Anxiety and depression: How far have we come?

James Scott:
Good to be with you, Clare.

Clare Blake:
Now, Hippocrates treated depression with bloodletting, baths, diet, and exercise. How far have we come?

James Scott:
We’ve come a long way in terms of understanding mental health and mental illness as actual illnesses that affect people and cause significant morbidity and significant reduction in quality of life. There’s been a concerted effort to try to reduce symptoms, get people functioning better. So I think really, the big shift has happened over the last 60 or 70 years. And that’s been in terms of psychological therapies, particularly cognitive behavioral therapy, which is widely available. You can get it on the internet, you can get through a podcast, sort of what we’re doing at the moment. You can go and see your own therapist. You can do online therapy. And then of course, there’s been the advent of medications. So we tend to talk about depression as being one illness that’s the same with everyone, but it’s not. It’s very variable from one person to another. In some people, the depression resolves very quickly and [they] recover, and have this really good response. In fact, that’s the majority of people. But in some people, it’s a severe, persistent, disabling illness that sometimes never goes away.

Clare Blake:
CBT that you mentioned, cognitive behavioral therapy, is really successful, but it also requires a lot of hard work.

James Scott:
Yeah. In terms of therapies, the more people put into it, the more they get out of it. And that’s true for most. It’s true if we go on a diet. The more you put into it, the more you get out of it. Same with physiotherapy, the more you put into it, the more you get out of it. Same with psychological intervention. So when people sort of really get stuck in a therapeutic process, do the homework, attend appointments and such, they’re much more likely to get a positive outcome. And that’s not always easy because we’ve all got such busy lives. And so trying to put aside time to do therapy is not easy.

Clare Blake:
Especially when you’re struggling.

James Scott:
Yeah. Yeah, that’s right. One of the core features of depression is it robs people their motivation, it causes this inertia in people. And so trying to get them to engage meaningfully in therapy can be quite challenging. And that’s one of the skills of the therapist is to sort of get people motivated to work at their pace, their goals, and get them really engaged in a therapeutic process.

Clare Blake:
Certain people are predisposed.

James Scott:
Absolutely. Some of the terrific science we’re doing here at QIMR Berghofer is looking at the genetics underlying the syndrome, underlying depression and anxiety and dementia and schizophrenia. Very clearly, there are genetic risk factors. People who have various genes that increase the risk of getting mental illnesses like depression. But there’s also environmental factors. We know things like exposure to trauma in childhood [is a] very strong risk factor. It’s interesting because it’s this combination where [there are] people that are genetically disposed to getting these disorders, and then life comes along – and unfortunately, they have adverse life events. We all are likely to have one or two adverse life events. But there are some people who, unfortunately, get experiences of chronic stress and trauma throughout their childhood – they’re much more likely to get problems like depression, anxiety, when they’re adults.

Clare Blake:
And on the flip side, some people just seem to have natural resilience.

James Scott:
Yeah. And that’s probably an understudied area of psychiatry. In psychiatry and psychology, we’re often looking at illnesses and problems and impairments. The focus isn’t as much on people who do well.

Clare Blake:
They’re not coming into your practice.

James Scott: 
I never see them. I never see them. We know that sort of growing up in a supportive family, having the support of school, having good friends, not being isolated, and being naturally intelligent, all of these things make people more resilient to mental health problems.

Clare Blake:
Most of us do, as you said, have worrying times. How do you know if you’ve crossed that bridge into depression or anxiety?

James Scott:
I think it’s often hard to know. In general, where the symptoms are persisting and where they’re causing impairments in people’s ability to function, that’s when help should be sought.

Clare Blake:
Do people around you notice before you do?

James Scott:
That’s actually, Clare, that’s a really interesting question. So we talk about internalising and externalising disorders. And so the internalising disorders are those, mainly around anxiety, depression, where people feel the experiences internally, and other people may not notice. And so it’s the individual who notices those. And when we ask parents about their kids’ mental health, if they are having internalising disorders, if their children are having internalising disorders, parents often say, “Oh no, my child’s fine. There’s no problems there.” When you ask the adolescent, they say, “No, I feel terrible. I worry every day. I can’t sleep. Life’s very difficult for me.” For the externalising disorders – so these are problems like aggression, like losing your temper, having conflict with others, being argumentative and such. And sometimes it’s the result of stress that people behave this way. They don’t know that they’re doing it, but everyone around them sure knows it because they become very difficult to be with.

Clare Blake:
Is that more likely to happen in teenagers or any demographic?

James Scott:
So girls, females, [are] more likely internalise. Males are more likely to externalise. So that’s a big one. You see in, for example, forensic populations and blokes in prison, and many of them have mental health problems and many have acts of aggression and such. Obviously, some are pure acts of antisocial behavior. But some are a result of males who are feeling depressed and anxious and reacting to those emotions in a way that’s quite destructive to others.

Clare Blake:
Anxiety is more common – and depression – these days, or is it just more talked about and better diagnosed?

James Scott:
It’s both. It’s both. There are a number of study designs that examine… They’ve taken a cohort of people from a generation ago, and they take another cohort now and they ask exactly the same questions. And what they show in some demographics, particularly amongst adolescent females, is increased rates of depression and anxiety. I was just reading a study this morning, which I’m part of, where we asked mothers back in the 1980s about their symptoms of anxiety and depression. And now we’ve got their daughters 30 years later and we’ve asked them the exactly same questions.

Clare Blake:
That’s fascinating research.

James Scott:
And what we’ve found, after you adjust for all sorts of things like education and socioeconomic status and such, because all these things have changed obviously over a generation – back in the eighties, mothers were much more likely to be at home and much more likely to be married, they were much less likely to have had a university education – so we adjust for all of those things. What we find is that rates of anxiety [are] about twice now, in women around 30 years of age, what they were [in] their mothers at the same time back in the eighties. So there certainly are some generational changes that have occurred.

Clare Blake:
Has that study gone to find out why?

James Scott:
Well, it’s really hard to know… What we’ve tried to do, within this study – I reckon it’s a brilliant study – what we’ve done is we’ve adjusted for a whole lot of things like is it around work, yeah, and work opportunities? Is it around having kids?

Clare Blake:
Expectations.

James Scott:
Yeah, all these things. We adjust for those, and there’s no difference. So we can’t really just put it down to the changes in people’s lives. So we don’t know why it is. We don’t know.

Clare Blake:
And anxiety and depression go hand in hand.

James Scott:
So they often go together, but not always. Some people will just have anxiety and not depression and vice versa. Some people are depressed, but not anxious about things, but they’re very highly correlated.

Clare Blake:
Now, depression can come and go, but anxiety really needs to be treated. Is that right?

James Scott:
I’d probably argue they both need treating. Because depression doesn’t always come and go either. It can persist. Depression tends to be a more episodic disorder. And it can last for six, 12 months. So in fact, I think the mean duration of depression is about nine months untreated, so that’s a long time to be unhappy for. It’s almost a whole year. Anxiety, you get state anxiety and trait anxiety. So when we talk about state anxiety, we’re really talking about anxiety that occurs at a particular point in time, usually as a result of some sort of stress, might be sort of a relationship breakdown or problems at work or something. Trait anxiety is people who are naturally anxious all the time – they’ve got high levels of sort of worrying out things. Of course, people who have trait anxiety, people have naturally high levels of anxiety, are more likely then to get more anxious when there’s problems at work or a relationship breakdown and such. Anxiety, we talk about most dimensions. There’s sort of physical symptoms, the emotions that people experience, and then the cognitive symptoms. And cognitive behavioral therapy really addresses all of those. That’s how it’s so effective.

Clare Blake:
Are there symptoms of anxiety that would surprise people [like] struggling with memory?

James Scott:
One of the really important things when we treat anyone with a mental health condition is to educate them about their condition so they know what they’re dealing with. If you’re 40 years of age and you have your first panic attack, and you get shortness of breath and chest pain and such, people immediately think, “Oh, I’m having a heart attack. I’m going to die.” It’s terrifying. When we educate people about the fact that this is an anxiety symptom, it’s just anxiety, no one’s ever died of anxiety, then people can manage that experience much better. If you think you’re going to die from it, of course you get super anxious and it just becomes a feed forward cycle. If you think, “Oh, this is just my anxiety. I’ve just got to take deep breaths or slow down,” then the symptoms go away.

Clare Blake:
Well, that’s for an older person that’s never been exposed to anxiety for themselves, but let’s talk about younger people for a while. You’ve conducted extensive research into child and adolescent mental health, including bullying prevention. Now, what do we know about the effects of bullying?

James Scott:
I think we’ve got to identify it. We have to identify it, and we have to prevent it, and we have to manage it. This was an area of research that I became very interested in from my clinical work. What I love about being both a clinician, being a psychiatrist and seeing patients most days, as well as a researcher, is that what I see in my clinical practice [I say] “Oh, that’s a really interesting research question.” So some years ago, I was doing my clinics and I was seeing all these young people, and they came from good homes and are content and happy and such in terms of their family life. But they’re coming to see me and they’re depressed and suicidal and so forth, and very high levels of distress. In the course of assessing these people – and this is back 15, 20 years ago now – in the course of assessing people, these kids kept saying, “Oh, I’m getting picked on at school and bullied at school.” And this was before there was much attention to bullying, and in fact, there was a lot of thought given to physical bullying, but not much else at that stage. The more I talked to these kids the more I thought “this is so much like kids who’ve been abused”. It’s the same, there’s a sort of shame about it. The kids were saying, “There must be something wrong with me. I must be causing this bullying. It must be some deficit myself that’s causing all these other kids to pick on me.” And so, as I worked with these kids, we tried various strategies, I went away and did some reading about bullying. I hadn’t actually been taught very much about it when I went through my psychiatry fellowship. It wasn’t talked about very much in the public space at that stage. A few things really struck me. One was at some schools, the bullying was just endemic. There’s just so much bullying going on, and in other schools there was almost none. The second was that when you took these kids out of an environment where they’re getting bullied a lot and put them in a different school, more often than not, the bullying wouldn’t continue. There was this kind of dogma at the time that there’s no point moving schools because they’ll just get bullied at the next school they went to. This wasn’t happening. And a third thing was that a lot of bullying was just happening to kids who were just nice, pleasant kids. It was really hard to understand… Well, I had in my mind at that time that kids who get bullied, they are probably things that made them more likely to get bullied.

Clare Blake:
The stood out for some reason.

James Scott:
Yeah, yeah. Just, say, targets in school and such. But most of the kids I was seeing, they weren’t standing out, they were just decent kids, and this bullying had taken on a life of its own in this environment. And it was really hard for the kids to stop it. And the fourth thing was that at that time, parents were very dismissive. “Oh, you not getting hit, so it can’t be that bad. You’re just being called a few names.”

Clare Blake:
Makes me so sad.

James Scott:
So we got involved with…

Clare Blake:
…The old sticks and stones. I think I grew up on that myself.

James Scott:
That kind of thing, yeah, yeah. So we’ve done a lot of research in this area and we show, first of all, the really damaging effects of bullying. And we show that adolescents who experience bullying had rates of mental illness in adulthood comparable to those young people who’d been sexually abused. So it was kind of that pathogenic, it had an equivalent pathogenicity of sexual abuse. And of course the idea of children being sexually abused is abhorrent to the community, and so it should be. But there wasn’t the same concern at that time about kids being bullied, even though the health effects were very similar in terms of mental health effects. And so we did a lot to raise awareness of the harm it’s done to children and adolescents who are bullied. About the same time, other people doing research in the space were reporting the same thing. We showed that those kids who are getting bullied were more likely to exit school early. They’re more likely to be unemployed at 21 years of age. So they were on this trajectory of psychosocial disadvantage, economic disadvantage, which of course just makes life so much harder for them. So as a result of this research and other research that people are doing, there’s been this real interest in trying to prevent bullying. And now, most schools in Australia have, or I think every school in Australia would have an anti-bullying policy. It was really interesting. They tried to do this big trial recently on bullying prevention. And so these were strategies that worked really well 15 years ago. Now when they did it, they showed that they don’t work anymore. And the reason is that there’s such good anti-bullying programs through the school now, that to actually improve upon that is really hard. So the strategies that used to work, because there was so much bullying going on, they used to be very effective, and the other schools are so good at addressing bullying, and don’t get me wrong, it still goes on. I know this. But it’s so much better than what it was that to show an even better effect is very difficult. So where do we go from here? We’re really pleased that there’s much more awareness of the problems of bullying, there’s much more of a public health approach to it, and schools are much safer environments.

Clare Blake:
And are kids getting listened to a bit more?

James Scott:
Very much so, yeah. Yeah, very much so. School is much more likely to respond. But we also know that there’s still some vulnerable populations of kids: Kids with disabilities, kids who stand out in one way or another, they’re still getting bullied and such. And so we’re really sort of targeting our bullying interventions.

Clare Blake:
Is it much harder to treat the developing brain in terms of medication than, say, an adult who’s suffering anxiety and depression?

James Scott:
I think the evidence for most medications in children and adolescents is much weaker. And partly that’s because we don’t do clinical trials on children and adolescents with these medications. They’re all done on adults. Sometimes, as clinicians, we take the results of most clinical trials and put them upon adolescents in particular. There are now some studies coming through showing that some medications are very effective for anxiety and depression in adolescents, and more effective than psychological therapies. But my clinical experience shows that often when children and adolescents are unhappy, it’s more external factors, it’s an unhappy home life, peer relationship problems, difficulties of their schoolwork, kids for some reason feeling like they’re not competent. Medication doesn’t work for that. Giving tablets to kids who are unhappy because home’s not safe doesn’t really help them. That involves other interventions to change the environment around a child to make things safer for them. So this is why I’ve been so interested in work on preventing child maltreatment, on making schools safer. On other initiatives, which really support the child’s living environment which they’re growing up in. We find they’re much more effective.

Clare Blake:
I guess keeping anyone off medication if you can.

James Scott:
Yeah, yeah. Look, medication has a role and I don’t want to dismiss it completely, because for some children it’s absolutely critical. And for some syndromes like ADHD, medication’s a treatment of choice, absolutely. But for other things, I think we need to be… we always need to be thinking about children in the context of their wider environment, in their family environment, school environment, and making sure that we optimise the environment around the children so as to make sure they’re safe at school.

Clare Blake:
On the medications, they’ve changed dramatically over the years and there’s the SNRIs and the SSRIs, and people who are doing really, really well on Prozac, one of the older medications. Are they just getting better and better?

James Scott:
No. I’d love to say they are, but they’re not. So there’s some big changes. So, let’s think about two syndromes. [Let’s] think about schizophrenia and let’s think about depression. Prior to the 1960s, there was no medication for schizophrenia. In the 1960s, medication called Chlorpromazine came along – accidentally found – shown to be effective in reducing the symptoms of schizophrenia. And since then, there’s been incremental improvements in the medications, but not a lot to be honest. And that’s since the 1960s. In terms of the antidepressants, the older antidepressants, what we call the tricyclic antidepressants, they were around in the 1950s. In the early eighties, medications like Prozac – an SSRI – was developed and came out. No real improvements since then. The leap forward of the SSRIs [is] that they’re safer. [In] the older antidepressants, an overdose [was] lethal. We were giving highly, highly toxic medications to people who were very suicidal. And of course that resulted in some overdoses and some fatalities and that was terrible. Now the antidepressants we prescribe to people, who are often depressed and suicidal, are much safer in overdose. Not completely safe, but they’re much safer in overdose. But they’re not more effective. They’re just much safer.

Clare Blake:
What proportion of people just don’t respond to medication?

James Scott:
That varies with the stage of illness you’re talking about. Let’s talk about psychosis. If you give people with their first episode of psychosis medication, you’ll get about an 80 per cent response rate. You’ll get complete remission in about 80 per cent of people. If they stop the medication and they relapse, they’ve got about a 50 per cent chance of recovering again. So when you get these sort of relapses and illness, [the] chances of actually responding to medication reduces. And that’s one of the real challenges because this illness comes on people who are in their teens or their early twenties, we give them medication, we get them better. And we can say, “Look, ideally you should stay on this medication for life. Because if you relapse, we’ve only got a 50 per cent chance of getting you well again.” But of course, no 18 year old wants to be on medication for life. And we can’t predict if they’re going to be people that will relapse or not relapsed. So this is all the clinical uncertainty that makes practicing psychiatry so difficult.

Clare Blake:
Now, we know you’re working on this study that you absolutely adore right now, but what else is your team here at QIMR Berghofer working on right now?

James Scott:
So right now we’re doing clinical trials and psychosis. So we’re looking to see whether or not there’s novel compounds. We’re particularly interested in [a] food additive that seems to be very effective as an extra treatment for people who have treatment-resistant schizophrenia, for example. We’re looking at whether or not some cases of psychosis can be caused by the immune system being dysregulated. So the immune system attacking the brain and causing the psychosis. So we’ve got a big study going in that. Traditionally, we thought psychosis was all dopamine, but there’s more and more evidence that for some conditions of psychosis it might be an immune-mediated illness, which requires a whole different set of treatments. We’re doing a whole heap of studies, understanding better about child maltreatment. How do we make family life safer for children so that parents can support their kids better?

Clare Blake:
Now, this information is general in nature. For your own personal advice, your doctor is definitely the best choice. Now, the stigma, has that changed a little bit, James?

James Scott:
Yeah… We talk about mental health literacy, so that’s just being able to understand what mental health conditions are and being able to talk about them. Mental health literacy in Australia’s improved enormously. So the sort of conversations people have about depression, anxiety never would have been had 30 or 40 years ago. That means that people are more likely to access treatment, get well as a result of treatment. So that that’s been really helpful. People who have mental health conditions don’t feel so isolated anymore. They know that other people have these conditions. These condition are really common.

Clare Blake:
If maybe you or someone you know who needs help with anything we’ve talked about today, you can call Beyond Blue 1300 22 46 36, or Lifeline 13 11 14. It’s been great talking to you. And for more on Professor James Scott’s body of work, or any of our other research, go to qimrberghofer.edu.au. Thank you so much for your time James. I know you’re very busy.

James Scott:
Lovely. That’s great. Thanks, Clare.