Depression is genetic – psychiatrist

SS: So you wrote a book called ‘When Antidepressants Aren’t Enough: Harnessing the Power of Mindfulness to Alleviate Depression’. Well, I've always thought of antidepressants as some sort of big guns against depression that are needed when all the rest is not enough. Am I wrong? 

SE: Well, antidepressants, you can think of as being big guns, but they're often helpful early in the treatment of somebody with depression. But the trouble is that they're not always completely effective for people. So for example, if you take a person who has depression and treat them with an antidepressant, at the end of 12 weeks, a third of them will have recovered, but two thirds won't recover. And if you give those people another antidepressant, another 12% of people will recover. So after two antidepressant treatments, 50% have covered but 50% haven’t. And for those people, that's why we developed our program to help people with mindfulness-based cognitive therapy.

SS: Well, before we dive deeper into the topic of mindfulness, let's try to deconstruct what is depression. I mean, it can be a serious mental problem that has to be treated by professionals. But how does one know that one is feeling not just like, you know, a bout of common blues but like a clinical depression? How do you know that? 

SE: Well, usually by the depth of the symptoms and the persistence of the symptoms. You're quite right, it's normal to have blues in reaction to life stresses at times. But when symptoms like impaired sleep, impaired appetite, seriously depressed mood, suicidal thoughts, persistent negative thoughts occur and if these last for two weeks or more than we think of a person as having a major depression or a clinical depression.

SS: Can I ask you something? Can you tell a person is depressed by their blood sample or an MRI brain scan, for instance? Or is it just the persistence and depth of the symptoms?

SE: Well, actually, there is no blood test for depression. There have been many attempts to try to find that but there is no blood test. But in terms of MRI, if you use a special test called ‘a functional MRI’ that measures brain function, a regular MRI is just like a snapshot of the structures of the brain. But a functional MRI measures how much blood flow is going in certain areas of the brain. And that actually can pinpoint depression because there are typical findings on a functional MRI.

SS: So I mean we're not like a medical or scientific program. We're just a program for a wide audience. Can you explain in simple words, what is happening in a brain of a depressed person? 

SE: The best way, I think, to simply describe it would be there are certain areas of the brain that generate emotions, the emotion-generating areas. One of them is an area called the amygdala. So if you're depressed that amygdala is hyperactive. And there are other areas of the brain that regulate emotion. These are areas like the dorsolateral prefrontal cortex, it's this area up here. And so normally, the emotion-regulation areas of the brain are сontrolling the emotion-regulation [editor’s note: emotion-generating] areas, but in depression, the emotion-generating areas are increased and the regulatory areas are decreased. So what we try to do with treatment, whether it be an antidepressant treatment, or with mindfulness training, is restore this area so it has primary control.

SS: What causes depression? Is it like chemicals in the brain that are imbalanced because I don't eat my veggies, for instance? Or is it because life around me is so tough and exhausting and stressful and bleak?

SE: Well, it's probably a combination. There's a definite genetic bias or basis to depression so that if your mother, father, brother, and sister, if they have depression, you're probably at higher risk for it genetically. And then if you take certain life stressors that occur, they may activate that genetic basis so you develop depression. So it's really a combination of your genetics and life stressors.

SS: You know, I've often read in many scientific papers that women are believed to be affected by depression much more than men and some studies even suggest that I think 1/3 of all women experience at least one depressive episode during their lifetime. Why? Is female psychology to be blamed for this unfairness? Or do women statistically have more reasons to worry during their lifetime? Why is it?

SE: Well, that's a good question. And we don't know all the answers to that. But it's definitely true, that in studies of depression, women outnumber men significantly, and it may relate to a number of factors. The hormonal basis in a woman is different. They may be more subject to certain life stressors than men are, and that men may, for whatever reason, perhaps genetics, tend to react to stress somewhat differently. So a woman might get depressed in a situation whereas a man might turn to substance abuse, to alcohol, for example. 

SS: I came also across several studies that suggest that people with higher IQ are more prone to mental disorders, including depression, anxiety. Do you see a connection there? Because we often see very bright, very talented people taking their own lives after a long depression. What do you say to that? How can you explain it?

SE: Well, I'm not sure if there's a really good correlation between somebody’s IQ and depression levels. Depression is an equal opportunity illness, it really affects people across different social classes and IQs. I mean on any given day, there's over 100 million cases of depression throughout the world. So it's a very widespread illness, and it affects people across the board.

SS: If depression hits, and then it seems to be okay, and you get over it, what are the chances that it will actually come back one day?

SE: Unfortunately, the chances are pretty good that it'll come back, it tends to be a recurring illness. That's why depression is the number one cause of disability in the world because it tends to occur initially in a person's younger ages, like when they're in their 20s, and that it recurs over their lifetime. So if you have an episode of depression, the chance that you're going to have another episode in the next 10 years is about 20%. If you have two episodes, the chance that you're going to have another episode goes up to 50%. And if you have three episodes, the chances are 90%, that you're going to have another episode.

SS: You know, I have this very famous and popular psychologist in Russia, and he's pretty radical in his beliefs and he told me once that, you know, everyone after 65, pretty much everyone should be put on antidepressants because their hormonal changes are so drastic that if you don't do that they will struggle until the end of their lives. What do you say to that kind of radical approach that people after 65 should be put on some sort of antidepressant?

SE: Well, I would disagree with that. I mean, antidepressants are very helpful for many people, but they're not without side effects and risks of their own. And most people over 65 don't get depressed. It's common, and it is a problem when it occurs, but most people are not going to get depressed.

SS: So you say that mindfulness is a great help against depression. But when you say ‘mindfulness’, what exactly do you mean by that?

SE: Well, ‘mindfulness’ is being aware of your experience, as you're experiencing it. So for example, it may be that as you're walking down the street, you're aware of the sensations in your feet as you're walking down the street. Or as you're sitting in a chair breathing, you're aware of the sensations of the breath, moving in and out, as you're breathing. So it's being aware in the present moment of whatever your experience is, and accepting it without any judgment or criticism.

SS: So you're saying, basically, when you're depressed and you're feeling terrible, and you don't want to get out of bed, you don't want to wash your hair, you don’t want to eat, just accept that state of being and what? Analyse it or do what with it? Isn't it like double torture?

SE: No, not exactly. For example, if somebody is depressed, what they're often involved with in their thinking is the past or the future. In the past, they feel as if they've experienced a loss, whether they actually have experienced a loss or not. They're tied up in their thinking about it and regrets and ruminations about it. And on the other hand, there may be anxious components where they're worried about the future. So they're focused on the past or on the future, and they're not focused on the present moment. And in mindfulness, we train them to be focused on the present moment. So if you're focused on your breath, for example, you're not thinking about past regrets, or about future disasters that are looming for you –

SS: Sorry for interrupting you, but usually when someone – well, not usually but in many cases, when someone experiences depression, for instance, it's caused by certain loss, like a very painful breakup, or you've lost a person that you loved so much to Covid. I've had many people like that around me. And they're depressed not because they're longing for the past or thinking about the future because it hurts that the person that you love the most isn’t next to you anymore. It's actually a very present thing. What do you do with that and mindfulness?

SE: Well, first of all, we'd have to say how severe and persistent the symptoms are. If the person is having a normal grief response, then that is normal. I mean, when you lose a loved one, it's normal to feel sadness. But depression is something different than normal grief. There are different ways of differentiating it, but for example, the person who is – if you look at their self-esteem, you get an idea. For example, if you ask a depressed person, ‘How do you feel about yourself after the loss of a loved one?’, the depressed person says, ‘I feel bad, I'm a bad person, I should have done more, I should have done this or that that would have saved this person and I'm a rotten person.’ If you ask a person who is in normal grief and is sad about the loss, but he's not depressed, if you ask them how they feel, ‘How do you feel about yourself?’, they'll say, ‘I feel okay about myself, it's just that I have this sadness about the loss I’ve experienced.’ So the differentiation can be done by the self-esteem. The person who's depressed has low self-esteem. And the person who is having normal grief still has intact self-esteem.

SS: Okay, so how does mindfulness work in terms of dosage? For instance, we know how antidepressants work on a chemical level, there are a pharmaceutical product. But a dose of mindfulness cognitive therapy isn't quite a pill. How does it work?

SE: Well, we teach people to be more mindful using this approach. And it helps them become more aware of the present moment, and less concerned about the past or the future. And how it works, actually, it isn't just smoke and mirrors, it actually affects the brain function. So for example, if we do a functional MRI of people getting trained in mindfulness-based cognitive therapy, we find that this area of the brain, the prefrontal cortex, which is diminished in depression, tends to come back up to normal levels. And those areas of the brain involved in emotion generation, like the amygdala, tend to go down from being hyperactive back down to normal levels. So mindfulness actually reverses the problem in the brain that depression is associated with it. The dose of mindfulness, that's a good question you raise, nobody knows exactly what the right dose is, whether you need to practice mindfulness for 10 minutes a day, or 30 minutes a day, or 24 minutes a day... It isn't clear what the dose is. We found people who practised even 10 minutes a day receive benefit. So the dose still has to be worked out exactly. It's not as simple as taking a medication, where you take this dose or that dose, but mindfulness, even in small doses, helps the person restore that normal balance in the brain.

SS: Have you had many cases where a person is really just motionless, lying on bed, looking at the wall, and then the mindfulness practice has completely cured him? Because I'm thinking maybe mindfulness plus antidepressant... ‘cause I can't imagine that person and, you know, they're like a zombie and you're like, ‘why don't you try mindfulness and meditate a little bit?’ Do you know what I mean?

SE: That's a good question. If you're talking about somebody who's so flattened out by depression, they're just staying in bed, it probably would be hard to teach them mindfulness. But on the other hand, in our research, for people who have what we call treatment-resistant depression, meaning they fail to recover despite two or more antidepressant trials, we took people who were on an antidepressant and taught them mindfulness techniques as an outpatient. They weren't in bed, but they came into sessions for eight weeks. And we found in those people, they had had depression episodes lasting on average for seven years. And we were able to teach those people on an outpatient basis, how to practice mindfulness, and in that, they became much less depressed and recovered, and in many instances went into remission. So you can teach people who are pretty seriously depressed, not completely bedridden by depression, but sort of just above that level, to learn how to become more mindful.

SS: So you also say that it's important to be aware that the way one may feel about the situation doesn't really reflect what the situation really is. But then how do we know what the situation really is if the only way we can perceive it is to have subjective feelings about it?

SE: Well, mindfulness helps give you a little bit of distance between the stimulus and your response to it. So for example, a young woman who was out on a date with a guy sitting at the dining room table, and the guy looks down at his phone to look for a message during the dinner. And if she's depressed, she might say to herself, ‘Oh, he's bored with me and I'm going to get rejected.’ With the mindfulness approach, we tend to help the person gain some distance from those kinds of thoughts. So if she has that thought, he's bored with me, well, give them some opportunity to say, that's just a thought. It's not a fact. She doesn't know that he's bored with her. It's just a depressive thought that she's having. And then can’t she come up with an alternative thought, ‘Well, maybe he's expecting an important message, or something, and it doesn't necessarily mean that he's bored with me.’

SS: The next thought that arises is like, maybe he's texting another woman. I'm kidding. Here's an alternative. I'm kidding. All right. So mindfulness talks a lot about being in the present moment like you've emphasised, and I know what that means, actually, because you know, you're upset, your life’s worthless, you've let everyone down, you feel tired, exhausted, stressed, you'll never get an Oscar, bla-bla, and then you look at trees for like two minutes and, you know, everything just seems better. Everything's not that bad anymore. But then what if your present moment is not green trees that can surround you or like a peaceful environment, but five hungry kids, no job, repo men outside, where do I get the resource out of that kind of a right environment, out of that kind of a present moment? Do you know what I mean?

SE: Well, not exactly. If your environment is so negative, I mean, that may be the reality of your environment at that time. I mean, mindfulness doesn't sugarcoat things, it helps you see things as they are. So you may view a situation from this angle or from this angle. And the difficulty with depression is you tend to view things from a negative viewpoint. I mean, there are certain thoughts in depression, which are, though common depressive thoughts, ‘I’m not good,’ ‘things will never get better,’ ‘things are gonna get worse in fact,’ ‘I'm not as good as my neighbour,’ ‘I'm not as good as the person sitting next to me,’  all kinds of negative thoughts, and what mindfulness does is help you gain some distance from those thoughts, it’s what we call decentering from those thoughts. So you can choose whether or not you want to believe those thoughts or not, or recognise they're just thoughts. What I like to think of it is with mindfulness it's like you're walking down a street in a town, and in the store windows are negative thoughts. In depression, you tend to go into the store and buy those thoughts and take them home as if they're yours. In mindfulness, you walk down the street, you still see the storefronts with the negative thoughts, but you don't go in and buy those thoughts. You can see them they don't disappear. But you don't have to take them on as if they're a pure fact.

SS: Professor, it's been really interesting talking to you, and thank you so much for this wonderful insight into mindfulness. Good luck with everything and I hope we meet again.

SE: Okay, nice talking with you. And if you're interested, my website stuarteisendrath.com has more information about it. And it also has some mindfulness meditations that are free on an audio link there that you can

SS: Absolutely.

SE: get a little practice. 

SS: Thank you so much. 

SE: Okay, nice talking to you.

SS: Have a great day, professor. Thank you.

SE: Bye-bye.