Saturday, 5 May 2012

More Depressed Than Average?

Whether we think of ourselves as "depressed" or "anxious" depends on what we think about other people's emotional lives, rather than our own, according to an important paper just published: Am I Abnormal? Relative Rank and Social Norm Effects in Judgments of Anxiety and Depression Symptom Severity

The work appears in the obscure Journal of Behavioural Decision Making, which is downright criminal. It deserves to be in the British Journal of Psychiatry ... and it's not often I think that about a paper.

In the first experiment, the authors quizzed people how many days per month they felt “depressed, sad, blue, tearful” or had “excessive anxiety about a number of events or activities.” They then asked them a series of questions designed to work out how they thought other people would answer than question. So they could work out where each individual thought they ranked within the general population, in terms of depression or anxiety symptoms.

Take a look. The top panel shows someone who felt depressed on 5 days a month, but believed this put him in the most depressed 70% of people. The second person felt depressed twice as often, but she thought she was below average.

They found that perceived rank was strongly correlated with whether people thought they "had depression" or "had anxiety" - much more strongly than actual frequency of symptoms. "Having depression" meant "being more depressed than other people".

That's just a correlation and doesn't prove causation, but in the second experiment, they randomly assigned people to get different versions of a survey which manipulated perceived rank, and they confirmed that rank was indeed associated with how "disabling" they felt a given level of symptoms would be.

Now, this is just common sense, in a way. Of course whether you think of yourself as abnormal will depend on what you think of as normal - that's what "abnormal" means. We understand ourselves in the context of other people.

But this common sense is maybe not so common nowadays; you can read a hundred papers about the chemistry, genetics or causes of "depression" without a consideration of what "depression" (i.e. "abnormal" as opposed to "normal" mood) is.

The implications are big. Here's my main concern. Right now a lot of people think that promoting the idea that mental illness is very common is a good idea. Their stated goal is that by 'normalizing' mental illness, we'll destigmatize it. This will both help the mentally ill to cope, and encourage people to talk about their own mental health and get help.

All very nice. I've accused such campaigns of being based on dodgy stats, but this paper suggests that such campaigns could end up having exactly the opposite effect from that intended - they could lead to under-diagnosis, and increased stigma.

Suppose being depressed or anxious becomes seen as more 'normal'. According to these data, this will make people who are depressed or anxious less likely to seek help, for any given level of symptoms. Change people's perceptions of other people, and you'll change how they see themselves.

Worse, normalizing distress could - paradoxically - make those who do seek help seem more abnormal. Think about it: if depression and anxiety are normal, surely only an abnormal person would need special help to deal with them.

It's a small step from this to the idea that mental illness is mere personal weakness, laziness, attention-seeking, or scrounging. 'What's your problem? Everyone feels down or worried sometimes... most of us just deal with it.' If everyone is mentally ill, then no-one is really mentally ill... so the "mentally ill" must have something else wrong with them. Not very nice.

I'm not sure if this has happened, or will ever happen, but it's something to think about.

ResearchBlogging.orgMelrose, K., Brown, G., and Wood, A. (2012). Am I Abnormal? Relative Rank and Social Norm Effects in Judgments of Anxiety and Depression Symptom Severity Journal of Behavioral Decision Making DOI: 10.1002/bdm.1754


Jules Evans said...

I agree, fascinating study.

But I don't agree with your main concern. I've found that people with emotional disorders severely underestimate how common it is for other people to have such problems, and overestimate their own unique messed-up-ness.

In CBT its called the magnification / minimisation bias - everyone else's life seems perfect, yours seems uniquely terrible.

The work on stigma is about changing this common bias, becoming aware of how normal it is for people to have periods of emotional unwellness.

But its ALSO about letting people know that there are ways to cope with such periods and either manage them or overcome them.

Speaking personally, my shame at feeling depressed / anxious and feeling made the situation far, far worse. Thats motivated me to write about mental illness, so that people who experience depression or panic attacks dont feel so completely bewildered and terrified by the experience as I did.

But just normalising it clearly isnt enough - we also need to hear stories of people who have come through emotional problems and learned how to deal with them. We need to be better informed about the practical steps people can take to get through such experiences.

all best


Anonymous said...

Being in despair is not a medical condition. There are always good reasons why you are down if you truly search your life. Or, alternatively, you could drug your brain with psychiatry's quack 'treatments' and indoctrinate yourself to believe you're brain diseased.

TheCellularScale said...

ha, anonymous @2, great example of exactly the problem Neuroskeptic is pointing out. You think being depressed is not only normal, but that it is the depressed person's fault. Charming.
Anyway Neuroskeptic, it does seem like maybe this 'normalization' campaign could backfire in the way you said (though I am not convinced that it actually IS yet). But what i want to know is how strongly and why the mildly depressed person/group overestimated how 'abnormal' they were.

Coordinamento Locale said...

To Jules Evans:

The life of someone with major (key term) depression seems terrible because it IS terrible.

It is NOT just a period of "emotional unwellness", and it doesn't resemble at all other people's common periods of emotional unwellness; that's why NS is exactly on the spot with this post.

To Anonymous:

I'm still not sure if you're just trolling, but being in despair/being "down" is not a synonymous of depression.

Neuroskeptic said...

Jules Evans: I get your point & I agree. But what I'm saying is, that's fine, but if it goes too far, then it could end up doing more harm than good.

As I said, "I'm not sure if this has happened, or will" but my worry is that it could do.

Personally, I found two things helpful in coping with my depression: 1) knowing that I wasn't alone & uniquely bad, but also 2) knowing that it wasn't normal (for me, and for people in general) meaning that it wouldn't last forever.

Both of those are important. My worry is that if we overemphasize one of them then we might forget the other.

Mental illness isn't rare & freakish but nor is it something 'everyone goes through every day'.

Ryan Stuart Lowe said...

As someone who found CBT very helpful in overcoming a period of (admittedly moderate) depression, I find myself agreeing with Jules Evans.

This kind of work dovetails nicely with a lot of recent discussions of social media -- i.e. the headline-grabbers "is Facebook making us depressed?" etc. It's why some cultural theorists are claiming that we're living in an "era of envy," etc. Our entire market economy is aimed at heightening envy for what others have, for what others are pretending to have, for what marketing crews are pretending others have, etc.

It goes to show that depression may be a cultural problem as much as a personal problem.

J. F. Aldridge said...
This comment has been removed by the author.
Rose said...

Totally agree with you. I am so glad to see *someone* at least questioning this ridiculous proposition that every human emotion is some kind of "disorder", as if human beings are like the mysterious VCR nobody knows how to program. I think we, as individuals, need to learn to take ownership of our "selves", rather than relying on so-called experts (or anyone else) to define us. Of course, it's easier to let someone else tell us the answer regarding who we are; but I think self-relization is an intentional stance that requires effort, and perhaps even some training. Are there any memes for this?

J. F. Aldridge said...

Throughout history, and where psyche diagnostics are still rare, I think the normalization of sadness has been, well, the norm, but now that we've removed society's melancholic from this norm and placed them in their own category, "depression," our averaging mechanism has been dramatically skewed towards happiness.

If you have a friend who is sad more often than you, you might think, "well, I must be a cheerful person." But if you learn they have depression that sentiment will probably shift to, "well, then, I must just be normal."

The reasoning you take in the article is that the de-stigmatization of the category "depression" will place it back in the averaging mechanism that calculates the "norm," and thus undo that skew, but I don't think de-stigmatizing efforts are usually effective in dissolving categories. I don't think they're even all that effective in de-stigmatizing.

Although, now that I think about it, it would be fascinating to look into how the Irish, Jewish, and Italian categories were all dissolved into Anglo-saxon in America. It's clearly possible for categories to be dismantled, but for some reason I think it has little to do with sensitivity campaigns.

P.s. Sorry about the repost. I'm getting used to blogger.

Altostrata said...

"Right now a lot of people think that promoting the idea that mental illness is very common is a good idea. Their stated goal is that by 'normalizing' mental illness, we'll destigmatize it. This will both help the mentally ill to cope, and encourage people to talk about their own mental health and get help."

The effect of this is that people are going to their doctors and demanding psychiatric drugs. Not being able to distinguish an abnormal emotional state from a normal emotional state, doctors are acceding to these demands.

Many more people are taking psychiatric drugs than their conditions warrant.

Doctors are incapable of being gatekeepers because psychiatric diagnosis is so vague. Psychiatric drugs are becoming elective, much to the benefit of the drug companies but to the detriment of public health.

Most psychiatric drugs increase the risk of diabetes, for example, and polypharmacy is a general health risk.

Doctors should be holding the line on unnecessary drug prescriptions, but they are mystified by the smoke and mirrors of the mental health industry, which is devoted to making mental illness very common. The new normal, you might say.

(Jules Evans, your post confirms Neuroskeptic's point -- people seeking "mental health" care overestimate their own mental illness.)

Peter Phelps said...

As a psychotherapist I work with depressed and anxious clients daily, and I think it's very important to draw a distinction between these states of mind, and the types of mental illness where people are delusional, or otherwise dysfunctional, to the point where they are a danger to themselves or others.

Clearly, people with major psychiatric disorders often require medication, but I would argue that many who are routinely prescribed anti-depressants by GPs don't need them at all. Sadly they are the default NHS response to transient depression or anxiety that is part of daily life, and always has been.

A certain amount of worry is completely normal, as is a certain amount of sadness. So when someone's husband dies after a long battle with cancer, why is it necessary to give them medication to stop them feeling the pain? Let them cry, bucketloads if necessary. Give them good quality professional help and support. And give medical doctors a decent grounding in psychology as well as a prescription pad.

True peace of mind does not come in a plastic bottle with a childproof lid.

omg said...

That's like saying everyone uses Apple so it's normal. It's NOT normal. Everyone is depressed right but unless coping skills are compromized / normalized like as in altering the environment - getting rid of trashy tv, movies, music, entertainment, all stuff to some extent contributing to coping strategies then that would change the depession stats. If its innate predisposition .. hmm.

Ivana Fulli MD said...

Peter Phelps said...6 May 2012 02:31

As a psychotherapist(...) when someone's husband dies after a long battle with cancer, why is it necessary to give them medication to stop them feeling the pain? Let them cry, bucketloads if necessary. Give them good quality professional help and support. And give medical doctors a decent grounding in psychology as well as a prescription pad.True peace of mind does not come in a plastic bottle with a childproof lid.///

And what about giving psychologists a decent grounding in psychiatry as well as some ethical grasp of the unproven efficiency of their tools?

See NS's posts on the subject of the latter .

For the former, I found myself repeatedly baffled by the fact that so many people do not know that acute grief can make people hallucinate and hear the voice of the deceased - just to take an example.

What is vexing is how much more convincing I sound when I show and give the RCP bereavment leaflet to mourners...

Nb: THe RCP website is dumb-friendly - even I can print their beareavement leaflet easily in the French version on offer.

(It is free for you to print although they ask for a donation.)

The new French president to be elected today should make it mandatory to distribute the RCP bereavment leaflet to every grieving family as soon as possible after a physician has written a death certificate.

By the way, I wonder if the psychologist are asking for the habilitation to deliver death certificates as well as the right to prescibe drugs?

Ivana Fulli MD said...

Here the link to the bereavment leaflet that teach people what to expect and help them to not feel "abnormal" when they are just suffering bereavment:

absoluterelativist said...

Great post, Neuroskeptic, this is why I love to read your blog!

Mental Illness Policy Org said...

You always have original thoughts. Thank you for this.
DJ Jaffe

Dario said...

I suspect that the discrepancy might also be due, in part, to the perceived intensity of the depression.

I don't know the exact wording used in the survey, but unless it was very precise, it could very well be that the subjects answered how they compared to everyone else on the severity of their depression, rather than just on the number of days a month they felt depressed.

Subjects may have said they felt "blue" five days a month, even knowing they were talking about very mild depression (which would lead them to rank themselves as not as depressed as most). And vice versa.

Anonymous said...

What's normal is a function of how one (arbitrarily) categorizes things. The lifetime incidence of terminal injury or illness is 100%. Within the subpop of people with malignancies, the prevalence of chronic pain approaches a similar rate.

In non-psychiatric medical treatment, normality is not particularly relevant. Artherosclerosis is normal. Obesity is rapidly becoming normal. When people die, the normal way to die is in pain.

We should treat things not because they're abnormal, but because they're unpleasant. Imagine a world where there existed decent treatment for major depression, but where major depression was much more frequent. Would the normality of major depression really prevent you from treating it? Psychiatry's focus on abnormality is already a dinosaur.

Beyond that, calling things normal or abnormal can have an effect on how people feel-- but ultimately, it would be unethical to let those concerns prevent us from full disclosure of everything we know. It doesn't matter if people would be best served by making something seem more frequent or less frequent, because we're not going to lie to anybody anyways, we're going to tell them the most up-to-date and accurate information that we have. Right?