goal isn't to start
right, it's to get right. What a great role model for
that. Yeah, no, we did the last couple
classes on AI and where he wanted to see the field going
and international conflict, like he's very much early adopter
thinking ahead. It's really, really incredible.
Yep, Yep, Yep. Marvelous.
It's amazing. Well, thank you so, so much.
For taking the time.