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 of caffeine and then I'm not able to fall asleep that night. Which is why I am partnering with Magic Mind and I'm officially a Magic Mind ambassador. I wanted to share this with you guys because it is one of the best finals hacks I have come across. I gave a bunch to my best friend.
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magicmind.co slash. She persisted 20 and you can get up to 48% off your subscription with code She persisted 20. So all of that will be in the show notes, but magicmind.com/shepersisted to 20 and use code. She persisted 20 for 20% off a one time purchase and 48% off 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.