Briefing on Life Events & DepressionBriefing on Life Events & Depression

And how we can measure them!

Stress & IllnessStress & Illness• There is a long tradition in medicine and psychiatry

linking stressful experience to illness.• However in order to test it in research terms

clarification of the definitions of stressful experience are needed.

• In particular the ‘stressor’ (event) needs to be differentiated from the stress response (distress, worry etc).

• Various characteristics of stressors also need to be identified to test the relationship to onset of depression o eg timing (in relation to illness); classification; threatening/unpleasant or

pleasant nature; independence of the individual’s vulnerability or (outcome) illness.

Feeling stresseda state of mental or emotional strain or tension resulting from adverse or demanding Circumstances eg "he's obviously under a lot of stress“. Something that causes a state of strain or tension.StressorA stressor is an external circumstance or an event that causes stress to a person. This can be termed as a negative life event or even a trauma, depending on its severity. For example, losing someone close, being evicted, losing your job, being mugged.

Definition of stress

Feeling stressed - depressionFeeling stressed - depression• ‘Depression’ can also be ambiguous since it refers both

to lowered mood as well as to a psychological disorder (‘major depression’).

• Major depression involves depressed mood and/or loss of interest together with 4 or more key symptoms which last at least 2 weeks (but on average duration around 3 months).

• Depression is measured by clinical interview, where the frequency and intensity of symptoms can be carefully collected. The diagnosis is then given by the DSM guidelines.

• but symptom scores can also give an idea of likely depression that is present. This includes the Beck Depression Inventory, or the General Health Questionnaire.

Measures - SCID for DSM-IVMeasures - SCID for DSM-IV

Major DepressionMajor Depression

• Interview to determine both number and severity of symptoms over the prior 12 months and at follow-up.

• Depressed mood/loss of interest and four or more key symptoms categorised as clinical case, together with significant distress/impairment.

• These include weight loss, insomnia, agitation, fatigue, feelings of worthlessness; poor concentration; recurrent thoughts of death or suicidal ideation/attempt

• Minimum length of episode 2 weeks. The average length around 4 months.

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Depression mattersDepression matters• Debilitating disorder

• negative effects on relationships, parenting, work, health care services and the economy.

• Prevalence (around 10% yearly, 20% lifetime) • increasing and at younger ages (peak age 18)

• Affects women more than men (2:1)

• Depression is ranked 4th leading cause of global burden of disease

• predicted to be 2nd by 2020 (WHO, 2001)

• Depression is treatable (therapy & medication combination) • treatment has increased (medication tripled) • but there are barriers to service-use (eg stigma) and insufficient provision

Slide 6

Causes – social, psychological Causes – social, psychological and biological and biological

• Depression is:• Linked to social adversity, poverty, disadvantage,

isolation• Linked to psychological vulnerability

(helplessness, low self-esteem, pessimism, lack of support)

• Linked to childhood experience (maltreatment)• Genes for depression have been identified

(serotonin transporter 5-HTTLPR) but genetically less heritable than most other psychiatric disorders (45%).

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Attitudes to depression Attitudes to depression

o Show it is now more than before believed by public to be biologically determined (88%) and to require medication (Blumner 2009)

o Stigma is still rife indicating belief in incompetence, dangerousness or blame; those with depression reporting shame or fear.

o Even though we know it is linked to misfortune and deprivation.

o Most of us could get depressed if the circumstances were in place.

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• Brown & Harris pioneered a social model of depression that was developed through researching community women. The start point was that social adversity/ inequality was the major contributor to depression through the role of stressors (life events).

• They showed in research studies how severe life events interact with psychosocial vulnerability in leading to depression. Vulnerability included childhood experience and problem close relationships (partner, close confidants, children) and lack of employment.

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George Brown& Tirril Harris

The Social Origins of Depression (1978)

Brown and Harris model (1978)Brown and Harris model (1978)

• A social model of depression was developed of community women. The start point was that social adversity/ inequality was the major contributor to depression through the role of stressors (life events).

• However, investigation of psychological vulnerability led to the study of cognitive factors, relationships and early life factors.

• The research then focused on the interaction of internal and external conditions over the life course, including childhood.

04/13/23 10GWBrown & T. Harris: ‘Social origins of depression’ Tavistock, 1978

Vulnerability-provoking agent Vulnerability-provoking agent

modelmodel• Research into life events and depression utilises a

vulnerability-provoking agent model.• Vulnerability is the ongoing susceptibility of an individual

which has lasted over time, often since childhood. This includes problem relationships, low self-esteem and often maltreatment in childhood. It can also include biological factors such as low serotonin transportation.

• Provoking agent, is the negative life event which can trigger onset of major depression at a particular time.

• Both elements are usually needed for a clinical depression to occur. This involves an interaction, which means the effect is bigger than either factor singly.

Vulnerability-provoking model and Vulnerability-provoking model and

major depressionmajor depression

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PsychosocialVulnerability

MajorDepression

Provoking agent

Interactioneffect

Time eg 12 months

Defining and measuring Defining and measuring stressorsstressors

Measuring experienceMeasuring experience

• Quantitative– Questionnaires/experiments; – Statistical analysis

• Qualitative– Interviews; observations; – content analysis

• Mixed-methods– Using more than one method for research question– Combining qualitative interviews with quantitative analysis

13/04/23 Slide 14

MeaningMeaning

The meaning of experience of life stress is important, both for the individual living through it and researcher investigating it.oMeaning of the experience important for measurementoFor theory generation and research findings;oFor empathic understanding; oFor clinical & social care practice

This is captured better in qualitative assessments e.g. narrative interview

13/04/23Slide 15

Stress measurement issuesStress measurement issuesMany checklist questionnaire approaches:• underestimate the presence of stressors by overly summarising the range of events possible •rely on reported rather than estimated threat/unpleasantness which can be biased by depression outcomes•do not reflect their timing in relation to onset•do not clarify the range of ‘others’ to whom events can be included.•do not reflect linkages of events and underlying difficulties

Any example - Recent life events questionnaireAny example - Recent life events questionnaire

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Life event: YES/NO Still affects me

Have you had a serious illness or been seriously injured?

Has any one of your immediate family been seriously injured:

Have any of your close friends or other close relatives been seriously injured?

Have any of your immediate family died?

Have any of your other close relatives or close friends died?

Have you separated from your partner due to marital difficulties?

Have you broken off a steady relationship?

Have you had any serious problem with a close friend, neighbour or relative?

Have you or your partner been unemployed or seeking work for more than one month?

Have you or your partner been sacked from your job or made redundant?

Have you had any major financial difficulties (eg debts, paying bills?)

Have you or your immediate family had police contact or court appearance?

Have you or your immediate family been burgled or mugged?

Indicate whether or not each event has happened to you in the last year and whether ‘still affects me’.

Event measurement issuesEvent measurement issues

• A wide range of events need to be covered in order to include all possible stressors.

• Events are acute (happen on one day) but difficulties chronic (last a month or more). Both are stressors and these can relate to each other.

• The context of an event (ie the circumstances in which it occurs) can affect how much stress-response or depression will occur. It is important to get a sense of the probable meaning for the person involved.

• Degree of threat/unpleasantness/severity is relevant to the response expected. This can cover a range of aspects such as danger, loss, rejection, entrapment etc

Measurement styleMeasurement style• Encompasses narrative accounts of personal

experience of stress and relationships attending to relevant context and the meaning of experience.

• A method both quantitative & qualitative to maximise potential analysis and theoretical insight.

• To work inductively from the narrative accounts to instruct later theory and measurement.

• Narrative, probing interviews coded according to predetermined, manualised criteria and rated according to expert judgement, aided by consensus agreement.

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Definition life event and difficultiesDefinition life event and difficulties

• Event: Discrete happening which indicates a change in environment or major assessment of role or relationship. Can be positive or negative. Can involve actual change (eg loss of relationship/role/ possession) or cognitive change (eg forecast about change; revelations about close others; decisions).

• Difficulty: Problematic situation continuous over time. Always negative involving objective unpleasantness.

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Life events and difficulties Life events and difficulties

interviewinterview

Brown & Harris (1978)Brown & Harris (1978)

• Semi-structured interview of objective stressors occurring in prior 12 months.

• Acute stressors (life events) and chronic stressors (difficulties)

• Severity assessed in terms of ‘likely’ stressfulness, threat or unpleasantness for average person in that context.

• Characteristics of severe events – classification plus focus, threat/unpleasantness, independence

• Severe event – ‘marked’ or ‘moderate’ threat/ unpleasantness lasting 10 days after start, focussed on self or jointly with significant other, not illness-related (ie part of the depression).

• Consensus and manualised examples for reliability.04/13/23 21

LEDS interview scheduleLEDS interview schedule

1.5 hour audio-taped interview & 3 hour 1.5 hour audio-taped interview & 3 hour

codingcoding

• 12 sections: Health, role changes, leisure & interaction, housing, employment & school, financial, marital, children, crises (police, burglary, attack), forecasts (news), general (decisions, positive events).

• Once event established question in detail about incidents leading to it or following from it to establish context. Determine when it happened and duration.

• Coverage – year before interview; range of significant others routinely covered: partner, children, siblings, parents, other household members, confidants. 04/13/23 22

LEDS rating scheduleLEDS rating schedule

Events (one per event)• Date• Classification• Actual change vs cognitive• Independence• Focus• Threat/unpleasantness (short

term/ long term; reported/ contextual)

• Relationship to other• Charateristics: Loss, danger,

matching difficulty, positive.

Difficulties (one per topic)

• Classification• Relationship• Date of change • Severity contextual• Severity reported• Independence

LEDS questions – eg maritalLEDS questions – eg marital• Have you and your partner both been living at home during

the last year?(If yes – have separated for a length of time?)• Have either of you ever considered a permanent separation or

divorce?(If yes – probe for details)• How well would you say you and your partner get on in

general?• Would you say there are any problems in your relationship?(Probe for details)• Has anything happened which has made you feel differently

about your relationship?(Probe for details)• In some relationships one of the partners gets involved with

another person. Has that ever happened to either of you?(Probe for details): Eg When first found out• How did things work out? Does s/he still see the other person?

Definition of provoking agentDefinition of provoking agent

• Severe life event: High level assessed threat/unpleasantness present initially and up to 2 weeks following and focused on the individual. Not illness related (result of symptoms).

• Major Difficulty: Chronic severe problem present at interview and lasting minimum 4 weeks. Majority last 2 years or more.

• Severe event matching difficulty: Severe event which matches an existing chronic severe difficulty in terms of classification and context.

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Research findingsResearch findingsLife events and major depression

In community womenMRC funded programmes of research

Islington studies of women Islington studies of women • First study (1980-5): 303 representative working-

class mothers in Islington, registered with local GPS and selected by questionnaire as free from depression and studied over 12 month period to look at onset of depression;o 10% had new onsets of depressiono 50% had provoking events/major difficultieso Vulnerability defined prospectively as an index of low self esteem

(negative evaluation of self) OR negative interaction partner or child OR lack of close confidant for single mothers.

• Second study (1990-5): 105 mothers in Islington selected for vulnerability but free from depression and investigated 3 times over a 15 month period:o 45% had new onsets of depressiono 75% had provoking events/ major difficulties

Presence of provoking agent and onset Presence of provoking agent and onset of major depressionof major depression

56

44

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No depression Onset major depression

Deaths

Provoking agentin 12 months Provoking agent

in 36 weeks prior toonset

None

None

Islington representative mothers: N=303

Type of severe event and depressionType of severe event and depression

Event category No onset

Onset % onset

Relationships (partner, child, close relative or friend (incl bereavement

59% 79% 23%

Pregnancy/birth 6% 10%

Health (self or other)

9% 3% 8%

OtherWork, material, other

25% 7% 6%

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130 Islington representative mothers with a severe life event

Deaths

Partner

Child

Pregnancy

House & Finance

Health Close others

Onset group (n=29)

Type of provoking agent and depressionType of provoking agent and depression

Islington representative mothers with event: N=150Islington representative mothers with event: N=150

No depression Onset major depression

Deaths

Severeevent

Majordifficulty

Matching D event

Severeevent

Majordifficulty

Matching D event

‘‘D events’ and onset D events’ and onset

depressiondepression

(130 Islington representative women)(130 Islington representative women)

Vulnerability for depression:Vulnerability for depression:Self Evaluation and Social Support measureSelf Evaluation and Social Support measure

assessed at first interview, before onsetassessed at first interview, before onset

A Negative relationships•Partner•Children•Lack of supportB Low self esteem•Negative view of self

•Single = any of A or B. •Joint = A + B

None

Single Joint

Joint

SingleNone

No onset

Onsetdepression

Prospective psychosocial model of Prospective psychosocial model of

depression: Islington series (1980-5).depression: Islington series (1980-5).

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onsetmajor

depression

Severe life events/matching difficulties

Conflict partneror child,

Lack confidant,Low

self-esteem

x1.9 x13.1

x10.2

x 45.8

(Relative risks shown)

Refs: Brown et al 1990; Bifulco et al 2002

VULNERABILITY PROVOKING AGENT DISORDER

What can protect against What can protect against

depression?depression?• Support: confiding in a close and trusted other,

and receiving emotional support can reduce the risk of depression.o Support can serve to help regulate negative emotions, provide practical

care and support, increase self-esteem

• Coping: good coping with a life event can help to avert a depression. Positive coping involves information seeking; downplaying some of the emotional side and being optimistic.o Problem coping includes pessimism, self-blame and denial of the event.

• Good coping and crisis support can greatly reduce likelihood of depression even in those with prior vulnerability.

Coping & Crisis supportCoping & Crisis supportwith severe event and onset of depression: with severe event and onset of depression:

(Vulnerable women with severe life event only)(Vulnerable women with severe life event only)

0

10

20

30

40

50

60

70

80% onset depression

CRISIS SUPPORTConfiding & emotional support from close other

Poor coping(denial, pessimism,self blame)

Good coping

Absent Present

69

25

133

Resilience

Using new technologyUsing new technologyTo update methods

Do we need an updated Do we need an updated

method?method?• Whilst the LEDS interview method is considered a

‘gold standard’ for measuring stressors, it has disadvantages which in modern times means it is not being used much.

• The measure is expensive in time, interviewer training and is restricted geographically to locations where an interviewer can reach.

• Questionnaires however are very limited in their capacity to reflect stressors accurately.

• Is there another approach using online technology?

Neither fish nor fowl…Neither fish nor fowl…

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Questionnaire Interview

Inter-Q!

Inter-netInterrogatePersonalisedTime-based InformedResearcher reviewed

Capturing life stress onlineCapturing life stress onlineESRC funded research projectESRC funded research project

We have funding for a 3 year project to develop a computerised life events measure ‘CLEAR’, which has both research and practice use:

-In higher education

-In clinical practice

-In health practice

Developing CLEARDeveloping CLEARCLEAR will be tested on two groups:•First year students to determine stressors when begin university.•An existing national sample of individuals with depression and comparison individuals.

•We hope to show this approach can validly and reliably capture in-depth life events information like an interview without the associated time and costs

We will post up We will post up progress onprogress on

our CLEAR project our CLEAR project which has just started!which has just started!