109. Understanding Depression: Causes, Cognitions, Comorbidity, + Coping Featuring UPenn Professor Ayelet Ruscio PhD

Aug 5

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Today we are going "into the classroom" with my Abnormal Psychology professor, Ayelet Ruscio! Dr. Ruscio's research a the University of Pennsylvania specializes in anxiety and mood disorders–their nature, classification, and comorbidity. (via psychology.sas.upenn.edu) We discuss why adolescence is such a crucial period for depression (and the role stress plays in this), the gender differences that contribute to higher rates of depression in females, tips to counteract rumination, ways teens can reduce their risk for mental illness, what is subclinical depression + ways to take action, why mental health skills are beneficial across the board, the relationship between stress and depression, common cognitive experiences in depression + how to counteract these, how and why comorbidity and cooccurrence of depression and other mental illnesses occurs, and how different are depression and anxiety really?

Mentioned In The Episode…

+ Constance Hammen Stress Generation

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Episode Sponsors

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About She Persisted (formerly Nevertheless, She Persisted)

After a year and a half of intensive treatment for severe depression and anxiety, 18-year-old Sadie recounts her journey by interviewing family members, professionals, and fellow teens to offer self-improvement tips, DBT education, and personal experiences. She Persisted is the reminder that someone else has been there too and your inspiration to live your life worth living.

a note: this is an automated transcription so please ignore any accidental misspellings!

[00:00:00] Sadie: Welcome to she persisted. I'm your host. Sadie sat in a 19 year old from the bay area, studying psychology at the university of pencils. She processed. It is the teen mental health podcast made for teenagers by a team. In each episode, I'll bring you authentic, accessible, and relatable conversations about every aspect of mental wellness you can expect.

[00:00:20] Evidence-based Tina proved resources, coping skills, including lots of DBT insights and education. Each piece of content you consume, she persisted offers you a safe space to feel validated and understood in your struggle while encouraging you to take ownership of your journey and build your life worth living.

[00:00:37] So let's dive in.

[00:00:41] Hello. Hello and welcome back to she resisted. I'm so excited. You're here today. This is one of my favorite episodes that I've recorded in a really long time. It is with one of my professors from Penn professor Rio. She taught my abnormal psychology class and she is a practicing clinician. She works with adults and she just brought so much interesting insight to the conversation about mental illness and mental health. And I learned so much during this semester course. Which you've probably heard bits and pieces of in the podcast if you've been listening consistently. But this episode is a really powerful conversation about depression, about anxiety.

[00:01:17] We talk about the importance of skills education. We talk about subclinical depression. We talk about stress, we talk about common cognitive experiences in depression. We talk about comorbidity. And so, so, so many things that I think most people aren't aware of when it comes to depression and anxiety, but really are very helpful to know if you are struggling or if you know someone that is struggling.

[00:01:40] I'm so glad that professor Russo joined me for this conversation. And I hope you enjoy it as much as I did. Her links will be in the show notes today. If you wanna learn more about her research, but yeah, I'm so excited to bring you into the classroom with me and learn more about mental health and specifically depression and anxiety.

[00:01:59] So with that, let's dive in.

[00:02:01] Thank you so much for joining me today and she persisted I'm so, so excited to have you on the

[00:02:05] Ayelet: show. It's such a pleasure to be here with you.

[00:02:07] Sadie: Of course. So I'm really excited for this conversation.

[00:02:10] We're gonna kind of go a little bit all over, but we're centering a lot on anxiety and depression and what lays the foundation for mental illness and really just kind of diving into those not risk factors per se, but talking about what happens in childhood, what teens can do to reduce risks. And then talking about how similar some of these different distress disorders can be.

[00:02:32] So. To start. I'd love to talk about why adolescence is such a critical period for depression. It's something that most people are somewhat aware of that things develop before 1824, but there's not a ton of understanding as to why that is. So I would love to get your perspective there.

[00:02:51] Ayelet: Oh, yeah, such a good question.

[00:02:53] And it's a question that mental health professionals have been pondering for a long time. Mm-hmm so, you know, we, for a long time people thought that depression really didn't start until adulthood. And it's really been the last few decades that increasingly psychologists, psychiatrists have realized that in fact, depression often begins sooner than that.

[00:03:14] We know that there is a really, really large. Increase in the rate of depression that happens during adolescents. So prior to about age 12 or 13, there are kids who get depressed. But they're relatively few. And most of those cases don't persist into adolescent in adulthood, but starting it around age 12 to 13, there's just a dramatic rise in the rate of depression associated increase.

[00:03:36] So about 3% of kids or so might become depressed at some point. but then the rates go up to about 17% by age 18, which is much more similar to the rates that we see in, in adults. Mm-hmm so why that is it's really important and interesting question. We don't have a great understanding. There are sort of some indicators from research studies.

[00:04:01] So what might be going on in the adolescent period that could be contributing to the increase? There is some thinking that this could be connected in part to biological factors, parti, particularly those that are linked to puberty mm-hmm . And it does seem for example, that kids who experience um, onset of puberty earlier, our increased risk for depression particularly girls.

[00:04:23] So there may be something going on, almost certainly something going on related to hormones. In addition there, it appears that there are increasing levels of stress, particularly uncontrollable stressors that occur in adolescence compared to childhood and in particular interpersonal stressors, especially for girls.

[00:04:39] So, I don't know if we'll get into this more later, but there's a, a very long literature indicating that there is a sex difference in depression. Girls are about twice as likely as boys to develop depression at some point in their lives. And that sex difference emerges in adolescence. So something about stress, especially interpersonal stress may be important in helping understand why it is that adolescents much more so than younger kids become depress.

[00:05:06] Yeah,

[00:05:06] Sadie: it's also interesting because I think a lot of the times when adults experience periods of stress, it's just a period. They've navigated that before they know they can get through it. Mm-hmm whereas in adolescence, when you experience academic stress or relationship stress or interpersonal stress, it's really for the first time.

[00:05:22] So you don't have that experience to be like, okay, I've coped through this before. It's gonna be okay. I know how to navigate this. This won't last forever. It's like, First time you're navigating it. There's not a lot of guidance there. And so it feels subjectively like that much overwhelming, more overwhelming.

[00:05:38] Ayelet: Yeah. I think that's a really important point. When we've gone through something many times before we know we can weather that we have coping strategies that have worked for us before we have kind of the bigger perspective to put this. Particular situation into, we know we can lean on our supports to get through it.

[00:05:53] Yeah. But it's harder when you're experiencing these things for the first time, especially when you're an adolescent and you're still trying to figure out who am I, how do I navigate the world? Who are the people in my world, who I have trusting relationships with? Yeah, so that, that definitely makes it more challenging.

[00:06:08] Sadie: Yeah. Are there other factors that add to that gender gap? In addition to girls having an onset of puberty more earlier on, there is kind of more social tension than there is with boys, but is there anything else that adds to that risk?

[00:06:22] Ayelet: For sure there are some of the factors that have been most studied or cognitive or sort of thinking related process.

[00:06:28] So girls are much more likely than boys to ruminate. This is sort of a, a style of coping with stress where girls are more likely to sort of sit and dwell on all the bad things that have happened. How, how is it, why do I feel this way? Why do I always get into these patterns? Why did that go wrong?

[00:06:46] And the more that people sort of sit and stew in that sort of negative. Past focus, thinking about things that are abstract things I can't do anything about anymore. The, the less productive that can be. So generally speaking girls are more likely to ruminate. Boys are more likely to engage in more active problem solving types of coping.

[00:07:05] And it turns out that all of us, when we ruminate feel worse and all of us, when we engage in more active problem, focused coping. Tend to be sort of more successful. So, you know, I think it's important to recognize that these are thought styles that can be changed. An interesting sort of related line of research is that girls are more likely to co ruminate, meaning they're more likely to get together with friends and dwell together on bad things that have happened.

[00:07:29] And that's also a pattern that's associated with sort of maintaining negative emotions over time. Mm-hmm so, you know, one of the things that your listeners might think about is if they find themselves. Sitting and stewing about bad things that have happened, that they really can't do anything about anymore.

[00:07:44] Thinking about, okay, what can I do that is constructive right now? Something active, something that will get me moving instead of sitting here and dwelling on bad things. And also if they find themselves getting into conversations with friends where they're kind of feeling stuck, they're. Helping each other in a way, stay stuck by going over and over bad things again and again, thinking about how can we change this conversation to be more constructive, more future focused, more practical.

[00:08:11] What can we do in the situation? Or even like, let's stop talking about this for now and go and do something active and fun. As a way of breaking that negative thought cycle.

[00:08:20] Sadie: I love that. And it's definitely helpful because you can hold each other accountable. Mm-hmm so it's not just you that's like, okay, I gotta stop ruminating, but together you can like, okay, what can we do?

[00:08:29] We're getting into this pattern again. Yes. Are there other best practices that people can implement to counteract these risk factors that are so common in teenage years? Adolescents? I'm sure there's basic things like getting outside, more, being engaged in relationships, but are there are other recommendations that you like to give.

[00:08:47] Ayelet: For sure. So I should say it's important to qualify this by saying that I work clinically with adults, not with adolescents. But a lot of the same strategies I think are helpful for adolescents. Those are helpful for young adults or older adults. So generally speaking, , doing activities that are active are good.

[00:09:03] So exercise. Always recommended as a way of improving mood, as well as keeping you sort of healthy and fit doing activities that give you a sense of mastery and accomplishment are good. So these can be pleasurable activities, but they can also be things that aren't all that pleasurable, but that gives you a feel feeling of accomplishment, like, okay, did the laundry check, right?

[00:09:24] Yes. You know, I, I ran this errand that had to be done check where you feel like, okay, I'm accomplishing things. So those are good too, but especially good are activities that give you a. Pleasure things that you really enjoy that can be by yourself or with other people. It doesn't have to be a great big thing.

[00:09:39] It could be as simple as, okay. I'm going to go for a walk with a friend I'm going to spend some fun, fun time with a sibling mm-hmm . I really enjoy. You know, reading this particular author, I'm gonna go to the library and, and get a book. I really enjoy reading. Yeah. All of

[00:09:54] Sadie: those are good things.

[00:09:55] It definitely makes me think of why a lot of teenagers experience like a shift in mental health when they go to college, because mm-hmm, all of these things, whether it's building mastery or. Doing activities you enjoy being active on a team are really built into your schedule in high school. And then in college, it's up to you to maintain those.

[00:10:12] So if you don't build those into your schedule, if you don't prioritize those, it makes sense why your mental health would struggle as a result.

[00:10:19] Ayelet: I think that's absolutely right. All of us experience a change in routine when we go to college, right? Yeah. Your routine is completely completely unended. And in addition, you're, you're making your way with new relat.

[00:10:31] Your, the structure that's built into your life in terms of when you eat and when you sleep. Yeah. And so on is changed and a lot more is put on the student to, to place those structures in place. Right. For them there aren't parents there saying, okay. Time to go to bed, right? Yeah. Or what did you eat for breakfast?

[00:10:49] You sort of have to do those things for yourself. And so it requires establishing new routines and routines that are healthy and productive for.

[00:10:56] Sadie: Yeah. One of the questions that I've gotten most frequently recently, which I hadn't had a lot of questions about before was like high functioning or subro depression that mm-hmm, isn't necessarily completely derailing activities or relationships.

[00:11:11] But's definitely there. I would love to hear kind of what that clinical definition is and then why it's still important to. Try and either get help utilize resources or at least attempt to problem solve, shift your behaviors and routines, even if it's not at the point where it's like, this is completely interfering with my quality

[00:11:31] Ayelet: of life.

[00:11:32] Yeah. That's such an important question. So we know that many, many more individuals experience subclinical levels of depression, and then those who experience clinical levels of depression. Mm-hmm For some of those individuals, those symptoms escalate over time and can turn into a major depressive episode that might need clinical attention, you know, all of us experience ups and downs.

[00:11:54] So it's important to recognize that having a few bad days doesn't necessarily mean you have a disorder or that this is something even that's concerning, but it's good to be attuned to how your mood. And how your behavior is. And if you're finding that sort of day after day, you're feeling very low motivation to do things that are important or things that you usually enjoy, or your mood is really low consistently.

[00:12:18] Then it's, it's a really good idea to do something to, to attend to that. There are lots of things that can be done is to seek help from a treatment professional, either psychotherapy or. You feel it's necessary and your provider recommends it, some kind of medication, but it's also possible to do other things that are less intensive, but that will be helpful to your mood.

[00:12:41] Some of those things can be as simple as some of the activities we talked about. But it also, there are self-help. Books, there are app based or internet based interventions that are less intensive than doing, let's say individual psychotherapy, but that can be quite helpful. Yeah. So looking into those resources can be good.

[00:13:00] And of course, talking with friends and family who can be helpful to you as well.

[00:13:05] Sadie: I also love reminding listeners that the skills that are working for people that are like severely, severely depressed. If those are working to lift that level of depression, there's a very high chance that those same skills are gonna work if you're having an off day.

[00:13:19] Absolutely. So if there's one person that like. Physically cannot get out of bed. And the skill that will work for them is doing the opposite of what they're feeling and lowering their phys physiological, emotional intensity, and asking for help and distracting from the emotion. Those same things will likely work if you're like a.

[00:13:36] I just cannot get to school today. I'm feeling so overwhelmed. I'm feeling unmotivated, like those skills transfer and you don't have to get to a certain level of distress to be like, okay, now we use the skills. Like if it's feeling uncomfortable, if it's bothering you, use the skills and it'll be easier to use them because the emotional intensity is lower, then that like life interfering life altering.

[00:13:58] Super bad depression that some people experience,

[00:14:00] Ayelet: I agree completely 80. You're absolutely right. Those skills are useful because they're like good life skills, right? Yeah. Yeah. So, like not avoiding things that are making you uncomfortable or you're nervous is always a good skill. Like staying active is a good skill.

[00:14:16] Examining thoughts that are unproductive and substituting more constructive, helpful thoughts. Those are all great skills at Ken and should be used even when you're. Let's say more mildly distressed. Yeah. Compared to being clinically depressed, I feel

[00:14:30] Sadie: like that's one of the biggest ways that I've seen stigma show up is like that emotional thought block where people are like, well, it's not that bad, or I don't need those skills that people would learn in therapy.

[00:14:40] And it's like, you're not even engaging in treatment. You're not even getting a D. This, like, it's not close to what you think of stigma preventing people from doing. And yet there's that still that emotional block of like, well, other people have it worse or I don't need that help yet. And it's like, well, why not target it early?

[00:14:59] So like you said, it doesn't get worse over time and develop into severe major depression.

[00:15:05] Ayelet: You're absolutely. and these are skills I use all the time. And it's actually like one of the best things I think about being trained in psychology is like, you learn these great skills that are helpful for everybody.

[00:15:16] And I, I tell everyone I know about them, including healthy people. Yes. So these are just, they're just sort of good coping strategies that all of us can benefit from, and you don't have to get to a certain level of severity to use them. And in fact, using those skills will help prevent you from getting to that.

[00:15:33] Sadie: Yeah. I remember being in intensive treatment and being surrounded 24 7 by people that were like highly trained in D B T and using it in every single aspect of their life, both at home and in practice, there was therapists, there were the community, they weren't called community residents, but they were the like psychology students that were getting their hours in, in practice.

[00:15:53] And they would do daily activities with us. And then there was the educators. And then of course all the. Kids and teens themselves were using these skills. And I remember leaving being like, why is everyone being so ineffective? Like where is the deer van? Where is the emotion regulation? Like guys, this could be so much easier.

[00:16:10] And it wasn't just like regulating anxiety and depression. It was just. Basic functioning and asking for help when you needed it and advocating for an objective. Like these are all things that if you're functioning well, you're probably already doing exactly. And if you're not their skills to address

[00:16:25] Ayelet: it, that's exactly right.

[00:16:26] I think these are often skills that people who are doing really well, high functioning and achieving the important goals they've set for themselves. Those are skills that they're doing intuitively. Yeah. And you're absolutely right. Like interpersonal effectiveness. That's always something you wanna do.

[00:16:42] Right? Emotion, regulation. That's always a good goal. Like mm-hmm, use those skills. It's actually, it's a gift to have that knowledge and, and using it on a regular basis can make you flourish. Even when you are sort of emotionally doing really well. It just strengthens everyth.

[00:16:59] Sadie: Yeah. And then when you do have those low points, which everyone does, you know, the skills that's, you know how to use them.

[00:17:04] They've worked before, and that's one less block to getting out of that low point, because you are skilled and knowledgeable and how to navigate the

[00:17:13] Ayelet: challenge. Exactly. And having practiced those skills again, and again, means that when you most need them, they'll be there for.

[00:17:19] Sadie: I love that.

[00:17:20] This week's episode is brought to you by teen counseling. If you've heard of better help, teen counseling is their branch specifically for teenagers. So it's an online therapy program with over 14,000 licensed therapists within their network. And they offer support on things like depression, anxiety, relationships, trauma, and so much more.

[00:17:38] In this episode, professor Rio and I talk about how effective treatment can be for both depression, anxiety, and other mental health issues, and one proven way to treat depression and treat anxiety is therapy and psychotherapy. And so a great way to get access to therapy is teen counseling.

[00:17:54] What you do is you go to teen counseling.com/she persisted, and you fill out a survey about what you're hoping to work on. So maybe it is depression, maybe it's anxiety, maybe it's relationships, trauma, whatever it is that where you are hoping to work on, they match you with a therapist that fits your needs and fits that area of specialty.

[00:18:11] If you are under 18, you then put in a parent or guardians email so they can provide consent to treatment and payment. But none of your information that you disclose in the survey is shared with your parents HIPAAs enacted.

[00:18:21] So I tried it myself. All it says is Sadie or whatever your name is, is helping to work with a therapist from teen counselor, from teen counseling. Please click here to learn more and give consent, but teen counseling is a great way to start therapy or meet with a new therapist. It's talk, text, video counseling, all from your home and extremely accessible.

[00:18:41] So if you would like to try out teen counseling, you can go to teen counseling.com/she persisted again. That is teen counseling.com/she persisted.

[00:18:51] So another thing that I wanted to touch on related to depression, which I think is so interesting, which is, again, not something that is commonly known is the relationship between stress and depression.

[00:19:00] So kind of stress generation and the kindling hypothesis. Mm-hmm , which if you don't know what those mean, we will explain. Don't worry. But I would love to kind of hear your perspective there. It's a really interesting school of thought that isn't always something that comes to mind when people are struggling, but it can be very helpful to be aware of if you are navigating depression.

[00:19:19] Yeah,

[00:19:20] Ayelet: absolutely. So the basic principle of stress generation was introduced by Connie ham in a Depression researcher. And what she discovered in her research is that many individuals who were depressed seemed to be engaging in behaviors that almost got in their own way, that were making things more difficult for them.

[00:19:39] Mm-hmm and so these were events that rather than sort of completely random acts like. I got, let's say, you know, there's a hurricane, for example you know, that's something that I have no control over. I did nothing for this hurricane to happen. I'm unfortunately sort of stuck in the wrong place at the wrong time.

[00:19:57] That would be an, an independent stress. Something's independent from me, but I. What she found was that many individuals, depression were engaging also in what she called or experiencing what she called dependent stress. So dependent stress, an example would be like frequent arguments with a boyfriend or girlfriend mm-hmm

[00:20:16] This is something that I contribute to in some way, or potentially could contribute to. I might have a very qu some boyfriend or girlfriend, but I also may be a person who is sort of repeatedly doing things that's causing arguments to happen or contributing in some way to this stress. , this has been a, and first, at least this was a controversial idea because we don't wanna blame the victim.

[00:20:38] We don't want to say like, you know, people who are depressed are doing like bad things for themselves. On the other hand, I think it's really important to recognize when we are doing things that are making things harder for us, so that we can take steps to try to improve the situation. And so the basic idea behind stress generation is.

[00:20:58] To some extent all of us contribute or can contribute to the stress we experience and the opposite side or flip side of that is that we all have the opportunity to reduce our stress levels by taking a hard look at what are we potentially doing that may be increasing stress for us. Mm-hmm so I'll give you maybe a minor example.

[00:21:18] If I'm a person who's chronically late. I just like, I can't get myself on schedule. Yeah, it is. I'm looking at myself too. right. So, you know, if I'm a person who's always late. I'm gonna be generating some stress for myself, right? I'm going to, let's say, pay a bill late. And as a result, I'm gonna have a fine, then I'm gonna have to pay, or let's say I'm going to arrive late to a meeting.

[00:21:41] And as a result, I'm gonna be taking less seriously by the people I'm supposed to be meeting with, or I'll miss some important information. So maybe for students, like maybe because I'm oversleeping all the time, I'm missing class or late for class. And then I misinformation I need to know in order to do well in.

[00:21:57] If I recognize that I am contributing to the stress that I'm experiencing by not managing my time. Well then by improving my time management skills, I can actually reduce stress in my life. That's a non interpersonal example, but an important thing to note is that Connie Hammond observed that most of the dependent stressors that she observed, especially in the women, in her sample.

[00:22:18] Were interpersonal in nature. So the women were engaging in behaviors that were increasing the likelihood of others in their life. Sort of arguing with them leaving them, you know, were relationships were more unstable or were ending or just were more stressful. You know, in their lives. So thinking very hard about what are the ways in which I may be contributing to difficult relationships mm-hmm and, and, and that includes selecting people to have relationships with who may not treat us the way we deserve to be treated.

[00:22:52] Yeah.

[00:22:53] Sadie: Yeah. I think that's a huge thing that, I mean is very, very valid stress to experience. And mm-hmm with depression. A huge thing is having a support system and a group of people that can support you. Yeah. And if your support system is doing the opposite of that, either like you initiating that or them initiating those conflicts that can add to.

[00:23:14] How difficult it is to come out of that depression, ask for help utilize resources and all of those things. In addition to kind of creating stress in different relationships, there are some like neurobiological, emotional, cognitive experiences that are pretty universal in people that experience depression.

[00:23:32] Mm-hmm what are some of those that listeners can kind of listen for and kind of observe that might be happening? I think it's a great. Way that can to hear things that can be really validating because depression can be so isolating and yet like you'll highlight in these universal things. It can be very relatable and again, universal in the experience, even though it is so internal and feel so subjective.

[00:23:56] Ayelet: Yeah, great question. So I can highlight a few of them. So one is kind of on a neurobiologic level. What is has been seen as often happening in depression is individuals who have a heightened sensitivity to stress. And, and heightened reactivity to stress. So areas of the brain that are in the, sort of the limbic part of the brain particularly the amygdala are sort of heightened in individual with depression.

[00:24:22] So a tendency to experience negative emotion, to react very strongly distress. And we see that prefrontal cortex areas of the brain that are involved in planning and in self-control self-regulation. Are reduced activity in those areas are

[00:24:36] Sadie: reduced. And if you're a team those aren't even fully developed.

[00:24:39] So that's no that you're more susceptible.

[00:24:42] Ayelet: That's exactly right. And in terms of the crosstalk between the limbic system and the prefrontal systems of the brain, they're sort of less tamping down of emotion by those frontal regions of the brain. And so people with depression kind of a universal feature is the sort of heightened sensitivity and heightened reactivity when stressors.

[00:25:02] And all of us experience an increase in distress, an increase in sort of that cortisol response when we're stressed, that is normal. It's actually very adaptive. What seems to happen in depression is that people have trouble shutting that process off in a prompt way. So, you know, it's, it's good that we react strongly when a stressor first occurs.

[00:25:24] So we can marshal our resources and deal adaptively with that stressor. We don't wanna ignore the stress, right? Mm-hmm , there's, it's there for a reason to warn us that something's going on in the environment we need to deal with. But then once the stressor has resolved, we need to be able to bring our bodies back down.

[00:25:39] And back to a regular stable state and often individuals with depression have trouble coming back down in a timely way. And they're sort of more sensitive and more sort of hyper aroused for, for a period of time beyond what healthy individuals might experience. Mm-hmm and maybe I'll talk about each of these universals and then we can talk about it.

[00:25:57] What could be done about it? So cognitive. Great. So cognitively what we often see as people tending to respond in ways. Tighten the stress by, by doing things like blaming the stressor on themselves and on stable things that can't be changed as opposed to looking for outside reasons why the stressor might have happened or recognizing the stressors come and go that they can be temporary rather than a stable feature of.

[00:26:25] Of me. So if I believe that when I encounter stressors it's because something is inherently bad about me, it's unavoidable and it's always going to be around. I'm going to be much more likely to stay depressed. Then if I recognize that stressors also are. You know, can be things that are temporary that are outside of me.

[00:26:43] And that can be controlled. Emotionally we often see high levels of sadness and distress, but also low levels of positive emotion. So what seems to happen is that people are feeling sort of very sad, very hopeless. But in addition, they can feel just a really difficult time feeling pleasure and, and joy and connection to other people.

[00:27:06] That really contributes to the difficulties of this disorder. And then interpersonally, oftentimes people withdraw from others. They isolate themselves rather than reaching out and connecting with other people. And that can make it very difficult for the depression to stop. In part because when we're alone we're more likely to ruminate mm-hmm and we're less likely to talk to people who can help distract us from what's going on.

[00:27:31] Can help give us a new perspective that might be helpful and help us lift our mood. Mm-hmm . So all these universals, I think in terms of thinking about how, how to address them. so an important first step is to recognize that, you know, when stressors occur, all of us are going to react. What we have some control over is how are we going to respond?

[00:27:53] And so if we know that we're a person who, when we experience a stressor, tends to be, you know, could react really strongly, which is actually very common, not just among people with depression, then thinking about, okay, what can I do now to deal productively with this? So we talked earlier. Active problem solving types of coping.

[00:28:11] What, what about the situation is sort of out of my control and it's like, I need to let go of that. And what part of this, can I do something about, let me actually make a plan for how I'm going to address this taking kind of concrete steps and having a plan in place to address the things that can be address.

[00:28:28] Cognitively, emotionally, interpersonally, rather than kind of withdrawing and isolating myself and thinking about all the ways in which things are going wrong. Can I, can I instead approach? So instead of avoid, I'm gonna go approach. I'm going to reach out to people who I trust and who I love. Who I know will help me get through the situation.

[00:28:50] Give me something else to do, encourage me to try something different. can I sort of think about activities that I can engage in that are going to lift my positive emotion and will help me curtail that negative, emotional experience? Mm-hmm .

[00:29:04] Sadie: It's so interesting. I remember one of the biggest skills that I utilized initially in D B T was opposite action mm-hmm and it sounds so counterintuitive because it's like, you're going to do exactly the opposite of what your emotions are telling you to do.

[00:29:17] Mm-hmm and it's almost, it is on instinct that we listen to our emotions that we lean into those urges because they're there to keep us alive. It's evolutionarily something that's very beneficial. Mm-hmm and. When you have struggled with depression for a while, and it's kind of skewing these emotional cues and it's not serving you to listen to them.

[00:29:37] Mm-hmm , you have to reteach yourself to not listen to them. And then at some point you kind of go back to listening to your emotional cues as they get more balanced, but it, it can be very counterintuitive, especially initially.

[00:29:48] Ayelet: Yes. That's exactly right. And I think, you know, it's, it's very natural that we want to avoid situations that give us pain, emotional pain, our physical pain.

[00:29:58] It's, you're absolutely right though, when you've been depressed for a long time, sometimes those emotions don't serve us very well. And we tend to wanna avoid everything, including things that are potential sources of, of pleasure and accomplishment for us. And so doing the opposite. Sort of encourages us to approach rather than avoid in ways.

[00:30:17] That can be very helpful. Yeah.

[00:30:19] Sadie: You did touch on this a little bit. Avoidance is something that can show up a lot with anxiety, with OCD, with other mental illnesses. There is a pretty high level of comorbidity of depression with other mental disorders. What are your thoughts there? Is it something that.

[00:30:34] Like the, is it like depression is the first thing that causes these other things to pop up or do these other stressors and overwhelming emotions then lead to this feeling of depression?

[00:30:47] Ayelet: I think it's probably both. Yeah. You're absolutely right. That rates of comorbidity or co-occurrence of depression with other mental disorders is very high in teens very often the co-occurring conditions.

[00:30:59] Other anxiety disorders. They can be eating disorders, substance use disorders. Sometimes depression is a response or a reaction to having those other conditions. So for example, if I'm really anxious, The depression may almost be like a demoralization reaction. It's oh, I'm so tired of struggling so much.

[00:31:22] Life is really, really hard. Yeah. Other times depression can actually contribute to these other disorders. So for example, if I'm feeling really down and depressed, I might use substances to try to make me feel better and that can lead to a substance. Problem. And then very often there's some third factor that's contributing to both the depression and the other disorders.

[00:31:43] So if I have a lot of stress, for example, that might increase depression as well as anxiety or substance use disorders. If I tend to engage in kind of problematic coping strategies that are, are causing problems for me, I may I may give rise to multiple disorders.

[00:31:58] Sadie: Yeah,

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[00:33:02] Again, that is the code XO S a D I E at checkout for 20% off your first order. the last thing I wanna touch on, which I thought was so interesting.

[00:33:11] One of my favorite things we learned this semester was about the idea of distress disorders and how similar generalized anxiety disorder and depression can be. Mm-hmm because. if I were to think about it going in blind, it'd be like, well, they're completely opposite. Like one is completely dampening your emotional expression, your mood, and the other one, it's like heightened arousal.

[00:33:32] Mm-hmm . And yet, as you explain, they can be so similar and it's almost like how you're interacting with your environment and causal factors that can kind of create the difference of how you're presenting. So I'd love to hear your thoughts there about the similarities and the differences of generalized anxiety and depress.

[00:33:49] Oh,

[00:33:49] Ayelet: yeah. So this is an area that I study and I find this so fascinating. So one of the things we talked about in class is that actually the genetic research suggests that genetically generalized anxiety disorder and major depression are the same disorder. It's so interesting. And we look at the clinical features of these disorders.

[00:34:07] They do have a lot of features in common. Right. So both disorders, for example have involve difficulties with sleep, involve difficulties with concentration and decision making involve difficulties with mood, especially high levels of negative mood, negative emotion, but there are some important differences too.

[00:34:24] In G a D of course, we see heightened levels of. Worry and anxiety and in depression, these are not central features. Although we know that depression is very heterogeneous and there are many individuals with depression who actually are quite anxious. Yeah, and, and very very restless have difficulty falling asleep and so on.

[00:34:44] It has a very kind of anxious, depressed, mixed presentation. Although worry has traditionally been thought of as a feature of anxiety, not depression. We now know. Rumination and depression and worry. And G a D are close cousins. They're not the same exact thing, but they're very, very similar. Both involve this process of thinking in an abstract uncontrollable fashion about things that are bad about me and that I.

[00:35:12] For the most part cannot change. Yeah. And worry is more future focused. Rumination is more past focused, but other than that, there's not too many things that distinguish worry from rumination. So one of the possibilities my students and I have been actually studying is perhaps that tendency to get stuck and negative repetitive patterns of thinking actually is a shared vulnerability factor for G a D and major depress.

[00:35:38] And there are you know, the, the active treatments for depression and anxiety. Have a lot of shared features. You know, many of the same strategies are helpful in psychotherapy for GD and major depression. And many of the same pharmacological treatments are effective for GD and major depression.

[00:35:56] So there definitely seem to be a lot of commonalities there for us to, to think about. There are some differences between JD and MDD, but they're hard to find anxiety disorders have been. Described in the literature as disorders where people are primarily concerned about threat, they're very sensitive to detecting potential threats in the environment.

[00:36:18] And I don't mean just threats like a spider, you know, a snake. Yeah. Like those sorts of threats, but threats where I perceive there is some potential for negative outcome for. In G a D this tends to take the form of thinking about all the bad things that could happen to me in the future and why I think I'm not gonna be able to cope with those bad things if they happen to me.

[00:36:39] Right. Mm-hmm and it, we have found some evidence that threat sensitivity is higher in, in G a D than in major depression. However major depression tends to show higher threat sensitivity than people who have no psychopathology at all. Yeah. So it might more of a matter of degree than really a complete difference.

[00:36:58] Exactly. And sort of conversely for major depression, we've been pursuing the possibility that in depression with distinguishes it from Gid and from other anxiety disorders is that low, positive emotionality that difficulty finding pleasure and joy in life and enjoying rewarding experiences when they happen.

[00:37:17] Yeah. And we have found some evidence that yes, reward sensitivity reward responding is lower in depression than in G a D. But once again, people with DD show, lower reward, responding than healthy individuals who have no psychopathology. So again, a matter of degree, mm-hmm, .

[00:37:34] Sadie: So interesting. And again, going in blind, you would not pick up on those things.

[00:37:39] Mm-hmm like, I think the way that we're aware of them as a society, they seem so different. Yeah. And yet, when you really do look at the presentations and when you look at the, the presentation in compared to. A normal presenting person. Mm-hmm, , they're very similar and there's a lot of things that overlap.

[00:37:56] And that's again, like, even from the treatment perspective, things that are effective on both fronts, which is great. If you are struggling with comorbid depression and anxiety, I think

[00:38:06] Ayelet: that's right. And, and what we know about generalized anxiety and made her depression is that. Usually go together. Yeah.

[00:38:12] It's very hard. Especially in clinical settings. It's very hard to find people who have one and not the other mm-hmm they often go together. And individuals who have both generally have sort of the most emotional distress. They're, they're most reactive to stress. And sometimes over time they're the individuals who are gonna be sort of more, have a more chronic course of illness.

[00:38:33] And so those are the individual we see as where it's especially important that they seek help. And learn and use those strategies regularly to manage their emotions and to cope successfully with stress. Yeah.

[00:38:45] Sadie: If there was one piece of research or literature or a statistic that you wish the general population was more aware of relating to depression, anxiety, and mental health, what would it be?

[00:38:57] Ayelet: I know that, oh, wow. That's a hard one. So I think that, I don't know if this is a statistic per se. Maybe I'll give you two things if it's okay. Okay. Yeah. So one thing that we talked about in class this semester, and for me is sort of the most mind blowing statistic about mental illness. Is that most of us will develop a mental disorder at some time in our lives.

[00:39:19] So general population surveys in the us have shown that approximately half of the adult population in the us will have a mental disorder at some time in their life. That's probably an underestimate. Yeah, because that number, it comes from studies of people who are living out in the community. And we know that people who are, let's say in institutions, for example, in prisons or in inpatient hospitals or people who've died prematurely due to suicide or accidents, have an elevated.

[00:39:49] Rate of psychopathology relative to others in the population. And it's also the case that when we ask people, have you ever in your life experience.dot? Yeah. Sometimes people forget. And they, or they perhaps there's

[00:40:01] Sadie: so much stigma in our society. No wonder that people would under report.

[00:40:05] Ayelet: And that's the other thing that people may be reluctant to report, especially since these surveys are usually done with lay interviewers who are stranger.

[00:40:13] And these are sensitive things to talk about, especially with some stranger who's come to your home. Right? And so when people are followed forward in time, we actually see rates as high as 70 or even 80% of people will eventually develop a mental disorder. Wow. Now that's really important and hopeful in a way, because it tells us that.

[00:40:31] It need not be stigmatized to have a mental disorder. In fact, the more rare and unusual situation is the person who reaches, you know, the age of 80 or 90, having never had a mental disorder. I think we have a lot to learn from those individuals. You're like, are you okay? I know exactly. Are you interacting in the world?

[00:40:49] How do you. Yeah. So there is more recognition of that and desire to, to learn from those individuals, but also to some extent, normalizes at some point in our lives, we're gonna go through a rough patch that might be really rough. For some individuals there will be recurrent problems or chronic problems and for others, the problem will re resolve and not recur.

[00:41:10] So I think it's just important to recognize. Mental illness is all around us in one form or another. And that having experienced this, we're not alone, we're actually in the majority. So yeah, that's, that's really important to note. And then I'll pair that with the second observation I wanna share, which is that effective treatments exist.

[00:41:27] We have some really effective treatments out there. And the, the real heartbreak for me is that so many people who struggle and suffer don't know about these treatments or don't have. Stevie treatments. Yeah. So I think if you are a person who is struggling with depression, with anxiety, cause I know that's the focus of today's conversation.

[00:41:45] We have effective treatments. You know, it's so important to get help because you know, those treatments can be extremely helpful. And given that these are problems that can persist and become chronic or recurrent over. The earlier you seek help, the better because learning those skills will help you.

[00:42:04] Not only deal with the current episode of depression, but prevent future episodes from happening in your.

[00:42:10] Sadie: I love that. I think that's the perfect note to end on and it's relevant to anyone and everyone, whether you yourself have struggled in the past, currently struggling may struggle in the future, are trying to support someone who is struggling.

[00:42:22] It really is something that is universally important to know and be aware of. And it, it just, it really just makes me wonder again how we have so much stigma when again, the majority of us do struggle or will struggle at some point.

[00:42:35] Ayelet: Yeah, I think that so often we don't talk about these things because we feel like we're alone.

[00:42:40] We feel ashamed. And I think if we open up the dialogue and, and are open with one another about this, we'll discover that in fact, many other people are dealing with very similar

[00:42:50] Sadie: things. Yeah. Yeah. Well, thank you so much for joining me today. I'm so glad we got to do this. Me too. Thank

[00:42:56] Ayelet: you so much for inviting me.

[00:42:57] It's been such a pleasure, Sadie. Of

[00:42:59] Sadie: course.

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