The Bow that Bends but Doesn’t Break: Might Flexibility Reduce Depression Risk?
The COVID-19 pandemic forced us to get creative about how we spend our time. For me, that meant venturing out to an archery course for the first time. As a clinical psychology PhD candidate at The Ohio State University, I needed a break from staring at the computer screen. In my pandemic fog, it seemed like the most natural thing to do at the time was pick up a bow. Of the many things I learned that day, the one that stuck was that there is an optimal draw. You should not over- or under-draw the bow. And most importantly, you need a bow that bends and doesn’t break.
For weeks after that experience, the bow analogy was apt to my pandemic experience as well as my research on how stress affects the body and mind in Dr. Jan Kiecolt-Glaser’s Stress and Health Lab. When we experience chronic stress, like the pandemic, it is as if there is a constant tension on that bow. Constant tension — that phrase may resonate. With this underlying tension, it is easy to lackadaisically underdraw; we’re tired and worn thin. Alternatively, every little stressor that arises may trigger an overdraw — like an overreaction with a flash of rage — or worse yet, the bow might break. Depression can onset, and we are off the course and out of the game altogether.
Okay, Enough with the Analogy
During the COVID-19 pandemic, depression rates soared to never-before-seen levels — affecting nearly one in three U.S. adults. And yet, even though we’ve all experienced some degree of difficulty in these unusual circumstances, many people never did develop depression. What protected them?
This question has been floating through my mind as I have continued to conduct therapy with patients throughout the pandemic. Over the past couple of years, I have witnessed first-hand how pandemic mitigation efforts have had the unintended side effect of increasing depressive symptoms, and in turn, potentially hampered immune responses to both the virus and vaccine. I also saw how many of us, as chronically-stressed and socially-isolated people, did not handle daily hassles very well and fell into the trap of depression.
A Brief Aside About the Complexity of Depression
To say that depression is a complicated disorder is an understatement. We know that there are many different presentations of depression (e.g., one study found 1030 different symptom profiles in 3703 depressed people), and depression has many different causes, including a combination of gene and environmental factors. To make matters worse, some people are misdiagnosed with unipolar depression when in reality they have bipolar depression. No wonder depression can be hard to treat effectively.
Another issue with depression is that it is self-perpetuating. It can increase physical and psychological responsivity to stressors. And there is emerging evidence that heightened and long-lasting physical responsivity to stress can worsen depression.
What exactly is a physical response to stress? You may be familiar with the term “fight or flight,” which refers to how the nervous system immediately jumps into action, followed by the endocrine system with a release of stress hormones to facilitate a coordinated response conducive to combatting or escaping a stressor. Interestingly, the immune system also responds to a psychological stressor just as it would respond to a pathogen (although to a lesser extent) — via a cascade of inflammation. Over time, this stress-induced inflammation may increase depression risk.
So What Can Be Done?
One key strategy is depression prevention — minimising depression risk so that it never actually onsets. The way we respond to daily stressors may provide a window into depression risk, and in turn, it may be an important target for depression prevention.
To pick up the bow analogy again, it is important to draw the bow with just the right amount of tension and release it at an appropriate time. Similarly, our physical stress response is meant to mobilise just enough resources to handle the situation and then return to baseline once it is handled.
Overreactions are a waste of physical resources and can cause unnecessary wear and tear on the body, and underreactions do not allow for optimal performance in a potentially dangerous situation. Also, prolonged physical responses needlessly tax the body, leading to misalignment with the current environmental threat.
Rumination and worry are often culprits of these prolonged responses. Another culprit is adverse experiences, especially childhood trauma, which can make it difficult to recognise safety, thereby leading to more frequent, intense, and prolonged physical stress responses.
A New Framework
With all of this as background, I’m suggesting a new framework for evaluating depression risk and a novel target for depression prevention: inflexible physical stress responses, or bodily responses, that are out of proportion to the current threat and do not return to baseline, but remain elevated, when the threat is resolved. So in our bow analogy, the bow is not released, and the bow is kept slightly taut.
For example, if your supervisor unexpectedly asks you to meet with them later today, you might assume that you will be reprimanded. So you spend the whole morning and most of the afternoon having a prolonged (anticipatory) physical stress response that does not align with the calm office environment around you. Instead, your supervisor shatters these expectations and compliments you on your exceptional work performance. As the meeting wraps up, they mention that you have spinach in your teeth. You spend the next hour reprimanding yourself about the spinach, and in doing so, you perpetuate the prolonged stress response. You return home exhausted and collapse in a heap.
Anyone familiar with cognitive reappraisal will recognise some thinking biases in the above paragraph (“thinking the worst,” anyone?). Indeed, our mental game can play a huge role in physical stress responsivity as well as depression risk. Cognitive-Behavioral Therapy boosts immune health, but it is not yet clear whether it changes how we physically respond to stress. There may be multiple ways to facilitate more flexible physical responses, including mindfulness techniques and exercise.
Even as we move from one world crisis to another, it is possible — and beneficial — to find rest and return to baseline. We are all capable of learning to engage stressors to the best of our ability and then rest. Learning to quickly draw and release in line with the target (stressor) may help to prevent depression. We can become like bows that bend but do not break.