Targeting wellbeing in depression:
How to overcome the “Pollyanna” problem.
Barney Dunn
Wellbeing Symposium
Exeter, July 2012
Scope of the depression problem
Depression is a major public health care problem, with a chronic, relapsing course (WHO)
A majority of depression is unrecognised and untreated.
We have efficacious psychological depression treatments but:
•
Only 50-60% response rate (Cuijpers et al., 2010)
•
Relapse common (Vittengel et al., 2007)
•
Worse outcomes in complex, comorbid presentations
•
Hinged solely around a disease model
•
Only available to small proportion of sufferers
There is a need:
1.
To augment existing treatments
2.
To develop novel, streamlined and accessible interventions
A translational research strategy
T1 gap
Basic Clinical Science
-
T2 gap
Therapy Innovation & Evaluation
Dissemination, Training, Access
Focus on neglected, hard to treat, but potentially important clinical features (e.g. anhedonia)
Develop understanding of maintaining mechanisms and then find ways to correct them in the lab
Use this to develop novel intervention components in the clinic
Anhedonia in MDD
• An inability to experience pleasure
• Cardinal but neglected symptom (Wood & Tarrier, 2010; Dunn, 2012)
• Relatively specific to depression (Clark & Watson, 1991)
• Major source of client distress
• Non-responsive to treatment (Brown, 2007)
• Poor prognostic sign (Morris et al., 2009; Wood & Joseph, 2010)
• Synergy with wellbeing funder and government initiatives
Potential to intervene at multiple stages of the
depression life course
Tx first
episode
Tx chronic
depression
Secondary
prevention
Maintenance
Tx
Primary
prevention
Anhedonia interventions may have particular benefit outside of acute episodes
How well do existing depression treatments target wellbeing?
Eudamonic focus (build a meaningful life)
- behavioural activation (e.g. Martell et al., 2010)
- goal setting and planning (e.g. MacLeod, 2012)
- well being therapy (Fava, 2012)
- some cognitive elements may exacerbate anhedonia – head heart lag
Neglect of hedonic wellbeing (build subjective pleasure)
- Need techniques to enjoy positive events as they occur to maximise benefit
- MBCT as an exception? (e.g. Geschwind et al., 2012)
Impact of antidepressants unclear
- May contribute to positive numbing (Price, 2009)
Harnessing the positive psychology movement
Population flourishing (Huppert)
Upward spiral of flourishing (Fredrickson)
The “Pollyanna” Problem
•
•
•
•
•
•
When acutely depressed, positive focus may be irrelevant or invalidating
The pressure to be happy can make people miserable
Can give message that negative emotion experience is solely a bad thing
Language of positive psychology can put people off
Application can go beyond the data
In depressed state:
- effect of techniques may vary (or reverse) in depression (e.g. suppression)
- techniques that amplify PA may also increase NA (e.g. elaboration)
- techniques may move clients away from a ‘rational’ position
Possible Solutions
Adapt positive psychology
• Modify language
• Select-appropriate comparison points for experience
• Promote flexibility in emotion regulation (Kashdan & Rottenberg, 2012)
• Blend positive and negative emotion techniques (Wood & Tarrier, 2011)
But:
- Will this account for mood regulation strategies potentially varying as a function
of current depression status?
- Will this account for potentially different maintanence mechanisms in depressed
and non-depressed states?
An alternative is to go back to the laboratory and build a detailed understanding of
anhedonia in depression
Themes from basic science 1:
Two independent affective systems (Watson et al., 1988)
Pleasantness
Negative
Neutral
Positive
PA is distinct from NA. Therefore:
• Reducing NA will not necessarily lead to improvements in PA.
• Different mechanisms may maintain PA blunting
Themes from basic science 2:
PA can be fractionated (e.g. Berridge & Kringelbach, 2009)
NIMH Research domain criteria (Rdoc) – positive valence system
- measure system at multiple levels: genes, physiology, behaviour, self-report
My research has a particular focus on ‘liking’
Research Strategy 1:
Measure positive affect dynamically
a) Anticipation….
b) Set Point
c) Reactivity
d) Regulation
……. e) Recall
Flourishing
Emotion
Experience
Anhedonic
Time course
• Which of these stages are disturbed has implications for treatment
• A further timeline to consider is anhedonia across the depression life course (e.g. chronicity)
Research Strategy 2:
Identify underlying mechanisms
Different mechanism may act at different (and multiple) points of dynamic
positive affect response
1. Mind wandering & negative contamination
2. Reduced positive information processing biases
3. Neglect of sensory and embodied information
4. Positive dampening appraisal processes
Evaluate how well existing treatments (BA, CBT, MBCT, antidepressants)
impact on these mechanisms
By identifying key mechanisms and developing ways to correct them in the
laboratory, novel targeted intervention components can be developed.
Key Research Infrastructure:
Establish prospective cohort via DiReCT
• Approach individuals from Devon Depression and Anxiety Service to
join prospective cohort (10000 per year)
• Extensive, multi-method assessment (self-report, genotyping,
cognitive-experimental, experience sampling) of positive affect and
mechanisms
• Follow up longitudinally to establish natural time course
• Measure if PA disturbances predict treatment response in routine care
• Recruit into ongoing clinical trials and experimental studies
Transdiagnostic potential
•
Anhedonia also prominent in other mental health problems
- psychosis
- social phobia
•
Similar bias in treatment focus in schizophrenia
- treating positive and neglecting negative symptoms
•
Depression (and anhedonia) frequently comorbid with physical
health problems
•
A wellbeing focus of relevance for all of these conditions
•
In future, genuinely transdiagnostic interventions may emerge:
- collaborative project with Watkins, Kuyken, Dalgleish et al.
Thank you for listening
Spare slides
Solution 2: Translate from the laboratory
• A dilemma is how quickly to move to translation
• One approach is to build a detailed basic science understanding of positivity
and anhedonia, rather than rushing instantly to the clinic
• MBCT v CBT as an example – need to merge clinical insight with a sound
scientific model
Two kinds of well being
Hedonic – subjective well being; pleasure, satisfaction and happiness
Eudaimonic – psychological well being; mechanisms associated with healthy
human functioning and adjustment
Tripartite Model
(Watson & Clark, 1991)
Anhedonia
Depression Specific
General distress:
‘neuroticism’
Arousal
Anxiety Specific
Effects of techniques may vary as a function of
depression status
Emotion Change: Composite affect
7
20
6
10
5
0
High NA
Low NA
-5
Number of intrusions
suppress - no instruction
(higher score = more negative)
15
5
4
No instructions
3
Suppress
2
-10
1
-15
0
-20
Group
Control
Depressed
Non-dysphoric individuals can successfully suppress affect and memory of
negative material (Dalgleish, Dunn et al., 2009; Yiend et al., 2006; )
The same techniques that amplify PA may also
exaggerate NA
60
50
Index Score
40
30
never-depressed
20
depressed
10
0
Positive
memory
happiness
Negative
memory
sadness
Negative
memory
fear
Negative
memory
disgust
Negative
memory
anger
Emotion Rating
•
•
Depression is associated with blunted response when spontaneously recalling
positive and negative memories (e.g. Rottenberg’s context insensitivity hypothesis)
If you elaborate memories, then depressed individuals show greater reactivity to
both positive and negative memories (Dunn et al., in preparation)
The realism challenge
• Positivity interventions may move depressed individuals further away from a
realistic position (Dunn et al., 2007; Dunn et al., in prep)
0.3
0.25
0.2
Control
0.15
Depressed
0.1
0.05
0
Analogue
Clinical
Study
Happiness during activity scheduling
(from 0 not at all to 100 extremely)
Estimated correct - actual correct
0.35
85
80
75
70
MDD
Control
65
60
55
anticipated
post-event
Rating
Fredrickson’s Broaden and Build Model
- positive affect builds resilience and buffers over stress (see Garland et al., 2010)
Downward spiral of psychopathology
Upward spiral of flourishing
Harnessing the positive psychology movement
• Increasing interest in promoting psychological wellbeing to encourage
‘flourishing’ (e.g Felicia Huppert)
A positive psychology example: 12 steps to happiness
(Lyubomrisky et al., 2005)
1. Gratitude
2. Optimism
3. Avoid overthinking and comparison
4. Practice kindness
5. Nurture social relationships
6. Develop coping skills
7. Forgiveness
8. Find ‘flow’ experiences
9. Savour
10. Commit to goals
11.Engage with spirituality
12. Attend to the body (exercise, meditation)
See also Action for Happiness website
Understanding mechanisms of anti-depressants
• Anti-depressants remain most common treatment for depression
• Elegant work is exploring antidepressants effect on negative cognition (e.g. Harmer)
• Possible impact on anhedonic unknown; clients qualitatively report positive
numbing on medication (Price et al., 2009).
Critical outstanding questions
•
When to intervene?
- acute adjunctive treatment?
- relapse prevention?
- primary prevention?
•
Who to target?
- all individuals at high risk?
- all individuals with a chronic relapsing pattern?
- just those with residual anhedonia?
•
How best to maximise efficacy and accessibility
- what mechanisms to target?
- smartphone and internet applications?
- group intervention delivery?
Building the right team
Across the lifespan
Multi-method and multi-disciplinary
From bench to bedside
A service user and clinician perspective