Targeting wellbeing in depression:

How to overcome the “Pollyanna” problem.

Barney DunnWellbeing Symposium

Exeter, July 2012

Scope of the depression problemDepression 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 treatments2. To develop novel, streamlined and accessible interventions

A translational research strategy

Basic Clinical Science Therapy Innovation & Evaluation Dissemination, Training, Access

T1 gap T2 gap

- 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

Secondary prevention

Primary prevention

Tx chronic depression

Maintenance Tx

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

Upward spiral of flourishing (Fredrickson)Population flourishing (Huppert)

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)

Negative Neutral Positive

Pleasantness

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

Time course

Emotion Experience

b) Set Point c) Reactivity d) Regulation ……. e) Recalla) Anticipation….

Anhedonic

Flourishing

• 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)

General distress: ‘neuroticism’

ArousalAnhedonia

Depression Specific Anxiety Specific

Effects of techniques may vary as a function of depression status

Non-dysphoric individuals can successfully suppress affect and memory of negative material (Dalgleish, Dunn et al., 2009; Yiend et al., 2006; )

High NA Low NA

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The same techniques that amplify PA may also exaggerate NA

• 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)

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The realism challenge• Positivity interventions may move depressed individuals further away from a

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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. Gratitude2. Optimism3. Avoid overthinking and comparison4. Practice kindness5. Nurture social relationships6. Develop coping skills7. Forgiveness8. Find ‘flow’ experiences9. Savour10. Commit to goals11.Engage with spirituality12. 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