Depression may be, as Rollo May famously said, an “inability to construct a future,” but it’s more than just psychology. It’s also a genetic issue. It also involves brain chemicals and toxins we pick up in our industrial environment. It’s about trauma and abuse. And it’s about the immune system and inflammation. It is, in other words, a many-headed hydra that is torturing an estimated 350 million (and growing) people around the world today.
Yet psychiatrists in the U.S. still frequently seek out only one of those dangerously bobbing and weaving constructions of teeth and horn.
Treatment becomes about moving us from one pill to another. Our doctors teach us essentially nothing about the full range of issues that contributed to the onset of our disease or the many paths to recovery researchers and sufferers have mapped out together throughout human history and continue to refine.
At the annual conference of the National Alliance on Mental Illness held in San Antonio last week, University of Tennessee assistant professor of psychiatry Dr. W. Clay Jackson issued a stirring critique of rampant “biological reductionism” dominating his field and urged a shift to a more comprehensive response to depression treatment.
“I think we’ve made two grand mistakes in approaching mental health in this country, maybe three,” he opened Friday’s session. “One of those grand mistakes is we have stigmatized persons who have mental illness and we have separated it from biological illness.”
However in recent years the medical establishment has overcompensated for that body-mind separation by making it all about the pill.
“We’ve overcompensated,” Jackson said, “to say it’s all about a chemical in a slot. So if you find the right peg with the right hole to match up synapses and neurotransmitters everything else is fantastic. So there must be a pill for that.”
In a sweeping overview of depression and its treatments, Jackson made stops at Hippocrates, whose “black bile” of melancholy “comprises all fears and despondences if they last a long time,” and Robert Burton’s Anatomy of Melancholy, which prescribed a healthy diet, meaningful work, proper sleep, music, and time with friends, all of which (well, the type and volume of music may matter) are finding clinical support today.
“Burton hadn’t learned about St. John’s Wort,” Jackson said, “which would have been a wonderful addition to his book but he didn’t get out much.”
Sigmund Freud delivered the notion of childhood to Western minds, allowing for an understanding of childhood trauma, which we now know (including psychic/emotional trauma as well as the dietary variety) is a critical element loading the gun for depression.
While German psychiatrist Emil Kraepelin is a hero of psychiatry for making way for groundbreaking contributions in how the human body relates to mental illness, his “tragic flaw,” according to Jackson, was in leaving in the dust 5,500 years of accumulated depression-related wisdom.
“It’s led to an explosion of pharmacotherapeutic options, but it’s led to a relative paucity of non-pharmacologic options for patients to follow – or at least non-traditional, non-allopathic options,” Jackson said.
But Jackson offered a unique gift to those crowds Friday by not only summarizing the high points of depression research and treatment but by offering a synthesis of that research.
Regarding genetics, he reminded folks that there is “no one” depression gene. “There are probably 1,700 depression genes and they all interact,” he said. And even then it is the environment and “early life adversity” that is believed to turn them on or off.
“Until about 10 years ago, we thought life was like five-card draw, Texas Hold ‘Em,” he said. “You get dealt your cards and those are your cards, you cannot exchange them. What we now know is you can actually turn your cards on or off by the environment that is set.”
That early destabilization does a number of things. It creates an atmosphere of inflammation that causes the immune system to go rogue, leading often to a raft of health issues. It puts people in a fragile emotional state so that events of seemingly mild significance send them into a tailspin. And, over time, that depression damages glial cells, responsible for clearing out glutamate (which is neurotoxic in excess), making GDNF (which supports healthy neurons and helps them connect), and controling glucose metabolism (the brain’s fuel). And depression is “probably” neuro-degenerative in its final stages.
Meaning for stigmas destroyers: “It makes as much sense [to blame depressives for their condition] as walking into an ICU and telling a post-coronary patient, ‘This is your fault. You gotta think better. Snap out of it, fella. What’s wrong with your coronary arteries?’ Because it is biologically driven, but it is environmentally and personality informed.”
Finally, depression causes the hippocampus to shrink, making the hypothalamic-pituitary-adrenal axis less effective and less able to put the brakes on the stress response, leaving damaging cortisol to flood the body.
Low levels of social support compound those early risk factors that so frequently lead to inflammation, which leads to cortisol and insulin going up, and things like hyperglycemia and weight gain, which in turn hobbles the effectiveness of anti-depressants. “There’s a reason depressant patients feel more pain,” Jackson said. “There’s a reason they have more illness or sickness behavior. There’s a reason they have fatigue. It’s like they have the mother of influenza all the time. Their inflammatory processes are rampant.”
It’s worth considering that the Greeks positioned the soul not in the heart (or the head), but in the stomach, where there are an equivalent number of primary neurons as inhabit the brain. Another challenge to psychiatry to expand their lens, it would seem.
The STAR*D study — the most comprehensive depression study to date — found that only 33 percent of sufferers respond after the first treatment of meds. By adding multiple other treatments, including more meds or cognitive behavioral therapy, for instance (“throwing rocket fuel at the brain,” in Jackson’s parlance), only about two-thirds achieve remission.
“There are types of metastatic cancer where we do better than this,” he said. “We are not succeeding. I am proposing it’s not because we don’t have better anti-depressants. I am proposing there is some stigma that associated with our model that needs to change and some of our approaches need to change.”
It is time, in other words, to move beyond the genetic-neurotransmitter deficit model of treatment and begin to treat depression as a multi-dimensional disorder.
That means pills, yes, typically, but also dietary changes, nutritional supplements, exercise, meditation, and more.
Among less-heralded approaches live some perhaps surprising results. Yoga nidra increases dopamine creation by 65 percent. Yoga asana has been shown to increase dopamine creation by 20 percent. Another field recognizes the contribution of “nutraceuticals” such as SAM-E (Adenosylmethionine) and L methylfolate (Levomefolic acid): required precursors for the generation of blessed seratonin, dopamine, norepinephrine, and melatonin. (And my personal experience suggests that electromagnetic health is another evolving consideration — avoiding areas of so-called electro-smog, for instance.)
“What we need are clinicians courageous enough to say, ‘This stuff is actually pretty complex that you got going on here, but I’m going to journey with you through this process.’ We need patients who are self-aware enough to say, ‘I’m going to take a pill. I’m going to take a supplement. But I’m also gonna exercise. I’m also gonna meditate. I’m also gonna get a $9.99 app for my iPhone that will remind me once a day to be grateful for something. And my gratefulness app is gonna improve my affect because I know that works as well as a pill in helping me in terms of my inflammatory disorder.”
And Jackson’s credentials? You can judge him by the string of letters behind his name (M.D., DipTh, FAAFP), his frequent speaking engagements, or his Southern bonafides as a child of the Blues (Country).
Tennessee, you may not realize, has long contributed to our understanding of depression. B.B. King’s song “The Thrill is Gone,” Jackson opened his talk insisting, is about anhedonia and lack of dopamine, for instance; while the Soggy Bottom Boys’ “I’m a Man of Constant Sorrow” is about recurrent depression.
“Our psychic pain,” Jackson said, “is your cultural gain.”
The home of Nashville may just repair the damage it’s wrought through this thing called “New Country” after all.
If you absolutely positively must have more depression science, check this page from Harvard Health Publications. They’re Yankees, true, but somehow they still crank out a few good ideas now and again, even without all the harmonizing.