Reblogging: The Many Origins of Depression by Dr. Kelly Brogan

Kelly Brogan is a psychiatrist practicing in New York city who approaches depression in a holistic fashion. Not only does she listen to your symptoms, but she takes a wide-angle view of a patient’s life to help each person find the appropriate treatments. I have done a lot of reading on the causes of depression, and based on what I’ve learned, I completely reject the notion of brain-based chemical imbalances. Depression, from all that I have learned, is a much more complex reaction to life-situations than a simple chemical imbalance. I agree with what Kelly says near the end of this article,”…taking a one-size-fits-all antidepressant is like turning off the smoke alarm and ignoring the fire.”  Read on to discover the myriad of causes for the fires inside.

What Is Depression?

Is depression a flat mood, an inability to participate in ‘normal life activities,’ or unexplained bouts of sadness? In spite of its singular clinical classification, depression looks different for each person. Like Leo Tolstoy noted in his famous novel Anna Karenina, “All happy families are alike; each unhappy family is unhappy in its own way.”

While all happy families aren’t necessarily alike, this adage speaks truth in terms of depression. Each person’s depressive symptoms – remember, depression is a symptom, not a disease – depend on their unique circumstances, bodily health, emotional history, and held beliefs. As the serotonin model of depression continues to lose its hold on mainstream psychiatry, a theory of depression as evolutionary mismatch has emerged. In this theory, depression is the result of modern living; we did not evolve in the context of environmental toxins, isolated living, and near-constant stress. Some argue that depression is a response to this mismatch, also called paleo-deficit disorder, and depression is simply a message from our bodies trying to protect us from the madness of the modern world.

However, even the evolutionary mismatch theory of depression relies on the dangerous assumption that all depression is the same: that depression is one disease, with one origin and a universal set of symptoms. Anyone who has been affected by depression will challenge this assumption. Depression can be caused by a constellation of factors that cause chronic inflammation – inflammatory foods, medications like the birth control pill, reduced sunlight exposure, and loneliness, to name a few – and manifest differently in different people. Some of the symptoms that qualify a person for a diagnosis of depression seem downright paradoxical: increased and decreased appetite, insomnia or fatigue, motor agitation or impairment. Even in one person, different depressive symptoms can appear at different times.

A recent scientific review article entitled ‘Depression subtyping based on evolutionary psychiatry: Proximate mechanisms and ultimate functions’ attempts to re-classify depression into twelve subtypes.1 For each of these subtypes, researchers propose different causes for depressive symptoms, as well as potential reasons that these subtypes evolved and purposes they serve. In this framework, depression may be (1) an beneficial adaptation that effectively addresses a specific problem (2) an adaptation that does not solve the problem (3) a byproduct of other adaptations or (4) a general pathological state that serves no purpose and is harmful.

The proposed twelve subtypes of depression

Twelve Causes of Depression, Explained by Scientists

In infection-induced depression, symptoms result from underlying inflammation. This classification is supported by studies showing that anti-inflammatory agents reduce symptoms of depression.2 Further, the ‘sickness behavior’ of chronic inflammation, including social withdrawal, might worsen depression.

Long-term stress activates the immune system, leading to chronic inflammation that creates depressive symptoms. Why would stress activate the immune system? For a good reason, actually – in our evolutionary history, stress meant a higher chance of being wounded, and our immune systems ramped up to protect from infections that could result from those wounds. But nowadays, stress is rarely caused by true danger. Instead, stress comes from working long hours (against circadian rhythms), feeling pressured to meet deadlines, and financial worries.3 The response of inflammation to stress seems to be an evolutionary mismatch; the immune response that served us for centuries is no longer beneficial.

In the ancestral world, loneliness literally meant death. If you were separated from the tribe, you were vulnerable to predators and other forces of nature. Loneliness is a powerful and protective message that impels us to seek the company of others, which was crucial to survival for many generations. While loneliness is admittedly less dangerous now, this fear remains imprinted on us and leads to loneliness-induced depression.

People who have experienced significantly traumatic events are more likely to be diagnosed with depression, which researchers call trauma-induced depression. In fact, one study of almost 700 randomly-selected patients with depression found that 36% of them were also diagnosed with post-traumatic stress disorder (PTSD),4 and a large meta-analysis of 57 studies revealed that the comorbidity of depression and PTSD was 52%.5 Like those suffering from loneliness, people with PTSD show elevated levels of pro-inflammatory markers.6

Depressive symptoms can result from conflicts in modern hierarchies, such as the workplace, social groups, and families. Humans and social animals establish hierarchies, and those at the top enjoy many benefits. Therefore, we all want to be at a comfortable hierarchical position to meet our needs. If we don’t reach our desired place in the hierarchy, our self-esteem suffers.

Hierarchy conflicts, such as unemployment,7 bullying,8 and striving for unreachable career goals9 are all associated with depression.

Grief is a common driver of depression diagnoses. Up to 20% of people who lose a loved one and are grieving are saddled with the label of depression. Even in animals, losing a mate, sibling, or offspring leads to depressive symptoms. 10

Similarly, romantic rejection can cause depressive symptoms. Researchers found that after two months, 40% of people who had been left by their romantic partners showed symptoms of clinical depression.11 The sadness following a breakup may indicate true love and disappointment, and these feelings might also help make more aligned choices in future romantic relationships.

Six months after childbirth, 10-15% of women are diagnosed with postpartum depression. Symptoms of postpartum depression include crying, hopelessness, anger, and loss of interest in the new baby. Many studies indicate that mothers who feel that they are receiving inadequate childcare support from the father or her family are more likely to be diagnosed with postpartum depression.12 That is, a mother’s feelings of overwhelm, tiredness, and depletion are often categorized as postpartum depression. It has been hypothesized that the symptoms of postpartum depression may serve as a signal that the mother requires more support.

Seasonal Affective Disorder (SAD), also called seasonal depression, is a mood disorder that strikes a person at the same time each year, usually in the winter. A person diagnosed with SAD exhibits general fatigue, decreased libido, and increased appetite for starchy foods. SAD is more frequent in people with evening chronotypes, and light therapy can help resolve the symptoms.

Chemically-induced depression is a subtype of depression that results from substance abuse, such as alcohol or cocaine, or a side effect of medications like benzodiazepines. Yes, a side effect of anti-anxiety and antidepressant medications may be more depression. This type of depression appears to resolve when people stop ingesting the drugs or alcohol.13 Furthermore, as many people who feel sad self-medicate with alcohol, alcohol abuse may confound other drivers of depressive symptoms.

Interestingly, evidence is piling up that environmental toxicants, such as heavy metals, neurotoxic compounds, plastics, and pesticides may cause depressive symptoms.14 15

Being diagnosed with a disease like Alzheimer’s, migraine, and cancer increases the risk of also being diagnosed with depression. In fact, almost two-thirds of women who suffer from breast cancer are also diagnosed with depression.16 Of course, the diagnosis of cancer is traumatic and causes many types of anxieties, ranging from financial to emotional, and cancer treatments may cause further injury that adds to the stress burden.

Overall, depression is a meaningless label until you find its personal meaning.

This peer-reviewed article presents 12 research-backed possibilities that could be root cause drivers of depressive symptoms – and there are likely more than twelve. Scientific evidence continues to show that depression is a sign of imbalance, not an inherited genetic condition that you are powerless to change. Imbalances can be caused by inflammatory foods, toxins, medications, life events like trauma, and stress – and taking a one-size-fits-all antidepressant is like turning off the smoke alarm and ignoring the fire. Release the fear and move into curiosity. Commit to lean into your symptoms, realizing that they’re only messages, reduce your toxic exposures, turn down the noise, and explore the root cause of these symptoms for true healing.

References:

  • 1 https://www.ncbi.nlm.nih.gov/pubmed/29051086
  • 2 https://www.ncbi.nlm.nih.gov/pubmed/18073775
  • 3 http://europepmc.org/abstract/med/12821012
  • 4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219856/
  • 5 https://www.ncbi.nlm.nih.gov/pubmed/23696449
  • 6 https://www.ncbi.nlm.nih.gov/pubmed/19780999
  • 7 https://www.ncbi.nlm.nih.gov/pubmed/28359031
  • 8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3926772/
  • 9 http://onlinelibrary.wiley.com/doi/10.1111/j.2044-8341.1970.tb02109.x/full
  • 10 http://press.uchicago.edu/ucp/books/book/chicago/H/bo12233936.html
  • 11 https://www.ncbi.nlm.nih.gov/pubmed/2016673
  • 12 http://www.sciencedirect.com/science/article/pii/S1090513899000161?via%3Dihub
  • 13 https://www.ncbi.nlm.nih.gov/pubmed/16930163
  • 14 https://www.ncbi.nlm.nih.gov/pubmed/18621076
  • 15 https://www.ncbi.nlm.nih.gov/pubmed/26987761
  • 16 http://www.europsy-journal.com/article/S0924-9338(07)01398-3/abstract

Reblogging: Are You Better Off Medication-Free?

A few weeks back, I posted my story of being overmedicated and getting off of pain medication and psychiatric drugs.  So when I read the blog post below, I thought it was a good follow-up to my story. I, too, was a victim of polypharmacy, which is why this post resonated with me. What is polypharmacy?  Here is a definition that is included in Dr. Brogan’s post below:

Polypharmacy is ambiguously defined as the prescription of 2-11 or more medications, simultaneously, 6 encompassing more than half of the American population. 7

For those of you who are interested in exploring this topic further, Dr. Brogan includes links to a lot of good resources. If you what to read my story of overmedication, here  is the link to the blog post–How Methadone Saved My Life–and if you prefer to listen,  here is a link to the the audio of my performance at Stoop Stories.

Deprescribing: Are You Better Off Medication Free?

I know that strategic medication tapering can be a ticket to an authentic experience of yourself. I get feedback like this, every week:

Is Gloria some kind of freak anomaly of someone who could possibly feel better off medication? You can see that part of her process was shifting out of a mindset that she was fundamentally broken, in need of medication as some sort of normalcy prop. I believe deeply in personal reclamation through a rewriting of this story of the broken self. But what if medications actually contribute to a poorer quality of life, not because of their metaphysical role in self-identity and outsourcing of power, but simply because of their toxicity, particularly in combination?

The Problem With Pills

We know that it’s not a matter of opinion, (despite what the NY Post would have you think!), that medications – properly prescribed – are the third leading cause of death in this country. 1 This does not include the quarter of a million deaths from medical errors 2 3and overdose, which in 2016 killed more than the entire Vietnam War. 4

These reasons and more are why I was delighted to read Poly-deprescribing to treat polypharmacy: efficacy and safety 5 in the journal Therapeutic Advances in Drug Safety. This longitudinal, prospective trial addresses the major symptom of our fragmented, specialist-driven, the left-hand-doesn’t-know-what-the-right-is-doing-health care system: polypharmacy.

Polypharmacy is ambiguously defined as the prescription of 2-11 or more medications, simultaneously, 6 encompassing more than half of the American population. 7

The author, Garfinkel, states that the epidemic of polypharmacy is driven by:

(1) the increased number of doctors/specialists and clinical guidelines; (2) the lack of evidence-based medicine (EBM) and knowledge regarding drug–disease–patient interactions in polymedicated; (3) barriers/ fears of medical doctors to deprescribe.

His study was conducted on patients >66 years old taking >6 prescriptions (never mind the 666!), and this intrepid clinician endeavored to offer them the opportunity to discontinue more than 3 of their meds, strategically assessing quality of life parameters.

Getting Free, One Med At A Time

After approximately four years, Garfinkel found that: Overall, 57.4% of PDP patients/ families reported an improvement as early as 1 month after the intervention. In 82.8% health improvements occurred within 3 months of the intervention and among 68% improvement persisted for more than 2 years.

Like the parable of the blind men and the elephant, feeling and describing only their part, neglecting the comprehensive appreciation of the whole animal, Garfinkel states:

…all too often specialists who treat patients ‘by their book’ have but one aim, to deal with their one aspect of the disease spectrum; no in depth consideration of the ultimate effects of medications they prescribe combined with other consultant’s interventions on patients’ overall welfare.

He also references the domino effect of prescription toxicity leading to new diagnoses and new medications, stating:

“The problem is further aggravated due to ‘prescription cascades’ where symptoms resulting from ADEs are perceived as representing ‘new diseases’.”

So, it turns out that when real life studies assess the effects of medications, stopping them – several if not all of them – can lead to a better quality of life.

I love his hopeful message, in conclusion:

Conclusions: This self-selected sample longitudinal research strongly suggests that the negative, usually invisible effects of polypharmacy are reversible. Poly-deprescribing] is well tolerated and associated with improved clinical outcomes, in comparison with outcomes of older people who adhere to all clinical guidelines and take all medications conventionally. Future double-blind studies will probably prove beneficial economic outcomes as well.

The study doesn’t particularly reference psychiatric medications (in fact, he references starting them during the study window), which, in my opinion, are the most difficult chemicals on the planet to detox from. While I acknowledge that the physiologic relief from discontinuing a medication may, itself, result in near-immediate improvement in quality of life, psychiatric medication taper seems to ask something more of patients intending for a medication-free life. The taper process asks for healing. Physical, emotional, and spiritual…and this healing does more than improve quality of life…it sets you free.

References:

  • 1 https://www.ncbi.nlm.nih.gov/pubmed/25355584
  • 2https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
  • 3 https://www.ncbi.nlm.nih.gov/books/NBK225187/
  • 4 https://www.vox.com/policy-and-politics/2017/6/6/15743986/opioid-epidemic-overdose-deaths-2016
  • 5 http://journals.sagepub.com/doi/abs/10.1177/2042098617736192
  • 6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635569/
  • 7 https://newsnetwork.mayoclinic.org/discussion/nearly-7-in-10-americans-take-prescription-drugs-mayo-clinic-olmsted-medical-center-find/