An expert on cognitive vulnerability to depression, psychologist Zindel V. Segal, Ph.D., is professor of psychiatry and psychology at the University of Toronto and prime architect of a treatment aimed at preventing relapse of depression.
How has the view of depression been changing in the last decade?
A number of indicators now reveal depression to be a recurrent disabling disorder. By contrast, earlier views often featured depression as a difficult psychiatric problem but one in which patients were pretty much in the clear once effective treatments could be applied.
Good longitudinal studies have followed depressed patients into recovery and beyond and found that for many there is a point at which depression becomes chronic and recurrent. Even if they manage to recover from an initial or second episode, they still carry a risk of suffering depression again, either as a relapse into the initial episode or as a new depression down the line.
Is there a difference between chronic and recurrent depression?
They're different ways of saying the same thing. You keep getting well, it keeps coming back. There seems to be a pivot point where, if people have an episode or two and they're treated well and engage some treatment that prevents other episodes, then the likelihood of developing a chronic disorder actually decreases.
What characterizes this pivot point?
Right now it's a bald number: If you've had three or more episodes chances are you have a recurrent form of depression. If you've only had one or two you don't yet, and you should do your best to stay well.
In recurrent depression there seems to be a way in which the processes responsible for triggering the episode become more autonomous. There seems to be an accumulation of the effects of having depression on the body and on the brain, which makes it easier for subsequent episodes to be triggered from life stress. This applies to the neurobiology of the disorder triggering affective reactivity, and the psychology of the disorder triggering negative thinking and pessimism.
What are the implications of this new view of depression?
It poses a greater need for patients to do something to prevent their depression even in periods where they're not feeling depressed. That's an important difference. Most current treatments emphasize working on acute illness.
There are a number of effective treatments—cognitive therapy, interpersonal therapy, pharmacotherapy—that help people in episodes of acute depression. The challenge is to sequence those with treatments that prevent relapsing.
Isn't it good enough to treat a single episode well with cognitive therapy?
Sure. And the latest data show that if you treat people well with cognitive therapy, if they really get it, that does the job right there. They actually learn skills that prevent future depression at rates on a par with continuing to take medication. They learn ways of working with low mood or dysphoric feelings that are different from the more automatic ways often ingrained in depressed people.
The problem is that the majority of people treated for depression are treated with drugs. They're not learning affect-regulation skills. Antidepressants will help them get better but they need to learn skills that help them stay well.
How do you get around that?
We had the idea to identify the operative ingredients of cognitive therapy and compress them into a maintenance form of therapy. Then people who recover on drugs can benefit from an intervention that will keep them from relapsing.
From clinical experience we observed that in cognitive therapy there is a process of metacognitive awareness, or decentering, that takes place. Patients are able to stand back from their thoughts, to see them just as thoughts and not reality. That step is very important in allowing them to work differently with their thinking so that it doesn't recruit negative feelings and feed the disorder.
We then realized that perspective is similar to what's created in a form of meditation known as mindfulness practice. We integrated mindfulness into a maintenance form of therapy.
How do you apply this to people who see depression as a disorder in some brain molecule?
Experts now recognize that depression is a multifaceted disorder with dysregulation in a number of different systems. There may be a genetic factor that influences a person's propensity to develop the depression, and there are brain chemicals that change as a result of being depressed—but you can reregulate them through psychological means.
Neuroimaging studies show that the same areas of the brain that are changed with Prozac are changed with cognitive psychotherapy. The good news is that there are different routes to getting better. It's not either your brain or your psychology—both of them speak to each other. And you can regulate brain mechanisms through effective psychological means. By the same token, living your life a certain way will mess up your brain, if you deprive yourself of sleep or you're not regulating biological rhythms.
How does mindfulness help?
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