Podcast: Depression 101

Jenn talks to Dr. Christian Webb about the intricacies of depressive disorders. Christian explains different forms of depression, shares advice on how to talk to a healthcare professional about it, talks about depression in kids and teens, and provides insight into how to make it through darker days.

Christian A. Webb, PhD, is an associate professor of psychology in the Department of Psychiatry at Harvard Medical School and director of the Treatment and Etiology of Depression in Youth (TEDY) Laboratory at McLean Hospital. Dr. Webb and his staff at TEDY investigate the etiology and pathophysiology of depression in adolescents, as well as the mechanisms of change in psychotherapeutic and pharmacological treatments for depression.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Hi folks, good morning, good afternoon, or good evening, wherever you’re joining us from today. Thanks so much for joining us for our conversation all about depression.

I’m Jenn Kearney. I’m a digital communications manager for McLean Hospital, and I’m joined today by Dr. Christian Webb, as my cohost.

One of the things a lot of folks know about depression is that it’s well-known for feeling hopeless, often worthless, and it’s really misunderstood by a lot of folks as something you can, quote, “Snap out of.”

It comes in a lot of forms. It can last for a long time or not much time, and it can impact all people, all ages, all genders, all races, all socioeconomic backgrounds, and it’s a topic that’s near and dear to me, and I’m really thrilled that we’re discussing it today.

Before I get into introducing Dr. Webb to everyone, I do want to remind folks tuning in that, number one, if you are suicidal or a danger to yourself or others, please call 911 or visit your local emergency room immediately.

We do have several resources that I wanted to share now, since depression is a very serious subject, and while we are talking about it today on this episode, there are programs that can help you if you are in dire need.

So if you are in the US, for the National Suicide Prevention Line, you can call 1.800.273.8255. If you prefer texting for free 24-hour support, you can contact the Crisis Text Line by texting the word hello, so H-E-L-L-O to 741741.

If you’re outside of the US, you can actually get a database of resources from the International Association for Suicide Prevention. If you have a mental health professional, and you think you’re in dire need of care, contact them, or lastly, you can call us at McLean at 617.855.3141 for more information if you think that you need admission.

So with that, I want to introduce Dr. Webb before I start asking him heaps of questions. So Christian Webb, PhD, is an associate professor of psychology in the Department of Psychiatry at Harvard Medical School, and the director of the Treatment and Etiology of Depression in Youth Laboratory at McLean Hospital.

As if he doesn’t do enough in a day, he has received several early career awards for his work on the treatment of depression, including from the American Psychological Association and the Association for Behavioral and Cognitive Therapies.

So Christian, I’m beyond, it’s weird for me to say that I’m beyond excited to talk to you, but I am. I think this topic has been a really long time coming in terms of episodes that we’ve talked about mental health. So thank you so much for joining.

I wanted to get started by asking you, so like I said before, the phrase being depressed still has stigma around people that could just, quote, “Get over their sadness,” and a lot of folks talk about it really casually, so what exactly is depression and just how severe can it be?

Christian: Well, first off, thanks for having me. It’s fun to be here. Yeah, that’s a good question. So in day-to-day use, we’ll say, “I’m feeling depressed,” and by that, we typically are referring to the emotion of sadness. “I’m feeling sad” or “I’m feeling down.”

So that’s one symptom of clinical depression, also known as major depression, but clinical depression has a specific definition and it’s much more than just feeling sad.

So currently we define clinical depression in the mental health community as having at least two weeks of five or more recognized symptoms, which can include depressed mood, it can include feeling sad as one of the symptoms, but it has to include other recognized symptoms, which we can talk more about. There’s nine in total.

So for example, in addition to feeling sad or down most of the day, nearly every day, you might be feeling very tired, you might have insomnia, trouble falling asleep, trouble staying asleep, feelings of worthlessness, loss of interest or pleasure in the things you usually enjoy, and there’s a bunch of other symptoms, which we can talk about.

You also asked about severity, I think, in that other part of your question. So it can really vary widely from person to person.

So one person might struggle with symptoms of depression, some of the symptoms that I mentioned, and they can function fine at work, at school, maintain social engagements. They’re kind of keeping it on the inside and they’re able to function, and friends, family, coworkers, classmates might not even know that there’s anything off.

Others might be, the curtain’s closed, bedridden, can’t get out of bed, and in profound, emotional pain, having suicidal thoughts. So it can vary a lot in terms of severity, and it can vary a lot in terms of symptom presentation, in terms of what kind of symptoms one individual with depression experiences versus another individual.

Jenn: So I know you had mentioned some of the symptoms that may occur with depression. With the full understanding that there is a spectrum of conditions, or symptoms, rather, are there some that are more common than others? And if so, what’s considered a common symptom of depression?

Christian: Yeah, so I mentioned depressed mood. Everyone knows that one, feeling really sad for most of the day, maybe every day, maybe nearly every day. Another really common one is loss of interest or pleasure in the things you usually enjoy.

So you’ve lost interest and enjoyment in your hobbies, and seeing friends, in activities. It all seems kind of blah, you don’t enjoy those things anymore. You’re not interested in those things anymore.

Difficulties concentrating and making everyday decisions, feeling worthless about yourself, feeling very guilty about things you’ve done or haven’t done.

I briefly mentioned difficulty sleeping. So I mentioned insomnia, difficulties falling asleep, or staying asleep nearly every night. Some individuals have that, others have the opposite, which is sleeping too much.

Another one that can go both ways is changes in appetite. So having the loss of appetite is common, although some individuals have an increase in appetite and an increase in weight. Another common symptom is feeling very fatigued.

You can imagine that can go in line with the insomnia, right? If you’re not sleeping much, you’re feeling really tired. And for some folks also having thoughts of death or suicide is also not uncommon.

Jenn: Can depression be caused by environmental or situational factors? So like a fresh example might be the pandemic or the fact that our climates are changing. I know that we had mentioned that there are some biological factors, but how much of it can be impacted by what’s happening outside of our body?

Christian: A lot. So the majority of individuals who are diagnosed with an episode of clinical depression will have experienced some type of negative life event in the prior month or so.

So that could be a fight with a friend, it could be feeling rejected from a group of friends, it could be a breakup, it could be a divorce, it could be a job loss, a stressor at school, so usually there is something environmental.

Now, often what we see is that there’s, those two things you mentioned work together, so there’s some underlying vulnerability factor. We can talk more about the different risk factors, things that put folks at risk for depression in terms of their thinking style, in terms of their neurobiology.

So some vulnerability factor that interacts with something, some negative life event happening. So you’re already a bit vulnerable, but you’re doing fine, and then you get hit with something bad happening in your life.

Jenn: Are there any major fundamental differences between situational depression and another type of depression like clinical depression, or can they both be classified as depression overall?

Christian: Yeah, the way that depression is defined now is just based on the symptoms. So it’s based on the duration of the symptoms and the number of symptoms.

I say now because things change over time, and if we looked at, move from psychiatry to the physical illnesses in medicine, we tend to define things based on the causes.

So if someone goes in and you’re having flu-like symptoms, they don’t automatically say, “It’s the flu.” They’re going to test it, is it COVID, is it the flu? Maybe it’s cancer.

It could be a lot of different things that is leading to the same symptoms, but the stages in psychiatry, clinical psychology now is really defining things based on symptoms.

There has been some work trying to distinguish between situational depression and non-situational depression, but it really hasn’t really found consistent findings.

Jenn: Is there a difference between feeling depressed and actually having an official diagnosis of depression?

And a follow-up question that an audience member asked was, “Have diagnoses of depression increased in recent years?”

Christian: Yeah, let me start with the second one. So most of my research focuses on adolescents, so that’s what I’m most comfortable talking about. There is evidence overall that depression rates might have gone up.

Again, I’m more familiar with the research in teens, and there’s evidence that, well, first of all, during the pandemic, as folks have read about, that there’s evidence that rates of struggling with stress, depression, anxiety, have increased in teens.

But over the last 15 years, since around 2007, there’s evidence that depression rates have actually gone up in teens, and they were already fairly high to begin with. And then the first part of the question was about sadness versus depression, is that right?

Jenn: Yeah, so feeling like you’re in a depressed mood versus having an official diagnosis of depression, are there differences between the two?

Christian: Yeah, there’s no clear cutoff, but it is, as I mentioned, a continuum.

So you could be feeling very sad, crying, feeling really down, but you don’t have this whole syndrome, all these other symptoms for long enough that a psychiatrist or clinical psychologist is going to say that you meet criteria for clinical depression.

So you, you might have three of the symptoms that I mentioned, well, right now, we’re not going to apply the label major depression or clinical depression. That doesn’t mean you’re not struggling, and that doesn’t mean that you wouldn’t benefit from having someone, a mental health professional to talk to.

Jenn: So is there a difference between bipolar depression and clinical depression?

Christian: Yeah, so I mentioned a couple of different terms that are used to define, they’re the official diagnosis of depression: clinical depression and major depression.

Another term that’s used is unipolar depression, meaning one pole you’re experiencing depression. Bipolar depression is something different.

Bipolar depression are individuals that are suffering and struggling with not just episodes of depression, but they’re also experiencing manic episodes, which includes elevated, expansive mood, sense of grandiosity, engagement in risky behaviors, sleeping very little yet feeling totally rested, so it’s a different set of symptoms.

And so the term bipolar refers to these two poles going from depression to manic episodes.

Jenn: I know that a lot of your research focuses on youth, so I want to talk about that specifically for a little bit. How common is depression in children and adolescents?

Christian: Yeah, so rates of depression in children is pretty low. So in children, around one to three percent of children will have experienced an episode of clinical depression. Then when you get into adolescence, you see this surge in depression rates.

By the end of adolescence, by around age 18, around 15% of teens will have experienced at least one episode of clinical depression. So it’s really this rapid surge that tends to level off.

So a lot of individuals who have a history of depression, have experienced the first episode during adolescence. The other thing that we see also is emergence of gender differences. So you see equivalent rates of depression in children, in girls and boys.

Then during adolescence, you see the separation where both curves are going up, but more so for girls, and the rates of depression are about twice as high, approximately, in girls than boys, by the end of adolescence, and that two to one ratio persists throughout adulthood.

Jenn: Can you expand a little bit on depressive presentation in youth? Is there any difference between how a kid or a teenager might be presenting depressive moods or symptoms versus what even like a young adult, like somebody in their early to mid-20s might be experiencing?

Christian: So there’s a lot of shared symptoms. Some of the differences that could be seen is irritability.

So it doesn’t mean that an adult doesn’t experience irritability or anger when they’re depressed, but it could be common in children or in teens that you don’t see as much of the sadness.

You might see them lashing out, being a lot more irritable than usual, which kind of makes sense if you’re suffering inside, that you might just lash out more, and be more irritable and snap more.

Behaviorally, teens spending a lot more time in their rooms, spending more time in bed, having trouble getting out of bed more, not really wanting to hang out with friends anymore, having difficulty with their grades, which makes sense if they’re having trouble concentrating and really not into it.

So those are some of the common presentations, but again, they differ a lot from person to person.

Jenn: One of the things that kids these days, as I’m not far removed from them, but they’re digital learners, there’s constant digital consumption, so video gaming, social media use.

Are you familiar with any connection between always being attached to a screen and depression?

Christian: Yeah, that’s a great question. So it’s obviously, there’s been a lot of articles and a lot of stuff in the media about that, and the research is really in the early stages.

So, that’s one of the things that researchers were looking at in terms of what I mentioned about the increase in depression rates in the past 15 years, around since 2007, which is when the iPhone came out.

So given just the correlation to the timing of the iPhone coming out, and social media usage, and ease of access on the phone, and being on a screen, and the increase in depression, people thought, “Well, maybe there’s something going on there as one of the causes.”

So initially the early research suggested that, yes, social media has, on average, a negative influence, but there were some problems with that early research in terms of the size of the samples, how we’re measuring social media use.

Is it subjectively, like you just tell me how much you’re using technology and screens and social media versus getting objective measures from the phone.

And so then there was some follow-up research, which found that with much larger samples and better conducted studies that suggest that, on average, there really isn’t much enough of an effect there.

And now there’s getting more fine-grain research saying, “Well, we’ve got to break apart how individuals are engaging with their phones and technology and social media,” because you can engage in a positive way or in a negative way.

So there’s, for example, there’s so-called passive use where you might just sit back, scroll through your social media feed, compare your body image to others, compare how much fun others seem to be having in their carefully curated social media presentation.

And so that could lead to the kind of comparisons and low self-esteem, or you could engage actively. It’s a way to connect with people, it’s a way to post creative content.

And so I think, there’s, again, it’s an active area of research and we’re learning that some ways of using it can be harmful, some ways of using it can be neutral, some ways of using it can be positive.

But it’s definitely something to look out for and for teens to really notice what impact is it having, and teens use it a lot, so what impact is technology use and social media use having on me personally?

Jenn: So in your research of kids and teens, have you found any trends with teens that are choosing to self-medicate like with marijuana or alcohol versus staying consistent with taking prescribed medication for their depression?

And if so, do you have any recommendations for parents who are having a hard time with kids juggling the two of those things?

Christian: Yeah, I don’t personally do research in the substance use area.

But yes, there are individuals, both teens and adults, that they’re really struggling emotionally, and so might turn to substances to make themselves feel better, which might work in really the short term, but in the long-term, just makes them feel worse.

And so that’s something that would need to be addressed if someone’s experiencing depression, plus is having some struggles with marijuana or alcohol or other drugs, that the substance-use issue really needs to be addressed upfront with a clinical psychologist in therapy or a psychiatrist.

Jenn: Have you found that using like a talk therapy app versus trying to get a kid or teen into therapy has been helpful? Do you have any knowledge on how these apps have been useful for treating depression?

Christian: Yeah, there’s really like a proliferation of ways of accessing therapy.

So conventionally, traditionally face-to-face therapy, you go to the office. Things have shifted a lot during COVID where there’s much more teletherapy, so you still see a therapist, but you see them via Zoom or some other video conferencing.

There is app-based therapies, as you mentioned, so via an app. That could be interacting with an actual clinician, it could be all content that’s already on there, so you’re not actually interacting with the clinician.

And then there are also internet-based therapies, which we’ve done some work on where it’s actually, the content’s already there. You’re not interacting with somebody, you’re learning skills like cognitive behavioral therapy skills, which is the most widely form of therapy.

The research so far seems to suggest that there might not be that much of a difference between these different forms of therapy on average, but then the big question is for whom is one type of therapy better suited?

So that’s on average, but are there subgroups of individuals that are better suited to one versus another?

There’s been a little bit of research on different kinds of internet-based therapy where, one, you do have weekly interactions with somebody who’s just checking in on you briefly versus, it’s called, guided internet-based therapy versus unguided where you’re all on your own.

And some research find that if your depression is a little bit more severe, it’s really helpful to have that guidance to keep you engaged.

Jenn: Exactly, I find, one of the things I’m passionate about is understanding human behavior trends, and if you’re having a really difficult time with that self-motivation piece, having somebody to guide you along that journey can be way more impactful than you trying to motivate yourself to actually get started.

Christian: Right.

Jenn: I did want to ask you about crisis lines. I know I brought them up in the beginning of the session, but have you studied any of the impact on crisis lines on depression for teens or teen use overall of crisis lines?

Christian: I’ve not done any research, but there’s a number of wonderful helplines out there. And it’s really important for individuals to have access to those when they’re in a moment of feeling unsafe in a moment of crisis. And so there’s a number of them out there.

They can easily be accessed and found just by Googling, and there’s some for different groups also, for different demographic groups, but no, I’ve not personally done research on that topic.

Jenn: I do want to keep in mind with the next question I have for you that, depending on the person, this answer is certainly going to vary, but what are treatments for depression, especially for teen populations?

Christian: Yeah, it’s a great question, a big question. There’s a variety of different treatments out there. So there’s antidepressant medications, and there are a variety of different classes of antidepressant medications. There are a number of different kinds of psychotherapy.

The form of psychotherapy that’s received the most research support is cognitive behavioral therapy. There’s also another form that’s received a fair bit of research support for adolescents called interpersonal therapy.

Cognitive behavioral therapy is one of the therapies that we’ve done research on in my lab with collaborators on teens.

One of the things that’s beneficial about cognitive behavioral therapy is that it’s been shown to be as effective as antidepressant medications in terms of reducing depressive symptoms.

And there’s some evidence, too, that receiving a course of cognitive therapy actually has protective effects at reducing the risk of relapse as much as, or even a bit more than if you stay on antidepressant long-term.

So you do a short-term course, a few weeks or a couple of months of cognitive behavioral therapy versus a group of individuals who stay on antidepressant medications long term, the cognitive therapy group does just as well in terms of reducing the risk of relapse, and there’s some initial evidence that they might even do a bit better.

Again, I should say that that’s on average, and an active area of research, including in our lab, is figuring out who is best suited for which treatments. We don’t have an answer to that yet, but that’s a very active area of research.

Jenn: So one of the things that we’ve encountered during the pandemic, especially, is that there are only so many licensed therapists or psychologists, psychiatrists in people’s areas.

So what could a parent do to help a teen that is depressed, but can’t get in to see a therapist? Are there ways that parents can help at home?

Christian: Yeah, so that’s absolutely right, for both teens and for adults, there’s an enormous shortage, and in some areas of the country and more rural areas, there’s even a larger shortage of mental health professionals and clinical psychologists and psychiatrists and others.

So one of the things that can be done is to explore. For example, if you’re on a wait list and it’s a lengthy wait list for therapy, there are some of these internet-based, web-based psychotherapy programs that you can access.

There are websites that can also give you information on what are the different treatment options that you could explore. So if you go to the Association for Behavioral and Cognitive Therapies, ABCT has some useful information there.

The American Psychological Association has different divisions. One division’s called Division 12. It’s the Society of Clinical Psychology. They’ve got a very useful resource list of the different kinds of treatments for different kinds of problems.

So you can look up, what problem am I experiencing or is my child experiencing? And what are the different, empirically supported, the different range of treatments that are options?

There also are websites evaluating digital therapies like mindfulness apps, internet-based treatments, and they’re evaluated by a clinical psychologist or mental health specialist to give you information about what apps, what internet-based treatments have research support for the problem that you’re experiencing or your child is experiencing.

And the name of that website escapes me right now, but feel free to shoot me an email.

Jenn: Do you have any advice on how to help a depressed teen that is having difficulty concentrating?

Christian: Yeah, that can be difficult because difficulties concentrating can come from a number of different issues. It can come from, are they having some actual attentional problems that precede their depression?

So it’s not so much about the depression. Maybe the depression made it worse, but they had some attentional problems. Maybe it’s attentional deficit disorder, maybe it’s something below that, but they’re having trouble concentrating, maybe it’s specific to specific classes, maybe it’s part of depression.

Maybe it’s difficulty concentrating that’s part of the first episode and they need treatment for the depression, as opposed to the other case I mentioned, they need treatment for the attention deficit disorder.

So in that case, the best thing to do is to contact your PCP, get a thorough assessment done, have them give you a referral to get a sense of what’s the root cause of this.

Jenn: Can you talk a little bit about whether or not populations are more likely to be diagnosed with depression than others?

Is this folks that have preexisting mental health conditions or other physical ailments, just to provide a couple prompts?

Christian: Yeah, so there’s a number of risk factors that have been linked to depression. So we know that different individuals who have different kinds of negative thinking styles can be at increased risk for depression.

So that could be, there’s been research on a number of different kinds of habitual, repetitive, negative-thinking styles, like self-critical repetitive thoughts about the self, pessimistic thoughts about the future, hopelessness.

Rumination is one, and so rumination refers to repetitive negative thinking about one’s problems and how one is feeling. Having a family history of depression, so that group of individuals are at elevated risk.

So if your parents, if your mom or dad or both, or going further back, have a history of depression, that can increase your risk. There are personality differences that have been linked to depression, there’s research on that.

There are some brain differences, some early research on that. For example, the brain’s reward-related regions, the pleasure centers of the brain, some evidence of blunted neural activity there can be a risk factor. Having traumatic early life events, so abuse early in life can be a risk factor.

And the critical point is going back to what I’d mentioned before that we usually see that individuals that have one or more of these risk factors, who also experienced some recent negative life event are the ones that we tend to see experiencing depression.

So you’re already vulnerable with some risk factor, you experience something bad happening in your life, and then you might fall into a depressive episode.

And it’s also important to note that, to really highlight that this isn’t deterministic. It’s not like you have one of these risk factors, you will develop depression. It’s on average, it increases the risk, and critically, depression is treatable.

We have a number of treatments. I just mentioned a few. They’re not perfect, but they can help a lot of people. One thing too is LGBTQ youth, there’s evidence there of increased mental health problems.

And also folks who just have experienced some recent stressors, could be chronic stressors or a major negative life event, as I mentioned earlier, are at risk of struggling with depression.

Jenn: Is there a way to tell if depression is causing another illness or if an illness is causing depression itself?

Christian: Yeah, that can be challenging at times.

I mean, it’s important to talk, if you having a physical medical illness, to talk to your doctor, your medical doctor, and, or a mental health professional if you’re having depression or struggling with some other psychological problem, but you’re also having a physical illness, and so you’re not too sure which came first.

And what they’ll do is look at the sequence of the onset of the symptoms. So maybe you had an accident or having chronic pain, and then you develop depression after the fact, which is understandable that you’d be struggling emotionally if you’re having chronic pain and really struggling to function.

Or vice versa, you might have someone who’s having symptoms of depression, that comes first, and then they start noticing some really bad GI symptoms, which are actually caused by the depression and the stress. It can be hard to tease apart those two, but a doctor will look at the sequence of the onset of those symptoms.

Jenn: So I know that we’ve talked about situational depression, we’ve talked about clinical depression, is depression a lifelong condition, or can somebody be considered, air quote, recovered from depression?

Christian: So the best evidence that we have to date is around 40 to 60% of individuals who have depression will have one episode of depression, and that’s it, which means that the other half, the other 40, 60% will have more than one episode.

That could be a few episodes, that could be many episodes. We do have effective treatments that have been shown not only to reduce symptoms of depression, but also reduce the risk of relapse.

As I mentioned, cognitive behavioral therapy is one, there are others like behavioral activation therapy, which is more focused on behaviors than thought patterns. Mindfulness-based cognitive therapy’s another one that’s been shown to reduce the risk of relapse, so that’s important to know.

And perhaps someone does have regular bouts of depression or bouts when their mood starts to drop, but because of the skills that they learned in therapy, like cognitive behavioral therapy, they are able to get themselves out before it gets too low, or really notice the patterns and reach out to their therapist for booster sessions.

There’s nothing wrong with getting booster sessions, for if we have a chronic physical illness and you have flare ups, we need some changes to our medications or to the treatment regimen.

And so you might need to have medication change or have some booster sessions in therapy, and that’s something that’s available.

Jenn: You mentioned mindfulness tools. Can you speak a little bit to how meditation and mindfulness can help relieve depression?

And I feel like I know the answer to this question, but how much practice in terms of meditative state, mindfulness is necessary for feeling relief of depressive symptoms?

Christian: Yeah, I can answer the second question quickly, that I don’t know of any research study that can answer that second question of how much you need.

There is a growing amount of research, both on meditation practice, as well as in forms of psychotherapy that integrate principles and practices from meditation. I mentioned one, mindfulness-based cognitive therapy.

There’s also other approaches like acceptance and commitment therapy called ACT. And there are other therapies that integrate mindfulness, like dialectical behavior therapy, which tends to focus on some other problems.

So in cognitive behavioral therapy, typically, this is over simplifying here, but in the cognitive piece, you’re helping individuals identify negative patterns of thinking that they’re having, and helping them to challenge and change, to modify those negative patterns of thinking.

With mindfulness, there’s less focus on change. There’s more focus on starting to be able to notice those negative patterns of thinking as they occur, rather than the default, which is we’re just immersed in those thoughts, and we don’t even notice it.

So mindfulness will teach you to kind of step back, a metaphor that’s used is like looking at the thoughts as they occur like leaves on a stream, and you’re sitting on the bank, on the edge of the river, rather than being immersed in the river, in the thoughts, or as clouds passing by your life.

So if you’re able to disengage from those negative thoughts, from those ruminative thoughts, and observe them, and notice that they’re events in the mind, they’re events the mind propping up, they don’t necessarily reflect reality, those negative thoughts, where they’re saying negative things about you or your future.

And so by disengaging, that can really, you’re not fueling the fire. Those thoughts will dampen down quicker. So that’s kind of the theory behind it. There’s been research on reducing the risk of relapse through these approaches.

And again, I mentioned this mindfulness-based cognitive therapy, which has gotten a fair bit of research support. We’re doing research on mindfulness apps for teens, and how effective that is at reducing negative patterns of thinking, and there’s good evidence of that, growing evidence of that.

Jenn: I know that you’ve talked about some varieties of treatment methods. Are you familiar with ketamine, TMS, and other emerging modalities as being successful for treating depressive symptoms or disorders?

Christian: Yeah, there’s research primarily in adults on a range of different types of treatment approaches for treatment-resistant depression, where you’ve tried some of the first-line treatments like therapy and antidepressants, and they aren’t working so well.

And ketamine is one, there’s electroconvulsive therapy or ECT, both of which are provided at McLean. There’s also research going on on a number of different approaches like transcranial magnetic stimulation with these magnetic pulses that stimulate brain activity.

There’s research on psychedelics also, which folks have probably read about, on psilocybin, for example, on reducing depression in those with treatment-resistant depression.

So there’s a lot of research going on, and some of those approaches like electroconvulsive therapy and ketamine have a growing amount of research support, but there’s still more research to be done.

Jenn: Is there any role in sleeping well, eating well, getting physical exercise, do those actually help depressive disorders? Is that something that would be supplemental to treatment? Any research that you’re familiar with on those?

Christian: Yes, absolutely. So having a healthy lifestyle, all the things that you mentioned, healthy diet, regular exercise, regular sleep schedule, all of those have a lot of research support.

So there’s even some research showing that for individuals with insomnia, don’t have depression, they have insomnia, you treat the insomnia, it reduces their risk of developing depression if you get them on a regular sleep schedule.

So this is an active area research in teens, as you can imagine just because school’s starting, they have to get up really early, they’re using technology, they’re staying up late, their sleep is all out of whack.

Of course, that can happen with adults, too, with screen time being used late or too much caffeine. So having a regular sleep schedule, exercising regularly, those can be very helpful, and it’s used, it’s integrated within therapy.

So behavioral activation therapy, as I mentioned, as well as in cognitive behavioral therapy, your therapist will look at your sleep schedule, will look at your activity level because those are good, really kind of mild to moderate anti-depressants.

Jenn: Is there any evidence out there about untreated depression and the impact it might have on a person as they get older?

Christian: Yeah, I mean, depression left untreated, again, if it’s the kind of individuals having repeated episodes, rather than just one, that can cause problems.

It can increase the risk of other mental health problems, you mentioned like substance use, it can also increase the risk of physical problems, and problems at work, problems in relationships.

And we know around 50% or 60% of individuals within wealthy nations like the US are not receiving treatment, and it’s higher in other nations.

So what is important, if you’re experiencing depression, or think there’s a loved one in your family that is experiencing depression, to try, and it can be hard to do given barriers in treatment access, but try to find some treatment for them.

That way, these negative consequences don’t come to bear.

Jenn: Do you have any advice on helping teens that are vulnerable or prone to depression, but are also having difficulty connecting with their peers?

Christian: Yeah, that could be, I mean, that’s a really individualized question. So what is causing those problems in that teen?

What are ways that a parent or teacher, a sibling can help encourage that teen to engage, connect, ‘cause connecting socially, it’s just so critical at that age, but it’s really an individual question of what’s really going on for that individual that’s getting in the way and causing problems.

Jenn: Have you noticed that the pandemic, in particular school closures, disruption in schedule, has contributed to depression or regression in kids that are either on the autism spectrum or have an attention disorder like ADHD?

If so, do you have any advice for how parents can help these kids?

Christian: I haven’t done research nor am I familiar with research specifically with autism or ADHD, or potential problems during the pandemic.

But overall, yes, it is the case that, not surprisingly, with school closures, with disconnection from peers, and inability to see them as frequently in person and to engage in social life is so critical for adolescents.

And sitting in front of a computer and doing your schooling through that, that that’s caused mental problems for a lot of teens.

Jenn: I want to talk about approaching your healthcare provider about the way that you’re feeling, especially if you think you’re depressed.

One of the challenges that I’ve seen in the doctor’s office is if you go to your primary care and they say, “How are you doing today?”

And if you’re doing fine, but you haven’t been most other days, you might say, ‘cause it’s a snapshot in time, like, “I’m doing fine,” and that might mean that you aren’t getting a depression screening for another four to six months, if that’s how long you are between going to see your PCP and seeking treatment.

So how can you talk to your doctor about the way that you’re feeling, especially if you think you’re depressed, in a way that doesn’t actually say like, “I’m okay in this moment, but I’m not okay any other time?”

Christian: Yeah, it can be difficult. This is someone you see maybe once a year for your annual, and it’s also someone who, PCPs are amazing, but they’re not specifically trained as clinical psychologists or psychiatrists, so they don’t have all that knowledge of what to look out for and what to ask for.

So, first thing to understand is just how common depression is. It’s understandable that it’s difficult to talk about.

But you take a hundred people in a room, 15 or 20 of them will have a history of depression, based on the prevalence rates, which is why many doctors will ask those questions or give a brief paper and pencil screener, or at least ask about symptoms ‘cause they have so many people coming through the door, they’re seeing folks that are struggling and they might not even know how to deal with it, or how to ask in the right way.

So I would say, just be your best, be your own best advocate. They see this all the time, given the prevalence rates. Mention that maybe you’re feeling okay now, but you’ve been struggling with these symptoms. There’s nothing to be ashamed about. It’s a very common problem.

Ask them about what their recommendations are in what you’ve been struggling with, feeling really down, trouble sleeping, feeling really worthless.

“Do you have any recommendations about, is this depression? Is this something else? Is this going to go away on its own? Should we address this? What are my treatment options? What’s available within the clinic or within the network of the clinic? Do you have recommendations for therapists or psychiatrists?”

So really, you need to be your own best advocate, which could be difficult to do if you’re struggling, but just remember, again, just how common it is.

Jenn: So out of curiosity, has the terminology on depression and how clinicians talk about it changed over the years?

We had a couple of folks write in saying, depending on the provider, the phrase like dysthymia, I think I’m pronouncing that correctly, has been mentioned, but it’s certainly not as commonplace as it used to be. Is that a phrase that’s being phased out or what’s going on?

Christian: Yeah, dysthymia, it refers to basically a lower grade, but still distressing level of depressive symptoms. You’re not meeting a full blown, five or more symptoms, two weeks, it’s lower grade, but longer lasting and more chronic.

So I think there, again, is just talking to your doctor about the symptoms you’ve been experiencing.

And usually that can go on for years, that, “Hey, for the last two years, I’ve had pretty chronic, feeling depressed, four or five days a week. It’s not 100% of the time, but it’s 40% of the time, having trouble concentrating, trouble sleeping.

This is really causing a problem for me. Is this depression or a form of depression? If you’re not sure, who can I talk to within the clinic? Or who can you refer me to that I can talk to and get some treatment for this?”

Jenn: I had a couple of clinicians write in and asking questions. The first one is do you have advice for how to respond to a patient that’s severely depressed, but is refusing help?

Christian: Yeah, I mean, that can be really difficult. I think it’s also similar to other questions I get asked about, you have a family member or a colleague or a friend or a classmate that you clearly see is struggling with depression.

You’ve brought it up trying to help them, but they’re not really, that advice isn’t really sinking in. I think all you can do is provide consistent support.

And that person might finally accept your help when they see you’re not giving up on them, let them know how much you care, what you’ve been noticing, that there are effective treatments out there, there’s a range of different treatment options that can suit your needs.

Maybe have other individuals that can give the same message, they’re hearing it from multiple places, but in the end, we can’t force somebody to get treatment.

Jenn: Do you have any advice for a patient with depression that is having a difficult time identifying the source of their depression?

Christian: Yeah, that’s really not uncommon to not know where the depression came from, and I think that’s where seeing a mental health professional’s really important, and a psychologist, a clinical psychologist can help you identify what the source is.

Sometimes, it depends kind of what the question’s about. Sometimes we don’t need to go all the way back in the past to find out the exact source to treat what’s happening now, what are the behavioral patterns, the thinking patterns that are contributing to depression now.

It can often be very helpful, but it’s not always necessary.

Jenn: Can you talk, I know we’ve talked a lot about child and teen populations ‘cause that’s where your research is really heavily focused, but what about depression in older or elderly populations?

Even if it’s been treated, is that something that generally gets worse with age?

Christian: So we tend to see, actually, if you look at, depression happens at any age, and there is a subgroup of older adults who experience depression and there are folks that specialize in that.

We have geriatric units here at McLean for folks that specialize in that. Just in terms of overall emotional well-being, one thing that you actually see is there’s struggles with teens on average, teens vary a lot.

You tend to see actually overall happiness levels, on average, increase over time and keep increasing in older adults, on average. But yes, there are many older adults that struggle with depression for a variety of reasons, could be linked to health conditions, could be linked to loss of a loved one.

And so getting help, seeing someone who has expertise, it’s another important thing to be your own best advocate when you’re asking about questions to a clinician, to a psychiatrist or a psychologist.

Ask them, “Do you have experience treating someone like me who is experiencing what I’m having?” Or, “Treating my child? Tell me about what experience you have,” but there are individuals who specialize in that.

Jenn: So if I think a loved one might be struggling with depression, how do I approach this topic with them? How do I get this conversation started?

Christian: Yeah, yeah, first be supportive, loving, and empathic. Talk about the changes that you’ve noticed in them, that you’re really concerned about them, that it looks like they’re really struggling, and how treatment can help.

You might not know about all the treatments, that’s fine. There are good treatments out there. And your loved one might need help to get started finding help, right?

If they’re having trouble concentrating, they’re really tired, they’re unmotivated because of the symptoms of depression, then they might need help finding a therapist, finding a psychiatrist, might need help getting a drive to the therapist’s office.

Or maybe it’s teletherapy or online, they might need help just connecting the Zoom session. So that’s something to look out for, that they might need help just getting to the first session, first couple of sessions.

Jenn: I would be remiss if I didn’t talk a little bit about COVID. We’re in, as I like to joke, we’re in season three of the worst TV series I’ve ever encountered. What are some of the ways that we could lessen the impact of the pandemic on our mental health? Any advice?

Christian: Yeah, I think it goes back to those lifestyle things that we mentioned, doing it in a safe way. We’re social beings. We need to socialize. We need to interact with others, be active and engaged.

I mean, the worst thing to do for your mental health is isolate socially, spend time sitting on the couch, just watching Netflix all day long. There’s nothing wrong with watching Netflix, I do too, but an inappropriate dose.

So isolating, being inactive, not exercising, eating unhealthy, not socializing, and those are all hard things to do ‘cause that’s some of the measures that we’re required, especially early on, to quarantine, isolate and all that.

So I think finding ways that you can sprinkle in your daily and weekly schedule things that you find are helpful for you.

It could be a walk outside, it could be a walk with a friend, it could be a social engagement via Zoom with friends, some things that you used to do that you know make you feel good and finding a way to do that in a way that is safe and you feel comfortable with.

Jenn: I’ve got one last question for you. Number one, because I want to be cognizant of your time, and number two, because the last hour has been like both a sprint and a marathon for you, and I am thoroughly impressed by how much knowledge you have.

My last question for you is any resources, tools, workbooks that you would recommend that would help somebody, whether it’s a loved one or themselves, navigate depression and/or be a good supplement for therapy?

Christian: Yeah, so some of the websites that I mentioned, and feel free to ping me if you have trouble finding them, I’ve mentioned the Division 12 of the American Psychological Association, the Society of Clinical Psychology.

Click on the problems, having depression, substance use problem, it will tell you the different treatments that are available that are supported by research, including self-help interventions.

And in terms of self-help books that are based in cognitive behavioral therapy, again, that’s a form of therapy that’s received the most research support, there’s one called “The Feeling Good Handbook” by David Burns, “Feeling Good Handbook.”

There’s also “Mind Over Mood” is another CBT-based one that has more exercises, less reading. So if you’d like to kind of read more, then “The Feeling Good Handbook” is the way to go.

If you just want kind of worksheets to work on skills, then the “Mind Over Mood,” but that’ll be all on that website that I mentioned.

Jenn: Amazing, I know that we are just about at the hour, so I’m going to wrap it up now just by saying, from the bottom of my heart, Christian, thank you so much.

This has been eye opening and transformative and super informational, so thank you so much for joining me to talk all about depression, and to anybody tuning in, this actually concludes our session.

So thanks so much for joining us today. Until next time, be nice to one another, but also be nice to yourself. Thank you again. Have a good one.

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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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