Nine big myths about depression — busted

Sana Qadar: When we talk about depression, it's almost like there's colloquial depression and then there's clinical depression. So colloquial depression is the way we throw around the word in everyday language, like, oh, I didn't get Taylor Swift tickets, I'm so depressed or so and so's partner broke up with them and they seem quite depressed. Clinical depression isn't that. Of course, language is fluid. The meaning of words change, and that's not a bad thing. But the muddying of the meaning of mental health conditions like depression can leave us confused about what we're dealing with.

Professor Ian Hickie: I spend most of my life now talking about the difference between distress, which is contextual, versus those who develop disorders, those where the context is the context, but it's not the real or the whole explanation.

Sana Qadar: And with depression, which is one of the more common mental health conditions, not only are many people confused about what it really means, there are all kinds of myths about it. Like that it's just a chemical imbalance in the brain, or that treatment doesn't work, or that treatment leads to suicide, or that psychedelics are a silver bullet. This is All in the Mind. I'm Sana Qadar, and for our first episode of 2024, we're going to wade through all of that with Professor Ian Hickie.

Professor Ian Hickie: I'm a psychiatrist and I'm the co-director of health and policy at the Brain and Mind Centre of the University of Sydney.

Sana Qadar: He's also the author of The Devil You Knew the Myths Around Depression and Why Your Best Days are Ahead of You. And how long have you been a psychiatrist? How long have you been in this space?

Professor Ian Hickie: Well, I've been a psychiatrist now for 35 years, fully qualified. And I was thinking the other day, if I chucked in the 5 or 6 years training before that, technically next year will be year number 40.

Sana Qadar: Oh, wow.

Professor Ian Hickie: Of being actively in the mental health professions.

Sana Qadar: Okay so you really know what you're talking about.

Professor Ian Hickie: Either that or I'm saying the same thing over and over again. No, things have really changed in a really positive way in the four decades now that I've been in it.

Sana Qadar: So today we ask, are you depressed or distressed? And what's the difference anyways? Depression is a term that's thrown around a lot casually. Also, seriously. But I don't think we always know what we're talking about when we say depression. So can you talk about what the difference is between depression and clinical depression?

Professor Ian Hickie: So the whole time I've been involved in depression awareness, first of all, we had to get people to use words that were emotional, anxious, depressed, fearful, sad. That had a great upside, people actually naming the emotions that they were experiencing and linking them then to behaviours. It's had a real downside. Everyone goes, oh, I know what that is. I'm sad, I cry, I get upset, bad things happen, I get depressed. I go, no you don't. You have normal mood. The professions I'm in and the bits that I'm interested in are those people that are categorically go off a cliff, have a different thing. So when I talk about clinical depression, I'm talking about that thing that about 1 in 5 people will have in their lifetime, meaning four out of five of us will not have that thing. We'll say we're depressed and we will cry and we will get upset and stuff will happen. And we'll probably have lots of mental health challenges in our lifetime, but we will not get depressed. So this thing about what it is that's different. So the trouble is we have sort of checklists of symptoms which are pretty non-specific.

Professor Ian Hickie: You feel low, you feel sad, you cry, you feel hopeless, you have sleep disturbance. You have other problems. People go, oh, I've got a bunch of those. So I'm depressed, right? I go, no, they're just the superficial layers of the thing that commonly are expressed. There are much more central features, like fundamentally losing pleasure in life, the anhedonia, lack of hedonism, much more important than low mood. And the second thing, the thing I make a really big fuss about is it's physiological. It's a perturbation, a change in the whole body, not just in your brain, not just in the way you think, but in the way your body clock runs, in the way your immune system runs and your hormonal systems, the disaggregation of all those body systems that translate to wellness, that translate to energy, that translate to being able to physiologically function. So a lot of my life is tied up with people say, I'm not depressed, I'm sick. I go, no, no, no, you are sick, right? And you are depressed because it's a whole body experience.

Sana Qadar: So that is what separates the disorder from everything else. Depression isn't just low mood and feeling sad. It's that plus the whole body effects and that loss of pleasure.

Professor Ian Hickie: You cannot appreciate a great spring day. In fact, you lose your emotionality. You may stop crying, you may stop responding. That is central. And it's then surrounded by typical ways of thinking, hopelessness, helplessness. I can't see the future. Thoughts of dying.

Sana Qadar: Luckily, as Professor Hickey said, this is something most of us won't experience.

Professor Ian Hickie: The more we've promoted the awareness of it, the more unpopular it's become to say, it's not something we all have. It's not simply fixed by exercise, not simply fixed by diet. So there are other behavioural and lifestyle adaptations that are really important to our general mental health and well-being. But they're not on their own treatments for depression. When we talk about that clinical thing, which is a really serious illness, if I sound too worked up about it, that kills people and ruins their lives and comes back and is not to be trivialised.

Sana Qadar: When patients come to Doctor Hickie, they often have a story about their depression.

Professor Ian Hickie: Are works difficult? The wife's a problem. I've got these other difficulties. The kids are annoying me. That's why I'm depressed.

Sana Qadar: But often that story is wrong.

Professor Ian Hickie: No, no, no, you are depressed. That's why you're having trouble with intimate relationships, kids, work, finances. You can't solve things. You're stuck. And that stuck often is a slowed down then in cognition, in thinking it's a loss of facial expression, it's a lack of interaction with others. So your psychologically and physically sick.

Sana Qadar: What you said a moment ago about how you're it's not that your work stress is causing your depression. You're having issues at work because you're depressed. That's really interesting. And that's that brings us to the myths. I want to talk about some of the biggest myths that exist out there about depression. Let's start with that one, though, because I think a lot of people do think that depression is caused by life events. You know, something goes wrong and you end up depressed.

Professor Ian Hickie: This is I'm glad you picked that up. In all the discussion I've done about this. This is the number one myth. Every human has a story as to why they're in this situation now. We humans do not walk around with no explanation. We all have a story, which is usually the story of how I got to your office, or how I got to the GP, or how I got to the psychologist. My wife just left me. I just lost my job. I'm in financial difficulties, which is often the precipitant the crisis. Someone's finally, as many men as examples here, has dragged that person into care. And the danger is the GP or the psychologist or somebody else goes, oh, well, that's the reason. Okay, so we'll just get a new job, new wife, new fiction, and the problem will go away. You go, hang on, hang on, hang on, back up. When did this start? How long has this been going on ? Now typically, if you come to talk to the spouse or partner of someone in this situation, actually he's been like that for five years and withdrawn. And we've lost our money and we've lost our house and he's drinking too much and I left. The depression came first. Its consequences have resulted in the crisis in our life now. It's not the cause, it's the consequence.

Sana Qadar: That's really interesting. So there's no cases in which, like a marriage breakdown or anything big like that leads to depression. It may lead to low mood, but not depression. Is that what you're saying?

Professor Ian Hickie: So lots of us will have been through relationship breakdowns, other areas in our lives, losses of jobs, financial difficulties that have caused us a great deal of emotional distress. And I think it's one of the big issues at the moment. I spend most of my life now talking about the difference between distress, which is contextual. These bad things happen, we lose, we grieve. We're upset by those things which are contextual versus those who develop disorders, those where the context is the context, but it's not the real or the whole explanation. Now, having said that, chronic stress. So people think it's an acute event. Something bad happened yesterday. So every time I have an acute event, earthquake, disaster, well everyone will get depressed. No they won't. In fact very few people. Chronic stress matters much more. If you are in a chronically stressful situation, you're caring for somebody or a chronic financial situation if you're in a bad, intimate relationship. In fact, my own doctoral thesis is based on bad interpersonal relationships and the course of depression. So prolonged stressful situations are associated with an increased risk. And it's the chronic stress. It's the effect of that on your physiology over time, which exhausts you and takes you if you're vulnerable still over the edge. So chronic stress is much more important as a risk factor and much more important to sort out.

Sana Qadar: What are some other giant myths about depression that you want to myth bust.

Professor Ian Hickie: That is psychological. You know, it's a cognitive process that you can talk yourself out of. Of course, if you've ever been depressed and people say to you, which we historically have said, well, get yourself sorted, just give yourself a stiff talking to drag yourself out of it. Anyone who's seriously depressed would go, that just doesn't work. Now, of course, the danger of some psychological therapies that are simplistically delivered in the middle of an acute episode of depression run that same risk. Now this is different to. So the severity of depression you have the type of depression matters which is a little bit different to preventing depression. Coming back and contemplating what has happened is really important to preventing recurrence.

Sana Qadar: Coming back to. So you said okay it's not psychological. What is it then? Because you also write in your section about myths that it's not just a chemical imbalance either.

Professor Ian Hickie: Oh no. So the chemical imbalance bit if we retreat into neuroscience here. Right. Your brain's a mushy thing with nerve cells of many different types, and they form circuits. And those circuits are cabling and chemistry working together to produce the complex behaviours that we have. So back in the 1980s and 1990s, when people trying to explain why antidepressants work, people use two terminologies, one of, oh, if you change the chemistry and lift one, there must be an imbalance in it. And then worse than that, there must be a deficit in it. You must lack serotonin or lack dopamine. And we're putting it back. These were attempts to explain, in fact, the serious research of the side never, never said either. They're just saying it works. My favourite example in my own personal life is ibuprofen. You know Nurofen. Yeah. You know, arthritis. I can't get out of bed in the morning and walk and do stuff at my age with arthritis that I have without the chemical assistance of some of those products, which then allows me to be physically active and actually reduce those things. But it's not the cause of my arthritis, a lack of Nurofen or ibuprofen or a lack of aspirin. I do not have an aspirin deficiency.

Sana Qadar: So if depression isn't caused by an acute life stressor, it's not the result of wonky psychology and it's not the result of a chemical imbalance. What causes it?

Professor Ian Hickie: So we can say at a population level, 30% is genetic, 10% is about childhood risk factors, 50% is about the current context, and 10% is we don't know. So now we've known that for 40 years. Only trouble is the genetics turns out to be really complicated. Not what we thought. The childhood one, which everyone says is the cause. You know, most interviews have people start with now about your childhood. And people spend years reconstructing their childhood. And for most people, it's not the cause. The complex interplay of their current environments matters, and things that have happened in their life matter. Not just events that have happened, but things like having had Covid, having had infection, having had cancer, what treatments you're taking, how many drugs and alcohol you take. There's lots of other environmental factors. Our biggest problem is that's all very good when we're talking about the population or people with depression in general. But for you, if you're depressed, that's no help at all because it doesn't tell you in your case what proportion is relevant to you. And this leads to this crisis in clinical care because people come in and go, what caused it? I go, yeah, look, um, we're never really going to know the answer to that.

Professor Ian Hickie: So a lot of this book and my, my life is about, look, let's not dwell on that, okay? Let's stop blaming your mum. Let's stop, because we'd probably never really going to know.

Sana Qadar: Okay.

Professor Ian Hickie: Let's work out how to get out of the episode. And then how do you stay out now then that is an individual journey of exploration because, uh, annoyingly, there is no brain scan or blood test or EEG. Some simple thing that says what your depression is as distinct from the next person in the waiting room. We have to kind of find out. And trying to work out, do you have certain types? And I try to emphasise here different types or pathways that make it more or less likely you're on a certain kind of path, and therefore certain kinds of treatment are more likely to work versus other sorts of treatments which are unlikely to work. It isn't random. Another great myth is that this isn't so much a myth. This is actually a bit more experiential. Many people just get the treatment. You have psychological treatment no matter what's wrong, no matter what sort of depression you've got. Start here with this CBT or start here with this Prozac like drug, this SSRI drug.

Sana Qadar: Just to be clear, SSRIs are a type of antidepressant. And they stand for selective serotonin reuptake inhibitor.

Professor Ian Hickie: Because that's what we do to everyone. Right. This is very unhelpful. But big health systems love that. Here is not just the checklist for whether you've got it. Here is the clinical pathway. Start here. All people start in square one. Do this. And this is so-called stepped care in Australia. You must all do psychological therapy first or you must all do SSRIs as the first drug, the Prozac like drugs. This is a really bad way to start. This is like it's just fever or it's just headache. We won't try and work out what's a brain tumour or a migraine. It's just headache. It doesn't help to get so generic that the treatments are just handed out in a generic way.

Sana Qadar: Explain that a bit more, because you write that clinical depression is not a single entity, which I, as someone who who's never had it and not really as far as I've known, known anyone with it. I didn't realise that there's different types of depression. Can you talk about the fact that there are more than one type of depression?

Professor Ian Hickie: Yeah, this is a problem we caused ourselves. So we have this huge public thing. We used to fight about this forever. Okay, 15 types of depression. It's been fought about for centuries. To the credit of the Americans back in the 1980s. They said, hang on a second. Why don't we just go and call it all major depression? So we'll just put it all there. And they did believe the Americans can be quite dominant in their single beliefs. They did believe at the time there was one final common pathway that it would all be explained by the stress arousal system. It didn't matter what the cause was. This would be the explanation for everything. So they promoted, on the one hand, major depression as the concept, and they were working on a neurobiology and a fairly narrow way of the stress arousal system being the cause. And then they looked for treatments. Sadly, those treatments haven't worked, but that's a separate story. In truth, there are a number of different pathophysiological pathways. There are like fever, like headache, like back pain. There are many examples where what is causing the problem is different. So the task these days is to find which depressive type and pathway you're on.

Sana Qadar: So let's just run through a few types. There's anxious depression.

Professor Ian Hickie: Anxious depression is the most common. And that's the one that responds best to psychological therapies and SSRIs. So it's good that the most commonly prescribed treatments also connect with the most people.

Sana Qadar: There's also what Ian refers to as circadian depression.

Professor Ian Hickie: So one of the newer ideas, and myself and my colleagues have tried to try and change the language and call it circadian depression. It is your body clock. It's not your wife, it's not your background. It is the change of seasons. It is travel. They're the people who do badly with SSRIs, and they do badly with cognitive therapy because they're not a cognitive problem.

Sana Qadar: And then there's a whole lot more like bipolar depression, perinatal depression, the list goes on.

Professor Ian Hickie: So what you said this, this marketing of the one thing has led to the one outcome for many people that's resulted in bad experiences.

Sana Qadar: Right. And are we in a paradigm shift with that now, or is that sort of still being worked through?

Professor Ian Hickie: Yes and no. In depression. We've done such a great job of making it generic and being out there and talked about. We kind of done ourselves a disservice. I make the. I give the example in the book one of the saddest cases I ever involved in, a woman with very severe postnatal depression almost lost her life and the life of her child, but her mum had been in a psychiatric hospital for two years after she was born, and no one ever told that story.

Sana Qadar: Wow.

Professor Ian Hickie: Now, if we had known that, if she had known that before the birth of the child, we would have treated that really differently.

Sana Qadar: So knowing what type of depression a person has is key to treating them properly. But before you even get to treatment, there's a myth they don't actually work.

Professor Ian Hickie: Okay, only in psychiatry would we be debating stuff about whether there's been meta analyses, studies for now, 30 years, even though the biggest meta analysis in the world about five years ago, done in Oxford, of all the thousands of studies and tens of thousands of patients said they do work. Now, that's at a high level. That does not mean they work the same for everybody. No treatment works the same for everybody. So the distribution then is some will get a lot better. Some people will have bad experiences, some will have no effect and some will benefit a lot. And then also I've said distinctly for some types of depression, different kinds of antidepressants are likely to be better or worse. So the differentials here, depending on what you've got. Imagine if we just gave penicillin to everybody with all infections. Anyone's got a fever, sore throat okay, you'd see an effect, but some people would be completely irrelevant trying to work out which ones should actually get penicillin is the next stage of that. Not to say penicillin doesn't work, but in our area, people go back and go, antidepressants don't work. That's just wrong.

Sana Qadar: A related myth to this belief that treatments don't work is the idea that treatments aren't necessary anyways. Because if you give a person long enough, they'll get better on their own. That can happen in some cases, but unsurprisingly, there's a risk.

Professor Ian Hickie: Great myths in the treatment of depression is that there was no damage done by an episode of depression, or by recurrent depression, like, you know, when it went.

Sana Qadar: That's damage done?

Professor Ian Hickie: To the brain.

Sana Qadar: Right Okay.

Professor Ian Hickie: Now, if you think about this medically, if I say to you, look, it doesn't matter how many heart attacks you have, your heart will be fine or how many infections you have of your kidney. You'll be fine. You go. You're kidding. Serious? Because the whole rest of medicine, the more recurrent episodes you have of all of those things, typically the more damage you do to that organ. Well guess what? Your brain's the same. Now we have evidence of depression as a risk factor to dementia, so treating depression helps to reduce the risk of dementia because in truth there is a physiology and a damaging one. There's stuff going on there neurobiologically during depression, which is bad for your brain. It doesn't just feel bad or look bad, it is bad. So the idea you can just be depressed as many times as you like, as long as you don't kill yourself, as long as you do something really bad and you'll be okay again when it passes is not true because many areas in depression go, oh don't worry. They'll get better if we just wait long enough. So no need to treat. Which if you think about many other areas of medicine, that's the weirdest thing to say. Don't treat the asthma, don't treat the diabetes, don't treat the heart. Because if they're alive, they'll resolve. But this gets said if I sound a little frustrated, a little upset about this after all these years, that still gets said every day of the week. And we go and look at public surveys. We have many people believe that's what they should do. They wait twice or three times as long to go for care, believing two things. My two biggest myths - treatment won't help or it doesn't matter, because I'll just recover spontaneously. And I'm going, actually, both of those things are wrong. Yes, episodes of depression do end, but they often do great damage and they often put your life at risk in the episode.

Sana Qadar: Sticking with misnomers about treatment for a moment, there's one about suicide that I've heard previously, and it's that antidepressants can lead to suicide because before they fully kick in, they can lift a person out of their depression just enough to give them motivation to then perhaps take their life. But is that actually a myth?

Professor Ian Hickie: If you go back before we had really any effective treatments for depression back and in psychiatric hospitals, particularly 1930s, 1940s, people often stopped. They just retreated to bed. They didn't move, and they're often unwell for two years. And then they'd slowly get better and improve terrible damage to their lives and everything else. When the tricyclic antidepressants.

Sana Qadar: Nothing's a quick definition. Tricyclic antidepressants are what are considered an earlier generation of antidepressant. They worked, but they cost a whole lot of bad side effects. Newer generation antidepressants are SSRIs, which, as mentioned, are things like Prozac. They definitely also have side effects sexual dysfunction and weight gain, to name two. But they are less severe than the side effects from tricyclics.

Professor Ian Hickie: When the tricyclic antidepressants and other things came into favour in the initial phases when people started to get better, they started to move. So they're in bed doing nothing. They started to move. And during that period where they started to move, some people then attempted suicide. Now they go, was that because they got treated, or is that because they actually started to move and enact the terrible thoughts they were having? So there's always, prior to the modern antidepressants being a concern, to watch people closely during the period of recovery, which is the phenomenon you just described. Then you go to the next level. The idea that hysteria in recent times that the new antidepressants in some way have created mass suicidal risk. If you look at the population level again, and I'm a co-author of studies in the British Medical Journal and others, at a population level, when increasing antidepressants goes up, suicide in the populations and suicide attempts go down. Now you go to the individual level. There's a group of people when they start antidepressants, including the new ones, SSRIs, in the first few weeks that they take the drug, some people become, if they're particular anxious, become more agitated, okay. And some people who are having suicidal thoughts say those suicidal thoughts are more intense and they some people become more motor active. So this is not a new phenomenon. But that does mean there's a caution. So warning people that it's possible that some people become more activated agitated, and they may express suicidal ideas is important, but it's uncommon.

Sana Qadar: While for most people, antidepressant treatments are effective, there are about 30% of people who don't respond. But the reasons for that aren't straightforward.

Professor Ian Hickie: This is the important thing. Many of those people in that 30% never get beyond the first set. They say, I've tried many antidepressants. You go, hang on, which ones have you tried? And then they tell you the brand names of what they've tried. They've actually had four different versions of the same drug of SSRIs or the Prozac like drugs. There are many, half a dozen of them on the market. You go, no, you haven't had four different things. You've had four are the same. And you probably don't have a depression that responds to that thing anyway. So you need to change to a different type of antidepressant. And now are many different types. I'm particularly focused on those that relate to the body clock system. There are new ones like ketamine. There are new other treatments, new brain stimulation techniques, and there are the psychedelics. There are other things happening. There are a lot of other choices, and there are different combinations of choices in different people. So if you think epilepsy or hypertension, lots of people don't respond to just the simple first off thing. Unlike in other medical areas, very few people get access to that better care to the what next.

Sana Qadar: I want to talk about psychedelics here. So the promise of psilocybin magic mushrooms. What do you make of that whole conversation. Because it was legalised in Australia last year, making Australia the first in the world to classify psychedelics as medicine. But this was all against the advice of the Therapeutic Goods Administration's own advisory committee and against the advice of many doctors. So where do you stand on the use of psilocybin?

Professor Ian Hickie: Yeah, talk about get surprises. I spend my life trying to change the health system. Nothing happens. You know, psilocybin, psychedelics, which we definitely were not having in 2022. Bang. You got licensed in 2023. So this has been hugely interesting. One of the factors is the reality that many people with severe depression and recurrent depression do not respond or have not responded to our commonly available treatments, and they're desperate. You know, the other problem with our antidepressant stuff is the slow rate of onset of effect. We say to people, you feel terrible, you want to kill yourself, but it's going to take 4 to 6 weeks to help. This is really and you'll get side effects tomorrow. It's really not a great therapeutic message.

Sana Qadar: Right.

Professor Ian Hickie: So there has been a market in these things. So just to go back one step on the psychedelics, ketamine which acts in a similar way, which is better investigated. So if I said psilocybin versus ketamine I'd say go down the ketamine path. Because it's much better research. But it has an immediate effect. People do say, wow, that depression, that black cloud lifted, I can see the light. I want to go out to dinner. I want to go out and have sex with my colleagues. I want to do stuff. I want to engage with pleasure again. Now, that often passes off very quickly. But something's changed. Something different is going on biologically, and it's chemically different, but biologically different. Whether so, people have been searching for alternatives and of course the illegal or, you know, DIY market, do it yourself market has always been out there, whether it's been cannabis or alcohol or psychedelics or stimulants. It's people are searching for other answers. So I think what's one of the factors that's driven this is in fact public need and the DIY industry. But there are big commercial interests behind this as well people as there is with medicinal cannabis and other areas.

Sana Qadar: So do you think we're over promising on psilocybin right now?

Professor Ian Hickie: Yes.

Sana Qadar: It wasn't a good idea to. Okay, right.

Professor Ian Hickie: Well, just think of all the criticism. I've had to sit through 40 years of saying, you know, Prozac is a dangerous drug and killing people. And, you know, if anything, you could argue it's a relatively weak drug that hardly does much harm. We know that psychedelics and we do know this. There's a whole other story that was all shut down by the Americans. It was all law enforcement. Nothing ever went wrong with the psychedelics in the 60s and 70s. Trust me, stuff went wrong. People became psychotic. People had bad trips. They had bad experiences. It wasn't simple. So yeah, it was. It was really psychoactive, but it wasn't all good.

Sana Qadar: Finally, is there one myth in particular that just refuses to die? Or one that's like, especially egregious to you that you'd love to have this book really kill?

Professor Ian Hickie: Yep. It's not physiological. It's simply social.

Sana Qadar: Tell me more.

Professor Ian Hickie: Now, that's not to say that social risk factors don't matter. They do. But it's like saying heart attack or cancer is just social or Covid is just social. Because it's spread by social factors. It's spread by, travel, you know, the epidemic relied on, you know, social factors allowed Covid to move around the world, but they did not cause Covid. But I have people sitting in me in my office every day going, no, no, no, Ian. No, no. It's social. It's because of X. Go no, no no, whatever, whatever was the combination of things that landed you here now. It's got to become now about you. And can we work out for you so you will know in the future what gets you out of the hole? Many people believe they're a depressive for life, an anxious person, and there's nothing they can do. So probably the core myth that I'm really attacking is work it out, get effective treatments, understand your own vulnerability, not the cause, your own vulnerability, and take steps to fix it so you can leave it behind.

Sana Qadar: That is psychiatrist Professor Ian Hickie. He's also the author of The Devil You Knew the Myths Around Depression and Why your best Days are Ahead of you. Now, if you know anyone who could benefit from listening to this episode, perhaps someone who's had depression in the past or is supporting loved ones with depression, consider sending it to them. We're available on the ABC listen app or whichever app you use to get your podcasts. This episode of All in the Mind was produced by Rose Kerr and Diane Dean. It was written, edited and presented by me, Sana Qadar and sound engineered by Emrys Cronin. That's it for this week. Thank you for listening. We'll catch you next time.