Good.
What a wonderful turnout.
Good evening.
I'm so thrilled to see so
many of you here tonight.
I'm Gina Vild.
I'm the Associate Dean for
Communications and External
Relations at Harvard
Medical School,
and welcome to our
second mini-med school,
our second Longwood
Seminar of 2019.
Tonight we're all here to
learn about depression and how
this complex condition
can be decoded.
So to all of us here
on the Longwood campus
and to those watching from
around the world, welcome.
We had many thousands
watching from 20 countries
around the world two weeks ago
for our first Longwood Seminar.
And I'd like to welcome all of
you who may be joining us again
tonight.
When we ask our past attendees
for recommendations on topics,
what they tell us is
that mental health is
very high on the
list, so we were
really happy to be able to
respond to your requests
to offer this topic this year.
Harvard Medical School has
groundbreaking research
under way.
And tonight, we're pleased to
bring to you two of our expert
faculty members who will share
their knowledge with you.
When you checked
in this evening,
you may have picked up a list of
local mental health resources.
We urge you to share this
with family and friends
if you think it will be helpful.
To learn more about this
topic, visit the Harvard Health
Publishing website.
And you'll see on the screen the
URL is www.health.harvard.edu.
And here, you'll find special
health reports, newsletters,
e-learning opportunities,
and blogs on mental health
and depression.
And you'll also find a
host of other science
and health related topics.
In particular, Harvard
Health Publishing
also offers a
special health report
on understanding depression.
And I'm happy to tell you
that those who are here
tonight and those, if you're
watching from the live stream,
may order the guide
at a discounted price
by using the code HMSLS
within the next 30 days.
And now, please join us.
I hope you'll join us for the
next two Longwood Seminars.
Next Wednesday,
April 17, we'll have
a panel of experts on artificial
intelligence and health care.
And on Tuesday, April
30, we'll conclude
with the mini-med school
on why sleep matters.
And if you are
planning to attend,
I urge you to arrive
early because whenever
we offer a program on sleep,
it's always well attended.
So on the screen,
you'll see information
related to how you can obtain
certificates of completion
if you attend three or
more of our seminars
and if you're a
teacher and would
like to receive professional
development points.
Our speakers will
be taking questions
at the end of their
talk, so you have,
if you're in the
audience, a little card.
We will be collecting
those, and our speakers
will try to get to as
many of those as possible.
If you're watching
through the live stream,
please write your
question in the comment
box on YouTube and Facebook.
And when you do, please
tell us where you're from,
where you're writing from.
Because it's really nice
for our audience to know.
Now I ask you to silence
all your electronic devices,
but do not turn them
off because we'd really
like you to join our
conversation on Twitter
by using the
hashtag #HMSminimed.
Did you know that 1 in 10 suffer
from depression in the United
States?
And the World
Health Organization
reports that, worldwide, 30
million people of all ages
suffer from depression--
sobering statistics.
When we were thinking
about tonight's program,
we were really in a
quandary because there
were so many aspects to it.
And we wanted to narrow
it down to a focus that
was specific enough where
we could really be in depth.
And because we know
it strikes people
of all ages and
particularly the elderly,
it has a wide range of
causes and symptoms,
it can be diagnosed as
temporary, minor, seasonal,
it can be classified as a major
mental health disorder as well,
and there are a host
of treatment options.
So when we thought
about what we wanted
to talk to you about tonight
and we consulted our experts,
we decided to focus on
how depression affects
men and women differently--
from its causes,
to its symptoms,
and its treatments.
And now, I'm pleased to
introduce our speakers.
Dr. Jacqueline
Olds is a part time
Associate Professor
of Psychiatry
at Harvard Medical
School and a consultant
in psychiatry at both
Massachusetts General
Hospital, McClain Hospital.
She's going to talk to us
about women and depression
and why females
are more frequently
affected than are men, which
is something I did not know.
But first, we'll hear about
how depression can impact men.
Michael Craig Miller is a
part time Assistant Professor
of Psychiatry at
Harvard Medical School.
He serves as the Senior Editor
for Mental Health at Harvard
Health Publishing and is at
Beth Israel Deaconess Medical
Center.
So please give a warm
welcome to our guest faculty.
[APPLAUSE]
Well, thank you, everybody,
for coming out this evening.
I feel like we're well placed
before the talk on intelligence
and the talk on sleep
because sleep, as you know--
when you don't sleep, that can
be a trigger for depression.
And intelligence turns out
to be pretty important, too,
for our for our happiness
and making wise choices.
I'm going to run through
first some general principles
about depression, and then,
I'll talk a little bit about men
before handing it off to Jackie.
This is my attempt
to draw an elephant.
People may remember
the story of the people
with impaired sight who
come up on this creature
and they touch
different parts of it.
One person touches the side
and thinks it's a wall.
The next person goes up
to the tusk in the front
and thinks it's a spear.
A person comes to the trunk
and says, it's a snake.
Another person feels the
enormous leg of the elephant
and thinks that
this must be a tree.
Another sitting on top of
this beast feels the ear,
thinks it's a fan.
And then there's somebody at
the tail who thinks it's a rope.
I choose this because this
is a little bit the problem
with depression.
We have many, many ways
of understanding what
the sources of depression are.
We may become depressed if we
experience stress in our lives.
We may have a problem
with our genetic makeup
that causes our temperament
to lead us to be
more likely to be depressed.
We may have suffered a loss
early in life or more recently,
and that can make us unhappy.
Medical problems can
cause depression.
Early experiences can make
us vulnerable to depression.
And of course, the relationships
that we swim in in our lives
can make the quality of
our life better or worse.
But that's not all.
Of course, everything
runs through the brain.
There is an argument going
back at least 400 or 500 years
to Descartes with the
argument about the mind
and the spirit, the body and
the spirit, being separate.
These arguments
are interesting--
the nature/nurture argument.
Am I suffering because
I have something
wrong with my biology?
Am I suffering
because of something
in my life experience?
But the reality is it all
runs through the brain.
The brain is the organ with
which we relate to the world.
It used to be that people would
say, oh, you're depressed.
You have a chemical imbalance.
That is probably not
a great metaphor.
It's one that's bothered
me for a long time.
But there are
chemical transmitters
in the brain that help
nerve cells that are really
the gut device that allow nerve
cells to talk to one another.
If you have a medical problem,
you're taking medications.
That can be a cause
of depressed symptoms.
We now know that
diet and exercise
are very important in
terms of how we feel day
to day, week to week.
Anybody here have a problem
with seasonal depression
in the winter time?
We're now in the spring, so
we're getting into longer days.
Many people feel worse
when the days are shorter
and there's less
light available.
We also know that, as
we go through life,
we face different challenges.
You leave college.
You have to find a job.
You have to figure
out what you're
going to do with your life.
You're in midlife.
You may have stress in
a relationship or a job.
In later life, you
confront inevitable losses
and the unfortunate fact we
all have to face, which is we
have a limited term
on this planet.
Now I don't know if
anybody's heard this term,
but I came across it recently.
It's something called
a "wicked" problem.
This is an idea that came
out in a paper in 1973.
These are a couple
of researchers
who were talking about
the problems of planning
in any kind of large context.
And it's been
picked up recently--
really over the
last several years--
in a variety of contexts.
A wicked problem is a
particularly difficult problem
to solve.
Now, "difficult" is
probably the wrong word.
Because there are many difficult
problems that are not wicked.
Now it's difficult
to go to the moon,
but it's a problem that can
be solved and was solved.
It was difficult. It took a lot
of energy and a lot of effort.
But we conquered that
problem many, many years ago.
There are many problems,
though, that we
face like poverty,
questions about economics,
and, I would argue, depression
that don't fit in this model.
And it's one of the
reasons that depression
is so hard to talk about.
And as Gina said,
this trouble we
had in figuring out what the
focus should be this evening.
So a wicked problem
is one that does not
have a defined formulation.
It doesn't have what they
call a stopping rule.
In other words, once
you get to the moon,
you've solved the problem.
You know you've
solved the problem.
With depression,
what is our goal?
We can't eliminate sadness.
We can't eliminate discomfort.
We can't eliminate pain.
It's part of life,
so how do we separate
what we think of as "normal
ups and downs," in quotes,
from something that becomes the
subject of treatment and study?
It's hard to test whether
you've solved the problem.
Again, what is the goal
if you're feeling down?
You know many people say--
they ask the
question, Dr. Miller,
how do I know whether
I've got quote,
unquote, "clinical depression?"
And I never know how
to answer that question
because it's a very hard--
you can look at the
list of symptoms.
And I'll show them
to you in a minute.
But it's a very, very
difficult question
to answer because it's
ultimately subjective.
The answer I often give is,
if you're asking the question,
you might want to
go talk to somebody
and discuss it to see if,
in fact, you have a problem
that you could get
some help with.
There's another
issue that comes up.
And people who are
here, I'm sure,
are interested in the subject.
And I'm sure you do reading.
You know all the disagreements.
In the last month alone,
there was a long article
in the New Yorker.
There was an article
in New York Times.
There was an article
in The Atlantic.
All with this
question about, are we
causing problems by prescribing
too many antidepressants?
And when people decide
they don't necessarily
want to take the
antidepressants anymore
and they try to
stop them and they
get into problems
with symptoms that
emerge when you stop a drug,
what do we do about that?
And you will find websites
that will say you should never
ever take a psychiatric drug.
There are organizations like
anti-psychiatry organizations--
fine--
who say the drugs
are just poison
and you should really solve
your problems in other ways.
And then, there are
there are problems
that really are based
so deeply in the biology
that taking a medication
can be helpful.
And you get arguments from
experts on either side.
And the experts get very, very
good at arguing their case.
And all of you are sitting
out there not knowing
who to believe.
That is, in a way, a
definition of a wicked problem.
So let's talk for a moment about
these categories of depression.
Before I show you the list--
you've, I'm sure, heard
some of these words--
I would recommend
for most people
who are trying to get
help with low mood
or what they think
of as depression
to not worry too much
about the diagnoses.
Because again, these
are not diagnoses
like pneumococcal pneumonia
or asthma or diabetes,
where you can identify
where the pathology is,
where the problem
is in the body,
and provide a treatment for it.
These are all what I call
"syndrome diagnoses."
They're collections of symptoms.
We use them in
psychiatry because it's
helpful to study treatments by
grouping people together who
roughly have the same symptoms.
But as with the
elephant, two people
with the same set
of symptoms may
have very different biology.
They may have very
different backgrounds,
many, many different
roads to getting to what
looked like the same thing.
So what it looks like
on the surface often
doesn't tell us exactly what
the underlying problem is.
The big diagnosis
in this category
is what we call
major depression.
This is the full
blown depression
with all of the
list of symptoms,
which we'll see in a minute.
It's very long lasting.
It doesn't have to
be long lasting,
but it's a very deep
distinct change in mood
with a variety of symptoms.
And as Gina pointed out,
it's highly prevalent.
17 plus million people
in the United States
alone have met the criteria
for this diagnosis.
Something that used to be
called dysthymia, now called
persistent depressive
disorder, what some people call
minor depression--
although the criteria and
the way people define it,
they'll argue about--
I think of this simply
as the Charlie Brown
form of depression.
I'm fond of this diagnosis.
My sister-in-law played
Lucy on Broadway in You're
a Good Man, Charlie Brown.
And so Charlie says to Lucy,
oh, Lucy, I'm so depressed.
And Charlie is one of
these guys who is always
at least a little bit low.
And this diagnosis,
this type of depression,
is the kind of thing
where I've always felt--
it's just so normal
to me to always feel
a little sad, a little
down, a little joyless.
So that's persistent
depressive disorder.
Bipolar depression.
So this is the
depression that emerges
in the context of
bipolar disorder.
Bipolar disorder is defined
as a cycling mood disorder
where people may have up
periods that are called mania,
or sometimes if it's not
fully mania, hypomania,
and end periods of
depression, which
is thought to have a
different biological basis.
Post-partum depression is
a well-known phenomenon.
It's distinctly different.
It's quite common for
women after giving birth
to have periods of
mood that varies
or to feel low, something
that's called "the baby blues."
But a smaller
percentage of people
have a depression that is
more like major depression.
And psychotic depression,
again, all this means
is a kind of depression that
is accompanied by symptoms that
involve changes in thinking,
hallucinations, delusions,
fixed ideas that don't
meet with reality.
So these are the basic
symptoms of depression.
People think of the
mood of depression
as being sadness or low
mood, but sometimes, it
feels like emptiness
or irritable mood.
And so many people with--
and I'll tell you
a story when we
talk about men and depression.
This is particularly
common with men
who may not describe
feeling sad or down,
but they'll be irritable
and feel empty.
Hopeless, pessimistic, feeling
guilty, worthless, or helpless.
This next one, loss of
interest or pleasure
in usually pleasurable activity.
You may have heard
the word "anhedonia."
Hedonism is taking pleasure.
A hedonist is somebody who just
loves having fun all the time
and goes after it.
Anhedonia is the inability
to take pleasure in things
that are normally pleasurable.
I go skiing.
I go to the movies.
I am out with friends, and
everything just feels flat.
I take no joy from anything.
Low energy, feeling
tired, poor concentration,
indecisiveness,
changes in appetite--
it can be either gaining
weight or losing weight.
And sometimes, it comes
out in physical ways
with aches and pains.
Now, the thing we worry about
most related to mood problems
is the risk of suicide.
Unfortunately, the rate
of suicide has gone up.
There are more suicides over
the last 10 or 20 years.
There was a long
period where there
was a falling off in the number
of suicides in the country,
but it seems to have gone up
in the last 10 to 20 years.
But as a phenomenon, it's fairly
rare, which is the good news.
But the bad news, again,
because it's rare,
it becomes hard to predict.
There are many people when
they feel bad they feel empty,
they may feel like
taking their own life,
they may think about it.
But fortunately, very
few people act on it.
But we're always
concerned with how
do we identify the people
who are really intending to.
And unfortunately, since
we can't read minds,
we really depend on
people telling us,
which they sometimes don't do.
So it's a very knotty problem.
But in general, risk goes up
when the depression is severe,
when there's a lot of anxiety
along with the depression,
and when there's distorted
thinking or something we
call psychosis.
It may be a higher risk when
there's been a recent loss--
a spouse dies,
particularly if it's
a long marriage,
loss of employment,
loss of social support
is a risk factor.
A personal crisis.
Now, a lot of these
things group together.
And that's when it
becomes particularly time
to be concerned.
If somebody goes through an
experience where they suffer
a tremendous loss, a spouse
dies, they lose a job,
but it's in circumstances that
cause them to be more isolated,
maybe cause them
to feel humiliated,
where there's a
loss of self esteem,
it can be a steamroller
effect where a person really
feels like there's no option.
Substance use, particularly
alcohol, is a huge part.
Something like 2/3
of all suicides
involve the presence of alcohol
or some other substance.
A person who's made prior
attempts is at more risk.
Now here are the two big ones--
a family history of suicide.
If you hear somebody's
parent committed suicide
and they're feeling
suicidal, that's
a time to pay very
close attention.
And fortunately, we
don't have this problem
as much in
Massachusetts as we do
in other parts of the country
where there are more firearms.
I was at a dinner
the other night
with a bunch of very
progressive, let's say,
very to the left
of center people.
I'm not making any judgments
one way or the other.
And a bunch of the
people in the room
said, you know,
there are more guns.
You know more people who
own guns than you think.
And in this group
of progressives,
something like 40%--
there were 12 people
there, so there
were like two or three
households that owned guns.
And I was a little surprised.
Personally, I've never held a
gun or had much of an interest,
but I was working with
some people from Texas
on a case where
I was consulting,
and all the lawyers owned guns.
And a friend of mine who was
giving a talk at the University
of Texas said, who owns a gun?
And about half the class
just showed their firearms
to the professor.
So even in Massachusetts,
where, fortunately again,
we have one of the lower
suicide rates in the country,
you might guess that in states
where gun laws are more lax
and where there's
less access to care,
places like Wyoming
and Idaho and Alaska,
the suicide rates
are much higher.
Let's talk about treatment.
So in your reading
of the popular press,
much of which is very good
and very interesting--
and I recommend you look for
these articles in The New
Yorker and The Atlantic because
they makes some good points--
you'll come away from
reading these articles.
And the problem with
most of the articles
is there's usually
some kind of bias
on the part of the
writer, which gets back
to this issue of
the wicked problem.
Because it's very
difficult to be
objective about these things.
There's a website
that we collaborate
with called HelpGuide,
which is very, very
good, worth taking a look
at, very practical advice.
And you can read this story.
This is a couple who decided
to start this website
because their daughter had
terrible depression, ended up
committing suicide, had
had a lot of treatment
with medication.
And they felt very
strongly that she
didn't get the care she
needed because all she got
was the medication.
She didn't get a lot of the
other things that she needed.
And so there's a lot
of very useful advice.
So I understand
that perspective.
But I also understand the
perspective of somebody
who suffers, gets a
lot of psychotherapy,
has a lot of love and
support in their life,
and yet, they have
this depressed mood
that's very dense.
And they take a medication, and
they feel tremendous relief.
The bottom line is
that this is not--
and again, this goes back
to the wicked problem.
This is not a
one-size-fits-all problem.
If you have a friend,
you talk to a friend who
going, I'm feeling
down, as people do,
and I'm thinking
about consulting
a psychiatrist or my doctor
and getting an antidepressant.
And the friend
says, oh, you know,
I have a cousin who
takes Wellbutrin,
and it really just
changed her life.
You should try that.
Well, that's no guide at all.
Now, if your mother
or father took
Wellbutrin and it
was helpful, that
might be a guide because a
person who shares your genetics
responded to it.
But in most cases,
it's completely
trial and error,
which is problematic
because people come in, I
don't want to be a guinea pig.
But in fact, the reality is
that the only way to find out
what works is to try things.
And this becomes a
problem with researching
medications and the
reason why the data is
so bad on medications.
Take 100 people and give them an
antidepressant, if you compared
them to people
who get a placebo,
40% will get better
with a placebo.
60% to 70% will get better
with the antidepressant.
And then there's a 20%, 30% who
don't get better with either.
But if you use a
different antidepressant
and you give it to
the same 100 people,
you may hit the same data, but
different people will respond.
So people's genetics
is different.
Their circumstances
are different.
Their tolerance for side
effects are different.
So the reason I put a 1 plus
to 3 plus in this category
is that medications
sometimes are
tremendously helpful, sometimes
they're a little helpful.
Psychotherapy is the other
big tool that we have,
a variety of types
of psychotherapy.
And it's also effective.
Cognitive behavioral therapy,
which you may have heard of,
is something that's
very well studied.
There's a lot of
evidence that it is also
very effective, as effective
as medication in the same data
range.
Brain stimulation.
That sounds like fun.
I do it reading a book.
You know, there's a lot of
forms of brain stimulation
that we all enjoy.
Netflix.
But what we're talking about
is the range of treatments
that are really historic.
The most effective treatment
for certain kinds of depression
is electroconvulsive
therapy, the treatment
made famous in One Flew
Over the Cuckoo's Nest.
It is extraordinarily effective
in selective groups of people.
It's lifesaving.
When I was a
resident, as somebody
who came in as an English
major who really wanted
to talk to people, I
was astounded at how
people could be deeply
depressed one day
and then, after
a few treatments,
they get tremendous relief.
And so there's a lot of
fear about this treatment,
but the way it's done
now, in a modern context,
it's very helpful.
But there are now newer
forms of brain stimulation,
which I'll tell you about.
And then finally, on
the positive side,
are lifestyle changes.
And I am surprised,
as a psychiatrist,
how much time I spend
talking to my patients
about healthy living.
I mean, they think
they're supposed
to get that from their primary
care doctor once a year.
But I'm kind of a
pain about this stuff,
and so I beat this drum.
On the negative side,
or the plus/minus side
to positive side, there are
things like herbal treatments,
omega 3s.
You read about them.
You go into Whole Foods or
your natural food store,
and people will tout them.
Again, nothing wrong with
trying these things--
and some people
will swear by them--
but the evidence is equivocal.
Light boxes are
helpful for people
who have seasonal
mood disorders,
and they are worth investing in.
Again, there are
very few treatments
that change everything
and turn complete darkness
into complete light.
But again, with a
combination of things,
you can see improvements.
I've sort of covered
a lot of this stuff.
The basic classes of
medications are listed here--
the SSRIs that you know
about, newer anti-depressants.
But then, there are these other
adjunctive treatments-- mood
stabilizers, antipsychotics
you'll read about.
Antianxiety medicines, depending
on a person's symptoms,
are often brought in to augment.
And these are the brand
names for those of you.
And this is the list
of the different kinds
of psychotherapy.
Cognitive behavioral therapy
is focused on thoughts.
Interpersonal
psychotherapy focused a lot
on structures and relationships.
Psychodynamic
psychotherapy, which
derives from psychoanalysis, the
Freudian therapy, is much more
you'll find--
the stereotype is that
the person just sits
there and doesn't say anything.
People are much
more talkative now.
Behavioral activation therapy
is something you read about.
I'm running a little
short on time,
so I'm going to skip over that.
And being creative.
Medication versus psychotherapy.
I think I've sort of implied
that medication can sometimes
be simpler.
You go, you get a prescription.
It's a little easier.
But it's harder in the sense
that there are side effects
to deal with, and it is a
trial and error process.
Psychotherapy requires
more of a commitment
but may be more lasting.
The hard part here is
that sometimes it's
hard to find the right person
and your insurance company
may not pay for it.
And there's now strong
evidence, very strong evidence,
that the combination
really is the best
treatment for depression.
There is strong evidence
that exercise helps.
With very serious depression,
you can't cure depression
with exercise.
But the more active
you are, the better.
The more you adhere to a healthy
diet, the better you'll feel.
These are all contributors.
I am a big fan of
mindfulness meditation.
I meditate.
I find that many of the things
that you might find in Buddhist
psychology are very powerful.
And I would argue it's the
oldest form of psychology
on the planet, dating
back 2,500 years
in terms of
understanding suffering,
the sources of suffering.
Yoga as a physical
sort of combines
the meditative effects.
Staying related,
being creative, these
are the kinds of things that
I recommend for everybody.
And if you build these
things into your life,
you give yourself a better shot.
I'm going to skip over this.
I've already mentioned
these different herbals.
There's a little bit of
evidence for St. John's wort,
a little bit of
evidence for SAMe.
Kava and valerian are
things taken for anxiety.
Everybody gets
things with acai now.
There's not very strong
evidence that it's helpful.
If you find it helpful,
if people find it helpful,
I wouldn't argue with them.
OK.
I'm going to now skip
quickly to the story of men.
And we can talk more about this.
People know who
Terry Bradshaw is?
Yes.
For those who are not
football addicted--
I've actually been
withdrawing from football
for a variety of reasons.
I don't like what it
does to the brain.
But Terry Bradshaw was the
GOAT before Tom Brady was.
He was the Greatest Of All Time.
He was the first quarterback
to get three Super Bowl rings.
He was the first quarterback
to get four Super Bowl rings.
But he then went on TV
and was a commentator.
He got cars, he got
land, he got horses.
I did not put
women on this list,
but I think there
were a few wives.
And I got to talk to him a
few years for an article I was
writing for Newsweek magazine.
Unfortunately, he was
filled with dread.
He would win the Super Bowl,
and the next day, he would say,
now I've got to get back on
the horse and do it again.
He felt flat.
No joy, no pleasure.
He said, I didn't
remotely consider
that I might be depressed.
I got to talk to him
as part of a campaign
that a drug company
was doing where he was
taking their antidepressant.
And he was the poster
boy for that for a while.
Depression in men.
The rates are
lower, but that may
be for a variety of reasons.
Men are less likely to
acknowledge depression.
They are less likely to
acknowledge depression
to themselves, as
I mentioned before.
They have less depression.
They make fewer
suicide attempts,
but they actually commit
suicide at four times the rate
that women do.
80% of suicides are men.
They're more likely to be
irritable and without pleasure
rather than sad.
And we may miss their
diagnoses because they
are using substances,
they're novelty seeking,
they're reckless, they
get into violent trouble.
This is a shorter URL that
you can use to get to the--
and the capitalization is
important for forgetting
to this special health report.
The punch line on the
Terry Bradshaw story
is that he told me about how
he got his third divorce.
He was unhappy.
He started taking
the antidepressant,
and he felt a tremendous relief.
So I asked him, so you know
you had the Super Bowl,
you're on TV, what do
you like to do now?
He says, eat peanuts,
which I thought
was terrific because
the reality is
that we don't solve depression
by winning a Super Bowl.
I mean it's nice if
that's what your goal is,
but very few people
get to do that.
And as you hear somebody
who did do that four times,
it was not a relief
for his depression.
But really, mood problems are
experienced in a kind of day
to day, moment to moment way.
And if you can find joy in
eating peanuts and sitting
with your family and
watching Netflix,
this is really, to my mind,
what you're looking for.
So why don't-- I
think I'm over time,
so I'll hand it off to Jackie
Olds who will talk to you about
women.
[APPLAUSE]
I think this is a topic
that I have actually
wanted to talk about
for a very long time,
even though most of the talks
I have been giving recently
are about loneliness,
since that's something
I've written about at length.
But you know, loneliness and
depression are closely linked.
It's a rare person who
experiences depression
who doesn't feel terribly
lonely because depression makes
you feel so apart
from everyone else
and as if your relationships
are more empty.
So I think some of
my work on loneliness
might be relevant today.
First, let me tell you the
story of one of my patients.
She came to see me--
I forget the slides symptoms.
She came to see me many years
ago because her life was
plagued with fears that she
would die of a dread disease
or that some catastrophe
would happen to her
and she wouldn't be able
to take care of her family.
And it's true that she had
a tendency to feel lonely.
And as she told me
about her life history,
I came to understand
it a little bit better.
She felt too closely held by
her immigrant Turkish parents,
and they never really wanted
her to leave home at all.
They didn't even
want her, when she
was a kid, to play
with other kids
because the world seemed
filled with dangers to them.
As she grew up and went to
high school and then college,
she fell in love and got
engaged to a boyfriend.
And even then,
her parents really
didn't want her to
move away from home.
But finally, at
about age 27, she
had the chutzpah to move
into an apartment of her own.
And after a while, she
moved in with her boyfriend,
and they got married.
But her life continued
to be plagued
with fears about terrible
catastrophes and sicknesses
and possible cancer.
And really, she came to me to
see whether I could help her
with this.
And I did prescribe
antidepressants,
and we did work
in psychotherapy,
but it didn't really
relent completely.
She continued having
it year after year.
And then one year, I
stumbled on the possibility
that her fears were somewhat
determined by superstition
because she'd had such a
pleasant and prosperous life
compared to the one
her parents had had.
And she felt guilty.
She felt that it was
such a wonderful life
that some catastrophe was
bound to happen to her.
And we both thought
about the evil eye
and how in Europe,
in the old country,
women had very little control
over how their loved ones were
doing, so they were always
trying to appease the evil eye.
And this is most demonstrable
when older women would
see a new baby and they would
say, you have a very ugly baby.
And you always said that because
you didn't want the evil eye
to get on your case because you
thought everything was going
to go hunky dory,
so you would always
be preparing for the worst so
that the evil eye wouldn't get
you.
And this made me wonder
about American women
and the way in which we might
be superstitious as well.
Now just to go back for a moment
to some of the things Michael
went over, these are the
classic symptoms of depression
that both men and
women experience.
And he showed you the
same list, but overall, we
could say that men are
more likely culturally
to conceal their sadness and
become irritable or angry
and use substances while
women have permission
to talk about their
feelings and often are
able to ask for treatment.
And so women's societal
permission to ask for help
and to talk about their feelings
really works to their advantage
when it comes to
getting treatment.
Here are some of the
symptoms that men
are more likely to show--
that they have a loss of
interest in some of the things
they used to like, sleep
problems, physical problems.
These are all
things Michael just
showed you a similar slide of.
And sometimes what they say
about men is that they have
so-called "masked
depression," M-A-S-K-E-D,
that you can't really
see it as depression,
but you see all these symptoms
that are different from how
the man used to be.
And it turns out that
that is a kind of mask
that a man puts
over his depression
because he feels it's weak
and effeminate to admit
to depression.
Now on the other
hand, these are signs
that women show more frequently
when they're depressed.
And they actually
correlate a little bit
with seasonal
depression because, you
know, overeating, excessive
sleeping, ruminating
and dwelling on things,
negative self talk--
a lot of that goes along
with seasonal depression,
which I sometimes
equate to a kind of wish
to hibernate until
the light comes back.
But the interesting question
that many people have wondered
about-- and I'm amongst them--
is why do so many more women
seem to experience depression
than men?
Is it just that men
are loath to admit it?
Or is it that women, in
fact, in their biology
are just a little bit more
likely to get depressed
and to be able to say so?
Here we see some of the
statistics on women in America.
And what you should remember
is that 1/8 of women
will develop clinical
depression over their lifetime,
so that's a huge percentage.
It occurs most often during
the childbearing years.
And more than half
of those women
will not seek treatment at all.
So even though they have all
that societal permission,
they don't necessarily
come to seek treatment.
We'll talk more about that.
Many people have speculated that
depression happens more often
in women for biological
reasons because
of all their hormonal
fluctuations.
And we know that depression
happens at 1.7 times more
often in women
throughout the world,
whether we're talking
about first world countries
or third world countries.
And the prevalence seems
to correlate with times
of great hormonal change.
It increases around puberty,
menstruation, pregnancy,
and menopause.
So certainly, there's
something biological about it,
but there may be more
than just the biology.
And so there are lots of
cultural generalizations
we can wonder about, too.
And as I say in this slide,
we can speculate about these
because nobody
knows for sure why
there is such a greater
percentage of depression
in women than men.
Just to talk about a
few cultural examples
at the beginning-- and then
I'll talk a little bit more
about my experience
in my practice.
As you can see from
this slide, women
are at increased
risk for depression
if work interferes with
family life too much.
But on the opposite side,
men are at increased risk
if family life gets too much
in the way of work life.
And in fact, in
this Canadian study,
which was a rather
large study, women
had an increased
risk of depression
if they worked full
time because that often
did get in the way
of their family life.
And so most of the
research implies
that if women can have a
flexible, part time work
schedule that allows
for a family needs,
then they're likely to
find some contentment.
And later, I'll talk
about how the more
hats, the more different
roles a woman has,
often the more contented she is.
But it's also true that there
was a very famous article
in 2012 by Anne-Marie
Slaughter called
"Why women can't have it all."
And it was a really
important article
because what it said is
no matter which pathway
you take nowadays as a woman--
you can decide that you're
going to be a full time mother,
you can decide you're going to
be a full time career person,
you can decide you're
going to try to do both--
whatever pathway
you pick, you're
always haunted by
guilt and doubts
about whether it
was the right one.
Even if you're living solo and
you decide not to have children
or you don't freeze your eggs
or you decide that you're
going to go without
children, women
who might be content
in a different era
are always wondering, should
I have done it that way?
Should I have done it this way?
So it does seem that all
those choices for women
have not necessarily led
to greater contentment.
We see that in
response to stress--
this is another
cultural difference--
that women are more likely
to essentially compare notes
with other women when
they're feeling stressed out.
And what it means is if they're
in a position where they don't
feel they have friends or
they don't have anybody
to compare notes with,
they often are overwhelmed.
Interestingly, nowadays
I find that women
who go to their friends
and say, you know,
I'm horribly depressed and
feeling overwhelmed and I just
don't know what to do.
I'm worried about
my children, and I'm
worried about my marriage.
The friend will say, well, I
think it's time to seek help.
And what they mean
by that is maybe
you should see a
therapist, which is fine.
Speaking as a therapist, I'm
glad they're in favor of it.
But I'm a little bit worried
that friendship used to be--
the currency of
friendship used to be
talking about the troubles
you had with a friend
and comparing notes so that you
could regain your perspective.
And nowadays, if you
go see a therapist,
you never actually
get that perspective
unless you have another
therapist like Michael
or me who will
say, well you know,
everybody feels
that way sometimes.
But in fact, it's a
little bit worrisome
that friends are so worried
about imposing on other friends
nowadays and that they feel
therapy is the right place
to go.
Now even though women have
often some different issues
than men in their
depression, overall,
we would have to say that the
specific treatments for women
are underdeveloped.
We don't have a completely
different pathway
for men and for women
in their depression.
We do now start--
there's certainly
medications that treat
menstrual dysphoric disorder.
And there are
hormones you can take
after or during
perimenopause to try to make
your quality of life better.
And just recently, there's a
new medicine called brexanolone,
or its brand name is Zulresso,
for postpartum depression.
So that's hot off the press.
We do find that
women tend to prefer
working with women
therapists often
because they can do a little
more of that comparing notes.
And they feel they
will be understood when
they talk about their issues.
But it's also true
that men sometimes
have a preference for
women therapists as well.
This is not just meant to be
an advertisement for women
therapists.
It's more that we
should recognize
that what girls do
when they're growing up
is talk about everybody's
psychological makeup,
figuring out what
makes each other tick
and what makes your parents tick
and what makes your brothers
tick and your sisters.
That is what we do.
And so it means
that everybody has
a kind of psychological
and psychiatric residency
as they grow up.
And that does help
in allowing us
to talk about psychological
issues as if we always have--
because we have.
It is true, however, that
many women and many men
prefer talking to
male therapists, men
especially because they feel
the male will understand
their issues.
And some women who were best
friends with their father
and maybe not so
close to their mother
may prefer working
with men as well.
Now here, I'm going to talk
about a number of things,
other possible cultural
reasons for increased
depression in women.
And each of these
little points is
going to have its own slide, so
you don't have to memorize them
because I'm going to go on
and talk about each of them.
But these are some
of the things I've
noticed after 40 years in
practice working with, I'd say,
70% of my practice was
women, young and old.
So first, let's look at this
changes in sense of purpose
over the life cycle.
You know many girls
grow up with the notion
that when they find their
perfect romantic partner,
that will be the answer.
But that is a kind
of myth that leaves
lots of women frustrated.
What if he or she
can't be found?
What if he or she doesn't
solve all their problems?
And it's also true that women
may consider having children
by themselves or with
a partner, and that
does sharpen their life with a
sense of purpose over at least
18 years and maybe longer.
But it means that when they
become an empty-nester,
there's a terrible loss
which may leave them feeling
without a sense of purpose.
And so they have to somehow
shift gears completely,
and that is a time when many
women can feel depressed.
They have poured
their heart and soul
into raising these children,
and the children fledge and fly
off.
And that is just
what they wanted,
but it doesn't mean that
they have an automatic sense
of purpose immediately.
And the women--
I think the reason there's
all that sociological research
about women needing several
roles like several hats
is because they don't have all
their eggs in the child basket
basically.
They have a job
which they might be
able to find satisfaction from
even when their children grow
up.
We do know-- and I'll
talk more about this--
that unstructured time can
lead to brooding and depression
in almost everybody, so
that's why a sense of purpose
is such an important
thing to find.
Now this next slide,
it sort of goes back
to my talking
about superstition.
And first, I have to tell you
an anecdote about my driving
carpool for about eight years
with two boys and two girls.
The boys were older.
The girls were younger.
And I got to hear them
talking to each other
about what they
were about to do.
So for example, if the boys
were talking about a test they
were about to take--
they were in the same grade,
the girls and the boys.
The boys were 2 and
1/2 years older.
So the boys would
say, oh, are you
ready for your history test?
Do you think you can do it?
And the other guy
would say, I'm ready.
I highlighted the whole chapter.
I really have it down.
Oh, you should see my chapter.
It's so well highlighted.
And the other boy would say,
well, you think you've got it,
I had my parents give
me three quizzes.
And I really aced them.
And I think I'm going
to do wonderfully.
So they would psych themselves
up to go take this test.
And I have to admit they did
rather well on their test.
But it was wonderful to
hear them talking about how
well they were going to do.
And then I would listen
to the girls talking
about getting ready for a test.
Are you ready for
the French test?
Oh, god, am I not ready.
I had to stay up till
2:00 in the morning,
and I still didn't know it.
There's something
wrong with my brain.
I just can't memorize
all those words.
And the other girl would say,
oh, I know just what you mean.
It was awful.
We are going to flunk.
Will you be my friend
even though I flunk?
Yeah.
I'll be your friend.
And then, they would go
off and take this test,
and it would turn out that, in
general, these girls did better
than the boys did.
But you would never know
from their talk to each other
that they were going
to do well at all.
And so I came to
believe that this
was the American
form of superstition,
that you don't want
to jinx yourself,
so you prepare
yourself for the worst.
And it's also true that in
any group of women or girls,
if somebody seems to be too
swell headed or conceited,
all the other girls and
women put them down.
Who do you think you are?
You think you're going
to do OK on the test?
Give me a break.
So it was really
true that there is,
from two different
directions, a kind
of force on women to not allow
themselves to psych themselves
up.
They psych themselves down.
And so my question is--
and I don't know the answer.
This is speculation-- if women
are always preparing themselves
for the worst, does
that affect the outcome?
Are they more likely to get
depressed because their self
talk is so depressing?
And it's depressing
because they're
trying not to jinx themselves.
That's not always true,
but it's sometimes true.
So I want you to
think about that one.
Then, I'm going to
talk a little more
about these romantic
notions that I alluded to.
If girls are still
brought up to believe
that a romantic partner will
solve all their problems,
does this mean
that they might not
try to excel in their
own right and they
might spend all their energy
and their creativeness
in trying to find the
perfect partner who will then
make them feel whole?
And that myth, which is not
as prevalent as it used to be,
but it's not
disappeared completely--
although my daughter
tells me that Frozen
is trying to work against this.
That because that movie
Frozen, in the end,
the sister rescues Elsa,
not Prince Charming.
So it's very important
to notice that this
is the first movie where a
woman rescued a woman when
she was in trouble in the
sort of Walt Disney firmament.
But with these
romantic notions, it's
so much easier to criticize
your partner than figure
out how to succeed yourself.
And at times, when
a woman is feeling
unhappy with how
she's doing, she
is quick to blame her
partner rather than accepting
the responsibility that
things might not be going well
for her own fault. And so I
can't tell you how many women
essentially feel that because
they nurtured their husband's
career that that kept them from
having a career of their own.
And sometimes, there
is some truth to that,
but there's getting to
be less truth to that.
And so it's not necessarily
a good marital policy
to always blame
the other person.
And certainly, we women have
sometimes had that tendency.
I often find also that the
attitudes of women around men
are not necessarily
what you would hope.
Many girls who were best friends
with their fathers growing up
had a kind of
deferential attitude
where they checked
with their father,
and they listened
to their father,
and they were so
proud of their father,
but always played
the deferential role.
And then, when they
grow up and they
have male mentors, or male
professors, or male partners,
they fall right into
those patterns again.
And the hard part is that
it causes them to not trust
their own judgment.
And I do have a
patient right now who
is about to take a position.
This is a woman of authority.
It means that she will
be the mentor instead
of having the male mentor.
And ever since she
said yes to this job,
she has felt completely sick to
her stomach, filled with dread
and worry that she
doesn't have good judgment
and that without the imprimatur
of a male mentor saying,
yes, that's what you should do,
she won't be able to handle it.
Then there's the overemphasis
on physical appearance
that women have to contend
with throughout their lives.
And if women are brought
up to see their power as
the same as their level
of attractiveness, then
as they grow older, they
feel more and more invisible
and disenfranchised.
And by the way, the bread
and butter of older woman's
conversations goes as follows--
did you see that that cashier
didn't even look at me?
I was completely invisible.
They just handed me the
money and said, no problem.
And I can't tell you how
often older women are feeling
like they're
oldness keeps people
from really acknowledging
or noticing their existence.
So when women do have jobs
with a sense of purpose,
that is able to
sometimes carry them
through the fading of their
level of attractiveness.
And also, if they
earn some money,
it makes them feel like they're
is still some power that they
have in a marriage or a
family even though they're
not who they used to be at 30.
This is the
sociological slide that
really says that when
women fulfill more roles,
they wear more
hats, then they're
more likely to be content.
And we know that many children
and men would like their wives
to be kind of always available
for rescuing them, or taking
care of them, or being there
if they have a question.
And so there's always
that pressure on women
even when they do have
a wonderful job that
gives them a sense of purpose.
And so there's always the
guilt to contend with.
But I think the
research seems to show
that women who both
are able, if they do
decide to have
families, to handle that
with at least a
part time job that
gives them some
flexibility, they
are more likely to be content.
But as we talked
about before, there
is this problem for women
who didn't work and raise
their children and then find
themselves with much too
much time on their hands.
And here's where I want to quote
a fantastic author whose name
is completely unpronounceable.
Csikszentmihalyi.
Mihaly Csikszentmihalyi.
Very good.
Very good.
He wrote a wonderful book that
I would recommend for all of you
called Flow, The Psychology
of Optimal Experience.
And this is an old book.
He studied contentment for
something like 30 years.
He was a professor
at the University
of Chicago of psychology.
And what he found is that the
more flow activities-- and I'm
going to tell you what those
are-- you have each day,
the more likely you
are to be content.
And what a flow
activity is is something
where you enjoy
doing it so much you
don't notice the
passage of time.
You could do it for as long--
you would like to not have
to stop doing that activity.
And you can see that you're
making improvements over time.
So it could be anything
from collecting wildflowers
to keeping the football
statistics to doing your stamp
collection.
It could be anything.
But the more flow
activities you have--
and often a job gives
you some flow activities
because sometimes
you love solving
the problems at the job--
the more likely you
are to be able to keep
your head above water
and prevent depression.
And this isn't
talked about enough.
But in fact, almost
everybody who
has huge amounts of
unstructured time,
like when you're on vacation
and you're on the beach--
it turns out most people
get fretful, and brooding,
and somewhat
depressed when they're
lying there on the beach.
You ask people, would you rather
be on vacation or at your job?
And most of them say, I would
much rather be on vacation.
But when you actually do
a diary eight times a day
when they're on
vacation, it turns out
they're less content than
when they're working,
which maybe is why so many
Americans leave their vacation
days alone.
Now the new model
of family, the sort
of modern notion of family,
at its best is as follows.
That both women and their
partners can do child rearing
and have careers.
Each has a kind of portfolio
of flow activities.
Neither partner is overvalued
for one thing-- physical
appearance, family
background, financial clout.
And each person can spell
the other in most activities.
So you know one partner can
babysit for the sick child
one day, and the
other partner can
babysit for the sick
child the second day.
Or one person can figure
out how to change the washer
in the faucet one day,
and the other person
can maybe figure
out how to change
the washer in the faucet.
So it's a very new
and wonderful model.
It's kind of aspirational
because few people achieve it,
but it's something
to think about.
Now what about all the
single women who live solo?
By some measures, these
women are the happiest.
And often, they
never have to change
the washer in the faucet.
They call the plumber.
But oftentimes, they have
superb social skills,
which allow them to cultivate
very long term friendships.
And they arrange
their social life--
even though it's hard
when you're living alone
to arrange a good
social life, the fact
is these women sometimes have
incredible social skills.
And they sometimes have
jobs which give them
a sense of calling, calling
meaning that they feel
they were meant for that job.
It gives them a huge
sense of purpose.
And their decision to
remain single or childless
was quite a wonderful one.
But some women may
feel judged by others
if they decide not
to have children
or not to get married
because they didn't have
that part of their experience.
And some of those
women feel it wasn't
a voluntary decision at all.
And sometimes,
they worry terribly
about how things will
go when they're older
and they need medical
care or they're depressed.
How will they manage without a
relative to take care of them?
We should remember
of all US households
27% are one person households
with women making up
more than half of those.
And that's in 2010.
In 1970, it was only
18% of households
were one person households.
I'm running out of time
here, so as Michael said,
there are lots and lots of
treatments for depression.
But the reason I want
us to talk about them
is that many people who
don't seek depression say,
well, I don't want to go see
a therapist who will tell me
what's wrong with me.
And I don't want to
take meds because I'll
be on them forever, and they
have horrible side effects.
They'll make you fat.
Why would I want
to go on medicines?
So many people too quickly
leap to the conclusion
that neither therapy nor
medicine is for them.
But the fact is there are a
lot of possibilities here.
There are all kinds of
non-medication interventions.
There are all kinds of
family therapy or couples
interventions.
There's talking therapy.
There is hospitalization
if necessary.
There are the rest cure and
forest bathing possibilities.
So there really are
some other things than
just hearing what's
wrong with you
or going on a medicine you
have to stay on for life.
Now I just showed this
picture of young women
because some of their
issues are very different.
And I just want to
mention them for a moment.
The typical young
woman is wondering,
will she ever get
asked on anything
that looks like a date?
Is she feeling like
all her friends
are having much
more fun than her
because she's watched Facebook
and it looks like everyone's
having a better time.
She's wondering if she'll
ever achieve her goals
or if she should freeze her
eggs if she wants children
or whether she'll ever find
either Mr. or Ms. Right.
Or maybe she's worrying
that she hasn't
done a good enough job of
being a friend or a daughter
or that she hasn't eaten
properly or exercised enough.
These are all the issues I'm
hearing from the younger age
group.
And they're a little bit
different from the older age
group.
I'm almost done here, and I
see my time it's almost done,
so that's good.
I want to say that women are
in a very different position
than men in terms of what
society gives them permission
to do.
Women are allowed to
show feelings much more
transparently than men, and
they can admit to depression
and not be seen as or feel
like they're becoming wimpy.
And then maybe
their greater leeway
to have and show sad feelings
may cause longer lives.
Because you know many of
the diseases like high blood
pressure and heart disease could
come from feeling so bottled up
and that you can't show
your true feelings as a man
because it makes
you less of a man.
But then, we also
have to ask ourselves
does this societal
permission for women
to show more feelings, does it
prevent the true empowerment
that women would like
to have in the workplace
because so many people, if they
do show feelings, say, well you
know, she's not
very professional.
Did you see she was crying
when she was hearing
perfectly reasonable feedback?
And there are all sorts of ways
in which women are graded down
for that societal
permission to show feelings.
So it's a kind of
interesting quandary.
As women spend more
time in the workplace,
will they become more
bottled up and have
more of a kind of blank face
where they try desperately not
to show their feelings?
And what are the trade offs
of having society's permission
to show feelings?
And with that, I'll stop.
Thank you so much.
[APPLAUSE]
Can you hear me?
Is this-- we have a lot
of great questions here.
And really, all the
questions that were passed in
are terrific.
Obviously we're going
to have till 7:30.
Is that right?
It was amazing and
wonderful to listen to you.
And you, too.
I thank you.
I wanted to ask you this
because it occurred to me when
I was reading the questions.
I'm sort of playing also
the role of the moderator
of the questions here.
I realize that we've been
terribly hetero-normative.
You mean if you're living
solo or you're living
with someone of the same sex?
No, no, no, no.
Of the same sex?
We have been talking about
heterosexual men and women.
Not me.
I said "partner."
No, no, no.
But what I'm saying
is that a lot
of the literature
that we're talking
about and a lot
of the experiences
that we're talking about
leave out the special problems
that one confronts
in an evolving world
where homosexual, the LGBTQ
community and transgender
individuals face problems that
don't fit into either side.
And I wondered if you had any
thoughts about how to talk to--
Those issues?
Those issues with this group.
Well, what I think is that no
matter which pathway you take--
and there are many more
pathways than there used to be--
the kind of memes of
society, the things
that we were talking about,
are there on the television,
in the newspaper, in the books.
And so you can't quite
get away from them
even if you've chosen to
try to get off the track.
And so I think
what we had to say
was not completely irrelevant.
There are so many same
sex couples in Cambridge
where I live who have
children and parenting issues.
And so I don't think what
we said was irrelevant.
But it might not be as relevant.
Yeah.
What it got me thinking about,
reading some of the questions,
was about this wicked
problem problem.
That it's also true.
When you were talking
about the children
in the car and their approach--
I mean, I was much
more like the girls.
You know?
Worry did I study
enough et cetera.
I think--
I guess I just want to alert
people that the generalizations
that we're talking
about here, we're stuck.
Because we're
trying to understand
the phenomenon of mood changes
by looking at large populations
because that's one
of the ways we learn.
But when it comes down to it--
There are a million exceptions.
There are a million exceptions.
And in fact, everybody's
an exception.
Right.
And that getting help for
whatever you suffer with
is always a one-to-one
conversation.
And actually, that is the
solution to wicked problems.
That not to have people
arguing at big conferences,
but to have a small group
or two people sit in a room
and discuss all the variations.
And that's really what one does
when one goes to seek help.
You know, I mentioned before
somebody asks, wanted to know,
if CBT is the therapy
with the best results
because it's the one
that's most studied.
And what's the
evidence for treatments
that are closer to the
tradition that we initially
studied in psychoanalysis
and psychodynamics
and psychotherapy.
In Boston, you're
more likely to find
people who have that
psychodynamic background
than you will in
many other places
because places like
here, and New York,
and Los Angeles, certain
cities that have been centers
for psychoanalytic teaching.
But somebody was asking
about the evidence.
So what are your
thoughts about that?
So CBT, Cognitive
Behavioral Therapy,
is a kind of
manualized therapy that
really seems to work very
well and has been studied
extremely much more rigorously
than many other kinds
of therapy.
And the studies seem to
show that it's very helpful.
But in real life, if a
person and their therapist
have a certain magic in how
they can talk to each other
and listen to each
other, it actually
doesn't matter what school
of therapy they're in.
It turns out that the
theoretical training
that the therapist has is not
as relevant as you might think.
What really is relevant
is whether they
feel a certain je ne sais quoi
when they sit with each other.
So I think that is even
more important than CBT
having wonderful statistics.
And I think the
evidence backs you up
because the most important
factor in studying
what psychotherapy is successful
is if you like your therapist.
Doesn't matter
what the theory is
if you connect to
the person, you
feel the person is understanding
you, and relating to you.
The challenge is
to find somebody.
I mean, I think that
we're old enough that we
use a lot of different things.
In the work that I do,
I use what I learned
in psychoanalysis school.
But I also use CBT techniques.
And I do as much teaching I
can about the kinds of things
that might be helpful.
In reality, you're not going to
find somebody who only does--
One thing.
One thing.
Coffee.
Here's a question.
Coffee?
Yeah we didn't--
"I have nicknamed
coffee as happy juice
from personal experience.
Do you have any
information about caffeine
and how it enhances
a happy mood?"
I know a little
about this because--
Take it away.
--I drink coffee, and I
have relatives in Finland.
Relative in what?
In Finland, where they
drink a lot of coffee.
Ah.
Where they did a
study that showed
that as the number of cups
of coffee per day went up,
the suicide rate went down
up to a certain point.
When you hit 7, 8, 9, 10 cups of
coffee a day, then it changed.
You know, what I know is that--
I mean, there are
a lot of substances
you have to worry about.
And something like 85% of
the country, maybe the world,
is addicted to caffeine.
I like coffee.
I like tea.
There you go.
But caffeine doesn't
seem to be problematic
and may actually be helpful.
It may even be that
caffeine is what we all
take for our mild attention
deficit disorders.
The fact is if
you're not somebody
who wants to take a true
stimulant in pill form
and you have coffee and you
use it throughout the day,
you can actually
concentrate even
though you don't feel like it.
Yeah.
Part of the problem with
coffee is caffeine withdrawal
is also profound.
You need that first cup of
coffee in the morning or else
you're going to get a headache
and feel kind of sluggish.
So it may be that if anybody is
weaned off caffeine for a while
and then started back up, that
first cup of coffee is amazing.
But then, it's really just
getting back to baseline.
"If you're taking
antidepressants and they work,
are you taking those for
the rest of your life?"
Shall I?
OK.
Well, why not?
You're one of the lucky
ones if they work.
I think of it like if you
take a medicine for high blood
pressure or you take a
thyroid replacement medicine,
if you're somebody who's taking
a daily dose of antidepressant,
it works for you, you're not
suffering side effects from it,
it is reasonable and
there's no evidence
that long term it's a problem.
And now people have
been on medicines
like Prozac-- which
Prozac came out in 1988,
so you have people on
these drugs for decades.
If you want to stop it for
some reason or another,
you have to be careful because
there are these discontinuation
symptoms.
Let me just say a little
bit on the other side, which
is that some of
these antidepressants
have major side effects that
people really don't like.
They get in the way
of sexual pleasure,
and they can also make
you gain weight over time.
And those are really kind
of major side effects.
So in fact, even though they can
work very well over a lifetime,
I tend to have a bias that if I
can get people off them, I try.
Yeah.
And I agree with that.
I was talking about the
singular case where--
I mean, there's some
people who take the drug,
and they don't have
any side effects.
Well, we're both also
aware of is that it changes
over the life, lifestyle.
So somebody who did fine
with an SSRI in their 30s
without sexual side
effects and they
get into their 50s and 60s,
then the sexual dysfunction
can actually be worse.
And so that, for example,
might be a trigger
to try to wean off it.
Their situation has changed.
Their relationship,
their biology
has changed in many ways.
And they may be able to
do without the medicine
or find other ways.
"Do you feel that all football
players suffer from depression
because of head trauma?"
Wow.
No, not all, but there are
terrible stories, suicides.
I do think that
the problem with--
again, there's all
kinds of places
where head trauma occurs.
It's not the big
concussion sometimes.
It's the regular impacts.
The other people who
get into problems
are soccer players, what
the rest of the world
calls football, with hitting
the ball with your head.
You see this problem with
professional athletes.
But obviously, some escape.
Again, it's not--
it doesn't have
the same effect on everybody.
You have some questions
there you might want to--
I just saw this one, which
says, "Are women really more
prone to depression or just
more likely to seek help?"
And I think that is the
most important question.
That society does give
women greater permission
to ask for help,
but there are also
some signs at these various
points in a woman's life
where she is more
prone to depression.
And when you think of
all the hormonal changes
and how important
childrearing is
and how important menopause
is and getting the menses.
And you realize that even in
a fractal way that every month
when a woman gets
her period, she
gets a little bit depressed
before her period comes.
Then she feels some relief
when the period finally comes.
So this is really
the $64,000 question.
And I find it a fascinating
one, but I can't really answer.
Yeah.
Again, I think that this
the inherent problem
in talking about
large populations
is that when you generalize,
you get it wrong because there
are so many different.
I do think from experience and
from reading the literature,
that there is a difference, that
there are differences in rates
and the biology is different.
And the hormonal
environment is different.
And a lot of the social
environment is quite different.
I was also thinking,
when were talking before,
about how women are encouraged
to express particularly
sadness, but they're not
encouraged to express anger.
Right.
And many women who are trying
to be forceful in a business
environment, in a
work environment,
find it very, very
difficult. Because if a man
comes and is forceful, that's
considered a positive thing.
If a woman comes as
forceful, she's called names.
Totally.
And that's an enormous problem.
One thing that I skipped over--
and people are asking about it--
a couple of novel treatments
which you mentioned
and that was on
one of my slides.
Ketamine is very interesting.
People may be
familiar with this.
This is an anesthetic
which is also
a hallucinogen
often used in things
like pediatric anesthesia.
It's used in induction
of anesthesia.
And in small doses,
it's now been
discovered that it has an
enormously positive impact
on mood.
There's some
evidence that if you
take somebody who's
terrible, they're really
very deeply depressed and--
Suicidal.
--very suicidal, and you give
them a small infusion of this.
And that feeling evaporates.
The problem with it
is it doesn't last.
And so what we're looking
for-- and this new drug,
esketamine, which
has to be given
in a controlled situation,
is a great advance.
But it's ready for
the evening news.
It's not quite ready
for prime time.
And it's extraordinarily
expensive.
And very expensive.
Yeah.
You know, along the
lines, the other thing
that's very interesting--
I don't know if people have
read Michael Pollan's book.
I forget what it's called.
But it's about--
LSD.
LSD.
And that's research that began
in the 50s and 60s in fact.
In my hometown of
Newton, Timothy Leary
was there with his
group going on LSD trips
and quote, unquote,
"studying" it.
But you know, there's really
some serious research going on.
And people report.
This is not
something that can be
done in a professional setting.
It's always done kind
of under the table.
But people report very
interesting experiences.
And this goes back
to this interest in--
which is obviously burgeoning
as well-- in mindfulness.
You know this
experience that people
take these
hallucinogens, and they
have an experience
where, suddenly, they see
the mind in a different way.
And when they have
finished the experience,
they don't look at their
thoughts in the same way.
One of my favorite expressions
that somebody told me once,
which I keep repeating, is don't
believe everything you think,
which is really
the basis of CBT.
Right.
You have negative thoughts.
Don't believe
everything you think.
Exactly.
Question it.
It's also the basis
of psychoanalysis.
I mean, you're having
these associations,
and it goes back to your
mother or your father
or whatever it is.
You've internalized
these things.
You have a story that
you tell about your life,
but it's just a story.
You can change it.
Don't believe
everything you think.
So there's something
about these hallucinogens
that seems to loosen up that.
It's true.
Here's a question that I like.
"The transition from college
to full time employment
can be challenging for
individuals in their early 20s.
Can you speak to any
depression related
concerns or characteristics
unique to this population?"
Well, I am a child psychiatrist.
And I have to say that during
between the time I grew up
and the time I
brought my children up
and watch them grow
up, the parenting norms
changed enormously.
So where I could disappear for
six hours in the day and nobody
thought anything of it
by the time I was eight,
you know, we kept a rather
close track of our children.
And now, people are keeping even
closer track of their children,
so children don't
have the same ability
to test out their
autonomy in the world.
And I think that then when they
go from college, which is still
a little bit protected,
into a job and an apartment
and a real life situation, they
often feel woefully unprepared.
And probably, that
does relate to the fact
that they weren't allowed
much freedom as kids,
that they were always
watched like hawks
and were kind of under
adult supervision.
And if you're always
under adult supervision,
you don't quite
feel that you can
solve a problem on your own.
So I think there has
been an enormous change
and that now this
transition is quite scary
and that we may have to
have the pendulum swing back
a little bit to give children
just a little more time
on their own to experiment
with their judgment
and learn some ability
to make judgment.
Yeah.
There's a great book
on this topic called
The Coddling of
the American Mind
by Jonathan Haidt
and Greg Lukianov.
It's really worth reading.
And they talk about
some of these issues.
There's a political aspect
to it, but there's also--
Jonathan Haidt is a
social psychologist
and talks about some of
the changes in parenting.
The term used to be--
well, used to just be parenting.
Then it was
helicopter parenting.
And now it's
bulldozer parenting.
When I went off to
college-- and it's not
like even that far away.
I'm from New York.
I came to Boston.
Speaking of elephants,
I went to Tufts.
I spoke to my parents
once a week maybe.
Right.
And now, you can be on the
phone texting after every class,
between every class.
The papers are edited,
the whole thing.
You know, it's kind of
constant management.
One of the points that
is made in this book
is that we don't want to
see our children as fragile.
We want to see them
as anti-fragile.
The idea that they
need experiences
that mold them and teach them
about what their own capacities
are so that they
can enter the world
and enjoy the pleasures
of independence,
and creativity, and the like.
How are we doing on time?
Maybe we can do
one more question.
One more question.
You've got a question?
[INAUDIBLE]
One more question.
OK.
OK.
It'll take me two minutes to
find the question, of course,
then we'll be out of time.
That's another way to go.
This says, "If depression
of mental health disorders
are so prevalent, if depression
and mental health disorders are
so prevalent, why
is access so limited
and treatment not always
covered by insurance?"
That seems like a fair question.
Well, you know, this
is a terrible problem.
When people call me
up for a referral,
it's very difficult
to find somebody.
And it causes us to
try to fall back on--
the answer is it's expensive.
It's expensive to sit and talk
to somebody who's experienced.
And if you want somebody to
really think carefully with you
about what you're
struggling with
and what the origins
of the distress is,
it takes more than an hour.
It takes hours and hours
to really understand
what somebody is about.
And that takes a lot of time.
And time is expensive.
There's no easy answer to this.
One answer, though, is to go
back to some of these basics
like paying attention to choices
you make about lifestyle.
There was a question
about sleep.
You know, get a
good night's sleep.
Pay attention to the
kinds of lifestyle choices
that you're making that may--
and these are very
difficult things to do.
But you were talking
before about this flow.
The one thing that's
great about the brain--
there are many things that
are great about the brain.
As Woody Allen says, it was
his second favorite organ.
But you know, people who
are fans of Star Trek, space
isn't the final
frontier, the brain is.
It's the most complicated
machine on the planet.
But it's enormously resilient.
And what we learned
in medical school
is that you're born
with your brain,
and then it just deteriorates.
That's not really true.
But what we know now is that
there's this thing called
neuroplasticity.
As you're listening to
me, as I'm talking to you,
our brains are changing.
It's not just the medication
that changes the brain.
Experience changes the brain.
Practicing the piano
changes the brain.
Meditating changes the brain.
Practicing--
And using real relationships.
Yes.
When you talk to people in
your life about your troubles
and you let them
try to be helpful,
it's amazingly effective.
It's not that only therapists
can make depression better.
Depression is
often time-limited.
And you can use the
network you've got.
And every hospital in the
city has some free care.
Yes.
So if you need to,
get psychiatric help
because it's not enough to
talk to your best friend.
Then every clinic in the city
does give some free care.
And primary care
doctors are highly
trained in behavioral health.
They know that health
first and foremost is
about behavior and lifestyle.
And so they're often
an excellent resource
for leading you to
people who can help you.
Exactly.
So I think we're out of time.
But thank you very
much, everybody.
Thank you.
[APPLAUSE]
Thank you so much.
