What is Depression?
A Mind of Your Own (Harper Wave, 2016) by Kelly Brogan, MD with Kristin Loberg explains that depression and anxiety are not diseases, but rather symptoms. Brogan is revealing this information to rescue the more than 23 million women considering or taking antidepressants. Brogan outlines a 30-day plan that will enable anyone struggling with depression to finally take control of their mental and physical health. This excerpt comes from chapter 1, “Decoding Depression.”
Psychiatry, unlike other fields of medicine, is based on a highly subjective diagnostic system. Essentially you sit in the office with a physician and you are labeled based on the doctor’s opinion of the symptoms you describe. There are no tests. You can’t pee in a cup or give a drop of blood to be analyzed for a substance that definitely indicates “you have depression” much in the way a blood test can tell you that you have diabetes or are anemic.
Psychiatry is infamous for saying “oops!” It has a long history of abusing patients with pseudoscience-driven treatments and has been sullied by its shameful lack of diagnostic rigor. Consider, for example, the 1949 Nobel Prize winner Egas Moniz, a Portuguese neurologist who introduced invasive surgical techniques to treat people with schizophrenia by cutting connections between their prefrontal region and other parts of the brain (i.e., the prefrontal lobotomy). And then we had the Rosenhan experiment in the 1970s, which exposed how difficult it is for a doctor to distinguish between an “insane patient” and a sane patient acting insane. Today’s prescription pads for psychotropic drugs are, in my belief, just as harmful and absurd as physically destroying critical brain tissue or labeling people as “psychiatric” when really they are anything but.
My fellowship training was in consultation-liaison psychiatry, or “psychosomatic medicine.” I was drawn to this specialization because it seemed to be the only one that acknowledged physical processes and pathologies that could manifest behaviorally. I noticed that psychiatrists in this field appreciated the role of biological actions such as inflammation and the stress response. When I watched fellow psychiatrists consult on surgical patients in the hospital, they talked about these processes much differently from when they saw patients in their Park Avenue offices. They talked about delirium brought on by electrolyte imbalance, symptoms of dementia caused by B12 deficiency, and the onset of psychosis in someone who was recently prescribed antinausea medication. These root causes of mental challenges are far from the “it’s all in your head” banter that typically swirls around conversations about mental illness.
The word psychosomatic is a loaded and stigmatized term that implies “it’s all in your head.” Psychiatry remains the wastebasket for the shortcomings of conventional medicine in terms of diagnosing and treating. If doctors can’t explain your symptoms, or if the treatment doesn’t fix the problem and further testing doesn’t identify a concrete diagnosis, you’ll probably be referred to a psychiatrist or, more likely, be handed a prescription for an antidepressant by your family doctor. If you are very persistent that you still need real help, your doctor might throw an antipsychotic at you as well. Most prescriptions for antidepressants are doled out by family doctors — not psychiatrists, with 7 percent of all visits to a primary-care doctor ending with an antidepressant prescription. And almost three-quarters of the prescriptions are written without a specific diagnosis. What’s more, when the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health did its own examination into the prevalence of mental disorders, it found that “Many individuals who are prescribed and use antidepressant medications may not have met criteria for mental disorders. Our data indicate that antidepressants are commonly used in the absence of clear evidence-based indications.”
I’ll never forget a case I consulted on several years ago that involved “psychosomatic” facial burning in a woman. Her story is insightful. She complained of an intense burning sensation in her face, though there was no explanation for it other than it being “all in her head.” Her symptoms were so disabling that she was barely able to function. I was still prescribing psychotropics at the time, but a voice inside of me knew there was something real going on, and it wasn’t at all in her head. But unfortunately the Western medical model had already labeled her as being a psychosomatic case, which called for psychiatric medication and couldn’t appreciate or even begin to understand the complexity of her condition. Antidepressants and benzodiazepines (tranquilizers including Valium or Xanax) didn’t help her. What ultimately did was dietary change, supplementation, and rebalancing of her bodily flora. Was this all a placebo effect? Clearly she wanted to feel better with such intensity that she would have done anything. But traditional medication didn’t cure her. At the heart of her pain and distress was an immune and inflammatory process that could not be remedied via antidepressants and antianxiety drugs. It was fixed through strategies that got to the core of her problem—that yanked the nail out of her foot and let the injury heal.
The idea that depression and all of its relatives are manifestations of glitches in the immune system and inflammatory pathways — not a neurochemical deficiency disorder—is a topic we will explore at length throughout this book. This fact is not as new as you might think, but it’s probably not something your general doctor or even psychiatrist will talk about when you complain of symptoms and are hurried out of the office with a prescription for an antidepressant. Nearly a century ago, scientific researchers were already exploring a connection between toxic conditions in the gut and mood and brain function. This phenomenon was given the name auto intoxication. But studying such a wild idea fell out of fashion. By mid-century no one was looking into how intestinal health could affect mental health. Instead, the thinking was quickly becoming the reverse — that depression and anxiety influenced the gut. And as the pharmaceutical industry took off in the second half of the twentieth century, gut theories were ignored and the brilliant researchers behind them were forgotten. The gut was regarded as the seat of health in ancient medical practices for centuries; now we can finally appreciate the validity of such old wisdom. Hippocrates, the father of medicine, who lived in the third century BCE, was among the first to say that “all disease begins in the gut.”
A multitude of studies now shows an undeniable link between gut dysfunction and the brain, chiefly by revealing the relationship between the volume of inflammatory markers in the blood (i.e., signs of inflammation) and risk for depression. Higher levels of inflammatory markers, which often indicate that the body’s immune system is on high alert, significantly increase the risk of developing depression. And these levels parallel the depth of the depression: higher levels equates with more severe depression. Which ultimately means that depression should be categorized with other inflammatory disorders including heart disease, arthritis, multiple sclerosis, diabetes, cancer, and dementia. And it’s no surprise, at least to me, that depression is far more common in people with other inflammatory and autoimmune issues like irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, insulin resistance, and obesity. All of these conditions are characterized by higher levels of inflammation.
To really grasp the fact that depression is not a disorder primarily rooted in the brain, look no further than some of the most demonstrative studies. When scientists purposefully trigger inflammation in the bodies of healthy people who exhibit no signs of depression by injecting them with a substance (more on this shortly), they quickly develop classic symptoms of depression. And when people with hepatitis C are treated with the pro-inflammatory drug interferon, as many as 45 percent of those individuals develop major depression.
So when people ask me about why we’re suffering from what appears to be an epidemic of depression despite the number of people taking antidepressants, I don’t think about brain chemistry. I turn to the impact of our sedentary lifestyles, processed food diets, and unrelenting stress. I turn to the medical literature that says a typical Western diet — high in refined carbs, unnatural fats, and foods that create chaos in our blood sugar balance — contribute to higher levels of inflammation. Contrary to what you might assume, one of the most influential risk factors for depression is high blood sugar. Most people view diabetes and depression as two distinct conditions, but new scientific findings are rewriting the textbooks. One game-changing study published in 2010 that followed more than 65,000 women over a decade showed that women with diabetes were nearly 30 percent more likely to develop depression. This heightened risk remained even after the researchers excluded other risk factors such as lack of physical exercise and weight. Moreover, diabetic women who took insulin were 53 percent more likely to develop depression.
Certainly you can draw the same conclusions that I’ve made: the rates of diabetes have skyrocketed alongside those of depression in the past two decades. And so have the rates of obesity, which is also correlated with increased inflammatory markers. Studies show that obesity is associated with a 55 percent increased risk of depression, and it cuts the other way too: depression is associated with a 58 percent increased risk of developing obesity. In the cogent words of a group of Australian researchers in a 2013 paper: “A range of factors appear to increase the risk for the development of depression and seem to be associated with systemic inflammation; these include psychosocial stressors, poor diet, physical inactivity, obesity, smoking, altered gut [function], [allergies], dental [cavities], sleep and vitamin D deficiency.”
In 2014 Scottish researchers addressed the gap between what the science says about the causes of depression and what patients experience when they find themselves caught in the default web of psychiatric care. In their paper they highlight the value of what I practice: psychoneuroimmunology. Indeed, it’s a mouthful of a word, but it simply refers to examining (and respecting) the complex interplay between various systems and organs of the body, especially those that syncopate the nervous, gastrointestinal, and immune systems in a brilliant dance that in turn affects mental well-being. These researchers point out that many patients who are told they have psychiatric conditions originating in their head or related to some (fictitious) brain chemical deficiency actually share real biological imbalances related to their immune-inflammatory pathways. These patients show elevated levels of inflammatory markers in their blood, signs that their body is on the defensive, activating processes that can result in unexplainable physical symptoms and that are diagnosed as psychiatric rather than biologic. And rather than treating the underlying biology, they are instead relegated to a lifetime of therapy and medication, to no avail.
The conditions examined by these researchers were depression, chronic fatigue, and “somatization,” the latter of which is what we call the production of symptoms with no plausible organic cause. These diagnoses have a lot in common in terms of symptoms: fatigue, sensitivity to pain, inability to concentrate, flu-like malaise, and cognitive issues. Isn’t it interesting that each of these conditions is often diagnosed as a separate illness and yet they share so much in common from a biological standpoint? As the authors state: “If psychiatry is to rise to the challenge of being a science, then it must respond to the [existing] data in reconceptualizing boundaries. As such, the data reviewed here challenge the organizational power structures in psychiatry.”
Personalized lifestyle medicine that accounts for the role of the environment in triggering inflammation and the manipulation of the immune and endocrine systems is the most sensible way to approach those individuals who would otherwise be candidates for multiple medications. It turns out that it may not all be in your head — but rather in the interconnectedness among the gut, immune, and endocrine systems.
In upcoming chapters, we’re going to be exploring all of these connections — the indelible links between your gut and its microbial inhabitants, your immune system, and the orchestra of hormones that course through your body in sync with a day-night cycle. These connections influence the state of your entire physiology and, as important, your mental health and overall sense of well-being. While it may seem odd to talk about the gut-based immune system in terms of mental health, the latest science reveals that it may be the body’s — and mind’s — center of gravity. Just as I write this, yet another new study has emerged that overturns decades of textbook teaching about the brain and immune system.
Researchers at the University of Virginia School of Medicine have determined that the brain is directly connected to the immune system by lymphatic vessels we didn’t know existed. That we had no idea about these vessels given the fact that the lymphatic system has been so thoroughly studied and charted throughout the body is astonishing on its own. And such a discovery will have significant effects on the study and treatment of neurological diseases, from autism and multiple sclerosis to Alzheimer’s disease and, yes, depression.
It’s time we rewrite the textbooks. And it’s time we treat depression for what it really is.
So if depression isn’t a disease, then what is it? As I briefly mentioned in the introduction, depression is a symptom, a vague surface sign at best that doesn’t tell you anything about its root cause. Consider, for a moment, that your toe hurts. Any number of things can cause a toe to hurt, from physically injuring it to a bunion, blister, or tumor growing inside. The hurting is a sign that something is wrong with the toe, simple as that. Likewise, depression is the hurting; it’s an adaptive response, intelligently communicated by the body, to something not being right within, often because things are also off in our environment.
Depression doesn’t always manifest with feelings of serious melancholy and sadness or the urge to sit on the couch all day brooding. I can’t even remember the last patient I saw who was like the person you see on a TV commercial for an antidepressant. All of my patients experience anxiety — an inner kinetic discomfort, restlessness, unease, and a lot of insomnia. In fact, most cases of depression involve women who are very much on the go and productive, but they are also anxious, scatterbrained, overly stressed out, irritable, forgetful, worrywarts, unable to concentrate, and feeling “wired and tired” at the same time. And many of them have been dismissed by the medical system; their psychiatric problems were created by mistreatment as they fell into the vortex of endless prescription medications.
Take, for another example, a forty-two-year-old patient of mine we’ll call Jane, who fell into this black hole after being treated for irritable bowel and acne with drugs, including the now discontinued Accutane (isotretinoin). Jane experienced a depressed mood, a common side effect of Accutane, and was then put on an antidepressant as she stopped the medication (isotretinoin is a retinoid, a strong medication used to treat severe acne; it causes birth defects in babies born from mothers who take it during pregnancy, so it’s carefully regulated and only available in its generic form under a special program). After the death of her parents, which triggered more symptoms of depression, Jane was diagnosed with a thyroid problem, and her doctor at the time prescribed radioablation therapy, which destroys thyroid tissue with radioactive iodine 131. This led to her having acute panic attacks, and she soon began taking Xanax. Symptoms of more thyroid problems, including brain fog, extreme fatigue, and physical pain, culminated in a diagnosis of fibromyalgia. Jane was then treated with birth control pills and an antibiotic and soon developed chronic yeast infections, bloating, and abdominal pain. By the time she came to me, Jane had a twenty-four-hour home health aide.
Jane’s experience reflects that of so many people labeled as depressed and sent away with yet another prescription. The system creates patients who are otherwise healthy and just need to recalibrate their bodies using simple lifestyle interventions, mostly around diet — not drugs. After all, it is through diet that we communicate with our environment. It’s a dialect that we’ve forgotten how to speak.
Reprinted with permission from A Mind of Your Own by Kelly Brogan, MD with Kristin Loberg and published by Harper Wave, 2016.
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