Clinical depression as the sports injury of academia

Beyond self-care: How an institutional approach could pay for itself (oh, and also reduce suffering too)

A painfully on-point satire of academia’s current approach to mental health. From this tweet by @Cooganlab

Academia is like an entire sports league, playing far below its potential

Imagine if a professional sports team invested time and money into recruiting the most talented players it could get, but didn’t hire a team doctor or physiotherapist. Imagine if getting injured was considered a sign of being unsuited for professional-level play, and that as a result players tried to hide their injuries and to avoid requesting treatment. Imagine if around 40% of the junior players, and an unknown but non-trivial proportion of the senior players, sustained injuries that impaired their performance. Players were sent links to websites containing tips about self-care for injury prevention, but to little effect.

The team would end up performing much worse than if the players had remained in good health. If all the other teams were like that too, then nobody would know what they were missing out on. The status quo of systemic and chronic injury would seem normal. That would be how things were, and how they always had been.

Imagine that, one day, it was pointed out to the team that hiring a doctor and physiotherapist might improve overall performance, yielding more wins and increasing ticket sales. A program of injury-prevention was put into place, with strength-training, the use of joint-supports and frequent check-ups. Players no longer tried to hide their injuries, and so received earlier treatment before the injuries became severe. The team started to play better and win more games. Ticket sales went way up. And, by the way, the players were happier and healthier too.

Academia is like the sports team, before it tries preventing or treating injuries.

“What do you expect?” people might say. “Of course there are injuries! Playing with the pros is hard.” That’s true, but it overlooks the fact that preventative measures would make injuries less common. With fewer injuries the team plays better, and it wins more games. The work on prevention is simply a good investment. In contrast, universities don’t seem to have figured out yet that they could be performing much better, even just measured purely in dollar terms, if they invested more in protecting the mental health of their students and faculty.

The sports injury metaphor: the mental-health equivalents

Depression, anxiety and other mental health problems are very complex conditions, influenced by a bewildering range of physiological, psychological, interpersonal and environmental factors (e.g. Engel, 1977). This makes them confusing to think about. My hope is that the sports injury metaphor presented here might help.

Below is a table summarising the main parallels. If you just want the main idea, then please feel free to peruse the table and then stop there. If you want more detail, with arguments for why the parallels might hold, and a brief description of my own experiences as an academic with depression, then read on beyond it.

My personal experience (which I haven’t publicly talked about before. Gulp)

I’ve had rather more personal experience of the relationship between depression and academia than I’d like. Hopefully something useful will come out of that, and maybe this posting is it. Below is a brief outline of my own experiences as an academic with depression.

I am a faculty member in cognitive neuroscience. I have often found doing research to be exhilarating: trying to see connections between things, and to explore new ideas. Sure, sometimes I would get a bit stressed about it, but who doesn’t? I might get bogged down by that for a while, but I would push myself harder and get past it. It isn’t the most relaxing way to live, but I enjoyed it, and it seemed to be working fine.

Until gradually it stopped working. I started to find that I couldn’t concentrate as well. I had always liked to read a lot of research papers, but now I could barely make it past the first page. I could hardly compose an email, let alone write a paper. Clearly, I just wasn’t trying hard enough. So, as I had done many times before, I pushed myself harder still. Surprisingly, or at least surprisingly to me, this didn’t seem to help. I had previously always found my field of research to be fascinating, but I started to feel no interest in it at all. My mood began to darken. I castigated myself for being too weak. I couldn’t think any more, and it was all my own fault. I felt completely certain that I would never be able to think properly again. Academics have a tendency to view their self-identity as rooted in their ability to think. I know I certainly did. So, it was very disorienting, and frankly scary, to feel that disappearing.

I felt ashamed, and tried to hide how I was from everyone. I couldn’t hide it from my wife, and to my immense good fortune she forced me to see a doctor. I was totally opposed to doing that at first, because obviously no doctor could do anything about the fact that I was weak and stupid. But to my further good fortune, I was treated by an excellent psychiatrist who, after some trial and error, found a medication that made me feel quite a bit better. He also worked with me on Cognitive Behavioural Therapy. I started to learn how to question my negative thoughts, although doing that in the heat of the moment is a difficult skill that I’m still far from mastering. I also learned, to my genuine surprise, that constant self-castigation was not an inevitable part of all people’s inner lives. I was absolutely certain that I would never get better. However, over the course of more than a year, I gradually did.

That first episode was over fifteen years ago. I stayed on a maintenance dose of medication, and continued to see a therapist occasionally but regularly. Things went fine. I did research, wrote papers, eventually landed a tenure-track job, and got some grants. My troubles were behind me. Or so I thought.

Relapse

Then, about four years ago I started to get sick again. This relapse has not been as intense as my initial episode, but it has lingered longer. Over the past few years I’ve been sometimes better, sometimes worse, but rarely back in full health.

I don’t really know what led to the relapse. It was probably a complex mix of causes, rather than just one distinct thing, but it is very likely that the pressures of faculty life played a part. The biggest difference from the first episode is that now I know I can get better. That makes the struggles feel less permanent, but it doesn’t make them go away. With more psychotherapy, adjusting or maybe completely changing my medication, doing more physical exercise, and (post-pandemic) more social interaction, I think I’ll eventually regain my health. That said, I am currently unsure whether staying in academia is right for me. I believe that universities could become much better environments for maintaining mental health, perhaps along the lines of the reforms suggested here. They are not like that yet, though.

Academia has a big mental health problem. A different way of thinking about it might help

Fig.1: The Yerkes-Dodson curve. Short bursts of moderate stress can help keep you on your toes. However, sustained high levels of stress impair performance. Put another way, stress gets your body and brain ready to run away from a tiger. High-level cognition is not much use when you just need to run as fast as you can, so stress briefly shuts it down. However, if you stay stressed for long periods of time, then your high-level cognition suffers.

My story is just one of many thousands, at least. Academia has a serious and very widespread mental health problem, but nobody seems to know what to do about it. Doing research is always going to be challenging, and grants and high-profile papers are always going to be competitive. However, even if one ignores the human cost and concentrates only on productivity, it seems unlikely that the status quo is optimal.

There exist many studies, news articles and editorials about the epidemic of mental health issues in academia. For example, Evans et al. (2018) measured anxiety and depression in more than 2000 graduate students across 26 countries, and found that around 40% suffered from anxiety or depression, more than six times the rate in the general population. Most discussion has been about graduate students and undergraduates, along with some talk, albeit much less, about faculty (e.g. Lashuel, 2020). Pieces calling for action have appeared in high-profile venues such as Science and Nature (e.g. Sohn 2016; Leshner, 2021), and the pandemic has made things even worse. However, even before the pandemic such articles had been appearing for several years (e.g. Smaglik, 2006; Gewin, 2012), and that reveals a problem: all that talk does not appear to have led to any changes in the situation.

Depression and anxiety, as well as being mood disorders, also impair cognition. Typical symptoms include difficulty concentrating, memory problems and the quenching of motivation and curiosity. They can also lead to social withdrawal, thereby hindering collaboration. Thus, academia is inadvertently damaging the very qualities for which it tries to select.

To put it in neuroscientific terms, universities recruit people based on how well their prefrontal cortex carries out high-level cognition. They then expose those recruits to high levels of chronic stress, which is known to be a potent dampener of prefrontal cortex (e.g. Arnsten, 2009; McEwen & Morrison, 2013).

Academia selects for intellectual acumen, then lets it get smothered under stress. It’s as if a sports team recruited the very best players it could get, and then just shrugged helplessly as it watched them gradually succumb to injury.

What would a less self-undermining version of academia look like?

One way to reduce injuries in professional sports would be to make everyone play more gently. Muscles don’t get damaged unless they are pushed to the limit. However, such an approach would obviously be self-defeating. The whole point of professional sports is to play as well as you possibly can, and competitive leagues and championships further enforce that.

Along similar lines, it might at first sight seem that the only way to make academic research less stressful would be for people to try less hard. Fewer discoveries would be made, fewer insights would be generated, and intellectual innovation would dwindle. This does not seem like a promising approach.

Fortunately, sports teams can work to minimise injuries whilst also striving to play as well and as hard as possible. Indeed, a major benefit of preventing injuries is that it boosts the overall level of performance.

What, then, would be the mental equivalent of injury-prevention?

The environment can be made less harsh, while still preserving excellence and competition

There are many ways in which the research environment could be made less damaging to mental health, without diluting the quest for excellence. Probably the most impactful single step would be for mental health issues to be openly discussed as normal and to be expected, just as injuries are in sport. In such an environment, people would no longer need to hide their difficulties, or to maintain a facade of invulnerability.

The liberating effect of this could be huge. Given the importance of social support for mental health, simply being able to talk openly with supervisors and peers about one’s struggles could be enormously helpful.

A nasty trick of depression is that it bullies its sufferers into not talking about it. It shouts in your ear that you should feel ashamed, and it dulls your judgment enough that you believe it. So, there are a lot of people out there, quietly suffering but trying their best to hide it. Office-mates and side-by-side colleagues might each be battling the same problem, unaware of each other’s struggles and each feeling uniquely defective and alone.

Although one might feel alone, the truth is completely different. Depression, anxiety and other mental health conditions are extremely widespread (recall the finding that 40% of graduate students are sufferers). When something affects 40% of people, it’s completely normal. And knowing that you are normal is perhaps the best antidote against feeling ashamed.

An atmosphere of open acceptance and discussion would also be likely to help reduce impostor syndrome, stress-induced procrastination, and a culture of excessive working hours. One hour of work filled with enthusiastic concentration is likely to be much more productive than several hours of being physically present in the lab or office but unable to concentrate due to stress, anxiety or depression.

The mental health activist Zoe Ayres (@ZJAyres on Twitter) has made an excellent series of posters highlighting the many stressors facing people at various stages of academia, ranging from the level of undergraduate to faculty member. They can be downloaded at https://www.zjayres.com/posters, and, in my opinion, should be displayed prominently in every university department. Fig.2 below shows her poster summarising the mental health challenges facing a faculty member. For me personally, the ones that resonate the most are “Competitive landscape”, “Yesterday’s news” and “Create a facade or fail”.

Fig.2: Zoe Ayres’ excellent summary of the many stressors in the life of a faculty member, from https://www.zjayres.com/posters. At the same site, she has made available equally informative posters of the mental health issues facing people at other stages of academia too: undergrad, master’s student, PhD student, postdoc, and technician.

Doing research is inevitably going to be challenging, so stressors of the sort shown in the poster cannot be completely eliminated. However, almost certainly, many of them could be reduced. Even just removing the pressure to hide one’s own struggles would be a huge step.

At the risk of stating the obvious, it is perhaps worth emphasising that simply hanging some posters on the wall is not enough. The crucial step would be to change the entire departmental attitude towards openly talking about, preventing, and treating mental health problems.

Obstacles to progress: our stubborn intuitions

Making a change to that sort of open and accepting attitude might seem almost absurdly easy. It would literally cost zero dollars. However, a much more difficult obstacle stands in its way. We all, to a greater or less extent, feel intuitions that are remarkably resistant to change, even when we can think of lots of sound logical reasons why they should be discarded.

Examples of such intuitions include:

  • If people aren’t tough enough to cope with stress, then they shouldn’t be trying to do research in the first place
  • It’s sad if some people end up dropping out, but we need to select for people who are tough
  • People should have enough willpower to overcome these sorts of challenges
  • Enough with the coddling and infantilising. People need to grow up

It’s important to acknowledge just how strong the pull of such intuitions can be. People might feel a little reticent about expressing these intuitions out loud, because they could sound a bit heartless. However, that doesn’t mean that we don’t sense these intuitions within us. I am literally writing this post urging people to reject such intuitions, and yet I very much feel their persuasive power. One reason why is that these are exactly the sorts of self-castigatory thoughts that depression shouts into a sufferer’s ear when it has hold of them.

Another reason, and a more general one, is that we have all at some time or another had the experience of being confronted with a difficult work deadline, of having felt like giving up, but of then willing ourselves into buckling down and completing the work. After having met the deadline, and exhausted, we quite rightly felt proud of the successful effort that we had just made. Isn’t depression just a euphemism for giving up and then whining “It’s not my fault. My brain made me do it”?

There is hardly a set of issues more difficult to think about than effort, volition, and self-control, as can be seen from even a cursory scan of the vast literature on free will. For now, and for the sake of brevity, I can only offer yet another sports metaphor:

Muscles that are worked hard will hurt. So, in order to succeed, any athlete must be able sometimes to “push through the pain”. However, it does not follow that such pushing is always beneficial. If the pain comes from a frayed ligament or a hairline fracture, then pushing through it will only make the problem worse. In order to stay competitive, the athlete must get medical treatment and allow the injury time to heal. In academia, it is often necessary to work hard even when one is exhausted, and to “push through” the pain in order to meet a deadline. However, too much such pushing will reduce performance, leading to depression, burnout and dropping out. Pushing yourself harder won’t help, if you are already slipping down the right-hand side of the Yerkes-Dodson stress/performance curve shown in Fig.1 above. As you find it ever more difficult to work, you push yourself ever harder, and the stress makes you shut down even more. This is a nasty vicious cycle, as I personally found out the hard way. Academia is how sports would be if people didn’t distinguish between tired muscles and a ligament that is starting to tear.

It is also worth pointing out that there exist many examples of prominent researchers who have suffered from mental health problems. Tragically, several of them are people who died by suicide. A few people have spoken openly about their struggles. There are doubtless many, many more who have felt unable to speak out. Given the still existing stigma, that is entirely understandable. Perhaps we can help to change that.

There are also some more concrete ways of trying to get past the above intuitions about weakness and coddling. An institution which, to put it mildly, is not known for coddling or for indulging weakness is the military. And the military, it turns out, has invested heavily in programs aimed at boosting mental resilience.

Resilience is not a fixed quantity. It can be trained

“If you’re not tough enough to handle it, then go do something else.” That may sound harsh, but is it actually bad advice? A lot depends on whether toughness is a fixed quantity or not. If it isn’t, then the advice could be changed to “If you’re not tough enough to handle it, then learn how to be tougher”. Recalling the importance of making change at the institutional level, as well as just at the individual level, the advice could be changed even more: “If you’re not tough enough to handle it, then learn how to be tougher. Also, let’s make the environment less unnecessarily harsh, so that we don’t waste so much talent.”

In sports, some players are naturally more injury-resistant than others, e.g. due to being very large or heavy-set. This quality is useful, but it is distinct from the skill, speed and agility that led the players to be recruited. Teams do not just sit back and watch their less heavy-set players get struck down by injury. They use well established methods of strength-training for injury prevention. The mental health equivalent of that is training in resilience.

A potential pitfall that must be avoided is to ignore the environmental changes that are needed, and instead to concentrate only on urging people to become better at withstanding stress. Indeed, that pretty much describes the current situation in universities. “Hast though tried a mindfulness webinar?”, as the tweet by @Cooganlab puts it. Incidentally, his tweet clearly resonated with people. At the time of writing it has been retweeted more than 1700 times.

Resources such as university counseling and wellness services are potentially useful. However, one of the most insidious aspects of clinical depression is that it can convince the sufferer that everything is their own fault, and that there is no hope of ever feeling better. The illness also tends to produce social withdrawal. Thus, the sicker someone is, the less likely they are to seek treatment.

An arrangement that is far likelier to be successful is one in which the institution itself reaches out actively to check in on people, and to offer help and treatment when required. That is especially true if the aim is the prevention of problems before they occur.

Part of this active outreach could usefully include training people to help improve their mental resilience, as long as this is done together with trying to reduce systemic environmental stressors, rather than as a substitute for that. Indeed, there already exist successful programs to emulate. Training programs in mental resilience typically include methods to question and reframe negative thoughts and emotions, similar to those of Cognitive Behavioural Therapy, as well as work on building up optimism, mental agility, mindfulness, and emotional self-distancing.

Here again, professional sports is an area that has long recognised the value of such methods for improving overall performance (in sports, the phrase “mental toughness” tends to be used, instead of “resilience”). A recent review of the effectiveness of mental resilience training in sports can be found in Stamatis et al. (2020).

As mentioned above, another role model, and perhaps a surprising one, is the military (e.g. Reivich et al, 2011; Sinclair & Britt, 2013). One possible concern, perhaps not always expressed, about efforts to prevent mental health problems is that they would lead people to become soft and coddled, rather than rewarding toughness. The military is, to put it mildly, not exactly a bastion of soft coddling. If mental resilience training is fine for soldiers, then it should definitely be fine for academics too.

A pioneer in this whole area is the Penn Resiliency Program, developed by Karen Reivich, Martin Seligman and their colleagues. The program has been applied in a wide variety of settings: high-schools, medical students in college, and the military. Recent systematic reviews of the effectiveness of mental resilience training programs include Forbes & Fikretoglu (2018), Joyce et al. (2018) and Liu et al. (2020). A mini-summary is that such programs do appear to work, although they are definitely no magic bullet. The key point is that mental resilience is not immutable. The all-too-persuasive intuition that says “If you’re not tough enough, then you should do something else” can be replaced with one that says “Let’s help to make people more resilient, and let’s work to make the environment less stressful”.

Outreach is to be applauded, but it defeats the purpose if it becomes yet another burden. Some medical schools, responding to high rates of depression in med students, have introduced “mandatory wellness” programs. This can even include making trainees document that they have completed the required number of wellness hours each week. If your wellness outreach is adding to people’s stress, then you’re doing it wrong.

Internal and external factors are both important

Depression is driven partly by the environment, and partly by internal factors such as genetics, physiology and psychology. It’s amazing how difficult it is to focus on the internal and external aspects at the same time. Clearly, universities could do a lot more to reduce the external stressors, as this post tries to argue. But internal factors matter too: otherwise sleep, diet and physical exercise wouldn’t help, and talk therapy and antidepressants wouldn’t exist.

Stubborn intuitions try to sneak back in at this point. Given that internal factors matter too, and given that some people become ill whereas others do not, does that mean that people who get sick are somehow weak or at fault? No, it doesn’t. If you happen to have some vulnerability due to your genes or your upbringing, that’s not your fault. Nobody is invulnerable to everything.

Our stubborn intuitions try to get us to focus only on what makes us feel comfortable. For university administrators, it’s comfortable to focus only on how students and faculty should learn to become more resilient. For students and faculty, it’s comfortable to focus only on how universities should work to reduce stressors. Both types of change are useful and important.

This post has talked mostly about changes to the environment that universities could make, but I’ve also tried to emphasise that resilience training could be useful too. But please, dear administrators, don’t just introduce some mandatory wellness programs and think that your work is done.

Summary: some easy initial steps to take, which cost no money at all

As I’ve tried to argue here, academia has big opportunities to improve its mental health situation. That situation is very much in need of improvement.

Even if all you care about is money, this would still be a useful step. Universities spend a lot of money on recruiting the most talented faculty and students that they can get. It’s simply a waste of that investment to sit back and watch those recruits perform far below their abilities, with their cognition impaired by unnecessarily high levels of chronic stress. Some amount of stress is unavoidable in the competitive world of doing research, just as there will always be some injuries in professional sports. However, sports teams have long known that by working to prevent those injuries they end up winning more games, and selling more tickets. Universities don’t seem to have figured out yet that if they work to reduce chronic stress they will end up with more papers and grants.

Some initial steps to take would not cost any money at all. Probably the most important would be conveying the message that people don’t need to try to hide their difficulties any more. If we were to view depression, anxiety and other mental health problems in the way that sports teams view injuries, then that in itself would remove a huge burden from people. Trying to hide your struggles is exhausting.

This would need to go far beyond just sending out a couple of positive-sounding emails containing links to mindfulness webinars. It would require clear, repeated and convincing statements by high-level university administrators, department chairs and faculty members. There would be sure to be doubters, as is entirely reasonable. The only way truly to convince people would be to demonstrate that such an approach really works. And the only way to do that would be to try it, and see what happens. Roll-out would not need to start off university-wide. Individual departments could try it first.

A crucial initial step would be to open people’s eyes to how widespread mental health problems are. It is remarkably easy these days to set up a free and completely anonymous poll. A department could send out such a poll, making sure to keep it extremely short and simple, in order to get a rough idea of what proportion of its undergrads, grad students, postdocs, staff, and faculty have been suffering from depression and/or anxiety that is severe enough to have made a sustained impact on their work.

Would the results match the 40% figure found in the Evans et al. (2018) study of graduate students? What would the figure be amongst undergraduates? Amongst staff? Amongst faculty members? This seems like it would be important information for a department to know. A free two-minute online poll, albeit imperfect, would be a big improvement over knowing nothing at all. Knowing the size of the problem would be the first step towards attempting some solutions. How about we give it a try?

Afterword: this probably applies to many other professions, too

I’ve written about academia because that’s where my experience is. However, it is very likely that these issues hold true in other professions too. Lawyers have very high rates of depression. Doctors experience serious rates of burnout. Competition can help to spur excellence, but it can also overload people with stress. Chronic stress impairs cognition, and that definitely does not spur excellence. If a company is full of people with stress-impaired brains, then it probably isn’t performing at its best. Make your employees less stressed. The share-holders demand it.

Cognitive neuroscientist, trying to understand the structure of neural representations.

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