Risk and Resilience
An online simulation and in-person activity
This activity was inspired by Dr Jehannine Austin's jar analogy.
The development of mental illness is rarely if ever, caused by a single risk factor.
It is a complex set of interactions that researchers are still trying to understand.
This game/simulation explores how some of these different risk factors may 'stack up' and lead to mental illness (in this case depression). It also demonstrates that recovery does not involve the removal of all risk factors, just sufficient changes to get people below their personal 'threshold'.
It should be noted that the data behind this game comes from population studies of depression (i.e. generalised trends across thousands of people) and cannot be reliably attributed to any one individual. (Read more about the research evidence below).
The game was first created as a physical wooden activity for use at in-person science festivals. An online simulation has also now been created (links to both are below).
Evidence base for the activity
[this section of the webpage is still under construction. Apologies for an inconvenience this may cause]
Skip to a particular topic using these links:
DNA is the instruction manual for your body. Each section of DNA is called a gene. Humans have around 25,000 different genes.
Some versions of these genes can make people more (or less) susceptible to depression.
However, genetic factors alone are not enough to make someone unwell.
In addition, depression is believed to be ‘polygenic’ – it depends on many hundreds of genes acting together1. Therefore, each individual gene has only a small effect on the overall risk of depression. Thus, in order to detect the gene edits that are associated with depression, researchers need to study very large numbers of individuals.
Researchers estimate that the overall heritability of depression is approximately 40%2.
In our game, the genetic discs represent 10%, 20%, 30% and 40% heritability (represented by increasing thickness).
Women are twice as likely to be diagnosed with depression as men3. This difference shows up during puberty and lasts throughout adult life4.
The reasons for this difference are still not fully understood, but there are some theories4:
- Biomedical model – related to female hormones
- Genetic – genes that are only active in women/act in a different way in women
- Other biological factors – e.g. how the female body responds to stress
- Life circumstances that are more frequent / have a bigger impact on women – e.g. life events, abuse or trauma, being a mother, poverty
- Cultural factors – the attitudes of the people around you towards women, family, stress or mental ill-health (what is considered ‘normal’).
- Psychological – e.g. coping style or belief in your own abilities.
In our game, the female disc is twice as thick as the male one.
The world in which we live and function has an impact on our health. Stressful life events and general living conditions during childhood can affect our future risk of mental illness.
In our simulation, these childhood factors are only added once (and there may be ‘none’ at that time point). However, in real life, these things can be cumulative, and several may stack together to further increase the risk of depression.
This is a current research topic, and many different things could have an influence. We selected these because they have the strongest evidence base.
Furthermore, almost every factor overlaps with another.
This complex picture has been simplified for the simulation.
Early Childhood Trauma
[This is an entire research field by itself!]
Research studies have provided strong evidence that traumatic experiences during childhood, such as abuse, neglect or loss, is associated with a dramatic increase in the risk of developing depression5
One study found a 4-fold increase in the risk of depression in people with multiple childhood adverse experiences5 (Felitti et al 1998)
In our simulation, childhood trauma is the thickest block that could be added at this stage.
Stressful life events during childhood
Stressful life events during childhood can cover a wide range of things7,8, for example:
- A death in the family
- Parental divorce
- A parent being admitted to hospital or going to prison
- Moving house
- The birth of a new baby brother or sister
Some studies expand this category to include things like fighting in family, feeling unsafe
in one’s neighbourhood or having sex when one did not want to7.
These indicators show how important it is to help and support our children and young people through stressful life experiences.
In our simulation, these stressful life experiences are represented by a relatively thin disc.
Low Family Income
Low family income has been associated with depression4, but it is very difficult to untangle this from other aspects of family life.
- The strain of financial stress can affect how family members relate to each other. There may be more conflict or harsh discipline in the house or perhaps parents are around less often to support the children, as they need to work long hours.
- Long term financial stress can increase the chance of separation/divorce of parents or conversely, it may be the divorce/separation that leads to low income.
- Similarly, life events like frequently moving house or witnessing violence may be more common in low-income families.
- The neighbourhood around the family could also have an influence if there are higher levels of crime or fewer facilities (e.g. playparks, community centres or youth clubs).
In our simulation, low family income in childhood is represented by a relatively thin disc.
Few years of education
Few years of education is associated with an increased risk of depression throughout life9.
But education is not just about achievement and grades, resulting in a higher paid job. Knowledge, skills, values and behaviours learned at school can help people succeed more generally10.
- Schools teach people how to learn – opening up the possibility for acquiring new skills and problem-solving abilities throughout life.
- Higher education teaches people to think logically and rationally, to see many sides of an issue and to analyse and solve problems.
- Education also develops effective habits and attitudes such as motivation, trust, perseverance, and the confidence to attempt to solve problems.
Overall, it is thought that education gives people the ability and motivation to shape and control their lives, and that this sense of personal control can support emotional well-being.
In our simulation, few years of education are represented by a relatively thin disc.
As we grow older, we continue to experience things that can impact our mental health.
Again, in our simulation, we will only look at one time point (and there may be no relevant life experiences at that point). In reality, different factors may influence one another to further increase or decrease the risk of a person developing depression.
As research continues, we hope to gain a better understanding of what influences the development of depression. For the moment, we have selected these particular factors because they have the strongest evidence base.
Previous Episode of depression
Research has shown that at least 50% of those who recover from their first episode of depression, will go on to have one or more additional episodes in their life-time11.
However, more research is needed to figure out who is at greatest risk and what could be done to prevent it.
In our simulation, a previous episode of depression is the thickest block that could be added at this stage.
Furthermore, in our model, recovery from depression is represented by the stack of blocks falling below the threshold line. At this point, the person is well, but still at high risk.
Physical or mental health condition
Depression often occurs alongside other health conditions including cardiovascular disease [as is being investigated by this CoMorMent project], cancer, multiple sclerosis and anxiety disorders.
There are lots of possible explanations for this overlap12 including (but not limited to):
- A genetic change that increases the person's risk of both conditions
- The side effects of a medicine for one health condition, may increase the risk of another.
- The mental health effects of being in pain, having limited mobility or being unable to socialise.
- Lifestyle factors (such as smoking or lack of exercise) may be risk factors for both conditions.
- Shared underlying biological cause (inflammation, hormones etc).
This is another area of active research and it is likely that many of these things overlap with both each other and with other risk factors.
In our simulation, the presence of another physical or mental health condition (comorbidity) adds a thin disc.
Stressful life events
Episodes of depression often occur after stressful life events13.
In particular, the death of a loved one can put people at higher risk of developing depression.
Other events that seem to increase vulnerability to depression include:
- prolonged marital conflict
- loss or 'exit' events (e.g. losing your job or getting divorced)
- Uncontrollable or 'fateful' events.
- Events that are life-threatening
However, not all individuals who experience stressful life events go on to suffer from depression. Researchers are therefore interested to find out what makes some people more resilient or vulnerable to depression.
In our simulation, a stressful life event will add a thin disc. Whether or not this leads to depression will depend on how close the person was to their threshold before that point.
People with a low income (relative to others in their country) are 1.5 to 3 times more likely to experience depression or anxiety than the rich14. Furthermore, this relationship goes both ways; loss of income can lead to depression and depression can reduce average income.
However, it is very difficult to separate out income from all the other inter-related factors such as job security, housing, pollution and crime.
Depression can hinder education and job productivity. And as highlighted by this CoMorMent project, depression can occur alongside other mental and physical health conditions such as cardiovascular disease.
Stigma may also play a role.
For this reason, researchers often look at 'socio-economic status' [a combination of education, income and occupation]. Low socio-economic staus is also associated with depression15.
In our simulation, a low income will add a thin disc to the risk stack.
Being a parent
Post-natal depression is well-documented and something that midwife's and health visitors are trained to look out for. However, depression in parents can occur at any point in the parenting journey, from pregnancy onwards, and in dads as well as mums.
Parenting can be very stressful, from sleepless nights with a baby, to worrying about the antics of a teenager. Some things can add additional stress such as parenting a child with a disability16 or being a single parent17.
However, there are also things that may reduce the risk such as having family and friends around for support.
[This page is currently under construction. The evidence base for the other risk factors will be added shortly.
Apologies for any inconvenience this may cause. If you are looking for specific information, please email our Knowledge Exchange Officer email@example.com ]
Much of our research focuses on gaining a better understanding of how these factors interact.
[Download a copy of the poster: Risk Factors Poster (PDF)]
[Poster Text: Who is at risk of mental ill-health?
The development of mental illness is rarely, if ever, caused by a single risk factor.
It is a complex set of interactions, that researchers are still trying to understand.
These are genetic factors that make people more or less susceptible to mental illness.
Mental health is 'polygenic' - it depends on many hundreds of genes acting together.
Even a gene that is strongly associated with mental ill-health only increases a person's risk by a very small amount.
These are external to the person and relate to the world in which they live and function e.g.
- Stressful life events (e.g. a death in the family)
- Early childhood trauma
- A physical health condition
- Having children
- Living arrangements
- Low household income.
Women are more likely than men to experience common mental health conditions such as anxiety or depression.
Most things that affect your physical health can also affect your mental health e.g.
- poor sleep quality
- poor diet/overweight
- Alcohol or drug misuse
Some things help us bounce back from hard times e.g.
- Close family and friends
- Ripke, S. et al. Major depressive disorder working group of the psychiatric GWAS Consortium. A mega-analysis of genome-wide association studies for major depressive disorder. Mol. Psychiatry 18, 497–511 (2013).
- Sullivan, P. F., Neale, M. C. & Kendler, K. S. Genetic epidemiology of major depression: review and meta-analysis. Am. J. Psychiatry 157, 1552–1562 (2000).
- Salk, R. H., Hyde, J. S., & Abramson, L. Y. (2017). Gender differences in depression in representative national samples: Meta-analyses of diagnoses and symptoms. Psychological bulletin, 143(8), 783–822. https://doi.org/10.1037/bul0000102
- Melissa Tracy, Frederick J. Zimmerman, Sandro Galea, Elizabeth McCauley, Ann Vander Stoep. What explains the relation between family poverty and childhood depressive symptoms?, Journal of Psychiatric Research, Volume 42, Issue 14 (2008), Pages 1163-1175, https://doi.org/10.1016/j.jpsychires.2008.01.011
- D.P. Chapman, C.L. Whitfield, V.J. Felitti, S.R. Dube, V.J. Edwards, R.F. Anda Adverse childhood experiences and the risk of depressive disorders in adulthood J. Affect Disord., 82 (2004), pp. 217-225 https://doi.org/10.1016/j.jad.2003.12.013
- V.J. Felitti, R.F. Anda, D. Nordenberg, D.F. Williamson, A.M. Spitz, V. Edwards, M.P. Koss, J.S. Marks Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study Am. J. Prev. Med., 14 (1998), pp. 245-258 DOI: 10.1016/s0749-3797(98)00017-8
- FRANKO, D., STRIEGEL-MOORE, R., BROWN, K., BARTON, B., McMAHON, R., SCHREIBER, G., . . . DANIELS, S. (2004). Expanding our understanding of the relationship between negative life events and depressive symptoms in black and white adolescent girls. Psychological Medicine, 34(7), 1319-1330. doi:10.1017/S0033291704003186
- PATTON, G., COFFEY, C., POSTERINO, M., CARLIN, J., & BOWES, G. (2003). Life events and early onset depression: Cause or consequence? Psychological Medicine, 33(7), DOI: https://doi.org/10.1017/S0033291703008626
- Chang-Quan H, Zheng-Rong W, Yong-Hong L, Yi-Zhou X, Qing-Xiu L. Education and Risk for Late Life Depression: A Meta-Analysis of Published Literature. The International Journal of Psychiatry in Medicine. 2010;40(1):109-124. doi:10.2190/PM.40.1.i
- Catherine E. Ross, John Mirowsky, Sex differences in the effect of education on depression: Resource multiplication or resource substitution?,Social Science & Medicine, Volume 63, Issue 5, 2006, Pages 1400-1413, https://doi.org/10.1016/j.socscimed.2006.03.013.
- Stephanie L. Burcusa, William G. Iacono. Risk for recurrence in depression,
Clinical Psychology Review, Volume 27, Issue 8, 2007, Pages 959-985,
- Gold, S.M., Köhler-Forsberg, O., Moss-Morris, R. et al. Comorbid depression in medical diseases. Nat Rev Dis Primers 6, 69 (2020). https://doi.org/10.1038/s41572-020-0200-2
- Mazure, C. M. (1998). Life stressors as risk factors in depression. Clinical Psychology: Science and Practice, 5(3), 291–313. https://doi.org/10.1111/j.1468-2850.1998.tb00151.x
- Stephanie L. Burcusa, William G. Iacono, Risk for recurrence in depression, Clinical Psychology Review, Volume 27, Issue 8, 2007, Pages 959-985, https://doi.org/10.1016/j.cpr.2007.02.005.
- Susan A Everson, Siobhan C Maty, John W Lynch, George A Kaplan. Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes, Journal of Psychosomatic Research, Volume 53, Issue 4, 2002, Pages 891-895, https://doi.org/10.1016/S0022-3999(02)00303-3.
- Stephen Gallagher, Ailish Hannigan. Depression and chronic health conditions in parents of children with and without developmental disabilities: The growing up in Ireland cohort study. Research in Developmental Disabilities, Volume 35, Issue 2,
2014, Pages 448-454, https://doi.org/10.1016/j.ridd.2013.11.029.
- Cairney J, Boyle M, Offord D R, · Racine Y. Stress, social support and depression in single and married mothers. Soc Psychiatry Psychiatr Epidemiol (2003) 38 : 442–449 DOI 10.1007/s00127-003-0661-0