The Depression Cure

Got Chemical Imbalance? What Big Pharma Doesn't Advertise

Stephen Ilardi, Ph.D. — Mon, 10 Aug 2009 15:26:59 +0000

A prospective patient recently asked me if her depression might involve some form of chemical imbalance. Like most Americans, she had seen hundreds of drug ads trumpeting the idea, but they filled her with a deep sense of helplessness. "I really don't want to take antidepressants," she explained. "And yet if there's truly something wrong with my brain chemistry, I'd pretty much have to get on meds, wouldn't I?"

She had aptly framed the conventional wisdom: Got chemical imbalance? Then you need to ingest some chemicals.

But the conventional wisdom is misguided. Yes, depression entails striking neurochemical abnormalities, but this fact - in and of itself - tells us nothing about how best to treat the disorder. That's because there are numerous ways of altering depressive brain function, and most of them have nothing to do with psychotropic drugs.

Consider the effects of exercise. Even moderate physical activity - brisk walking three times a week - has been shown in two landmark studies to fight depression as effectively as Zoloft. Simply put: exercise changes the brain. It enhances the function of dopamine-based circuits that mediate our experience of pleasure, along with our ability to initiate activity. Likewise, physical exercise stimulates the brain's synthesis of BDNF, a growth hormone that guides the repair of damaged neurons and triggers the sprouting of new neuronal connections. Because BDNF levels plummet in depression, the disorder actually leads, over time, to atrophy of the brain's memory and reasoning centers. But exercise carries the potential to help reverse depression's neurotoxic imprint.

Neurological function is also critically affected by diet. For example, a deficiency of omega-3 fatty acids - key building blocks of brain tissue - has been strongly linked to depressive illness, in part because omega-3 fats facilitate the brain's use of "feel good" neurochemicals such as serotonin and dopamine. Omega-3s also serve as raw material for the body's construction of anti-inflammatory hormones, which help calm the cerebral inflammation that often characterizes depression. Accordingly, high-dose omega-3 supplements, typically in the form of fish oil, have been shown in multiple trials to exert a potent antidepressant effect.

Bright light exposure represents yet another proven strategy for altering brain chemistry. Specialized light receptors in the retina connect to circuits deep in the brain that regulate circadian rhythm. And sunlight - over 100 times brighter than typical indoor lighting - is the prime stimulator of the eyes' photoreceptors: it triggers a cascade of neurochemical reactions that help keep the "body clock" in synch. On the other hand, prolonged sunlight deprivation leads to depressive disruptions in biological rhythms that govern sleep, appetite, energy, and mood. Fortunately, regular bright light exposure - either via sunlight or specially designed light boxes - can restore healthy circadian function to the brain. Over a dozen published studies support its efficacy in the treatment of depression.

Then again, one of the most effective ways of changing the brain is simply to change the mind. This fact often surprises people, but it really shouldn't, because modern neuroscience has convincingly demonstrated that mind and brain are flip sides of the same underlying reality. In the oft-quoted words of Marvin Minsky, "the mind is what the brain does." Thus, by definition, any alteration of thoughts or feelings is reflected in corresponding shifts in brain activity.

Yet we in the West are the intellectual heirs of Cartesian dualism - a belief that mind and body are radically distinct, unrelated entities - and this legacy often renders the insights of neuroscience difficult to accept. Thus, it can be downright jarring to hear the psyche touted as a direct path to the inner workings of our neurochemistry. That's why so many were shocked by recent news accounts of changes in brain function among patients in psychotherapy for depression: if you're a dualist, there's no conceivable mechanism through which mere talking could possibly affect the brain.

Of course, pervasive mind-body dualism also helps explain why Big Pharma's mantra of "chemical imbalance" remains such an effective marketing strategy for the sale of its products. Too bad it's a strategy predicated on scientific illiteracy.

Stephen Ilardi is an associate professor of psychology at the University of Kansas and author of The Depression Cure: The Six-Step Program to Beat Depression without Drugs.

Dietary Sugar and Mental Illness: A Surprising Link

Stephen Ilardi, Ph.D. — Thu, 23 Jul 2009 15:49:22 +0000

Noted British psychiatric researcher Malcolm Peet has conducted a provocative cross-cultural analysis of the relationship between diet and mental illness. His primary finding may surprise you: a strong link between high sugar consumption and the risk of both depression and schizophrenia.

In fact, there are two potential mechanisms through which refined sugar intake could exert a toxic effect on mental health.

First, sugar actually suppresses activity of a key growth hormone in the brain called BDNF. This hormone promotes the health and maintenance of neurons in the brain, and it plays a vital role in memory function by triggering the growth of new connections between neurons. BDNF levels are critically low in both depression and schizophrenia, which explains why both syndromes often lead to shrinkage of key brain regions over time (yes, chronic depression actually leads to brain damage). There's also evidence from animal models that low BDNF can trigger depression.

Second, sugar consumption triggers a cascade of chemical reactions in the body that promote chronic inflammation. Now, under certain circumstances (like when your body needs to heal a bug bite), a little inflammation can be a good thing, since it can increase immune activity and blood flow to a wound. But in the long term, inflammation is a big problem. It disrupts the normal functioning of the immune system, and wreaks havoc on the brain.

Inflammation is associated with an increased risk of heart disease, diabetes, arthritis, and even some forms of cancer . . . it's also linked to a greater risk of depression and schizophrenia. And again, eating refined sugar triggers inflammation. So does eating heavily processed molecular cousins like 'high fructose corn syrup'.

If you think about it, it makes sense that our bodies don't handle refined sugar very well. After all, for the vast majority (99.9%) of our existence as a species, there simply was no such sugar. We were endowed with a sweet tooth so that we'd crave the highly nutritious fruits that were available - sometimes in short supply - in the ancestral environment. But with the advent of processed sugar cane a few centuries ago, the blessing of our formerly adaptive sweet tooth suddenly turned into a curse - causing us to crave foods that we were simply never designed to process.

As I've become increasingly convinced by these research data, I've begun gently encouraging my depressed patients to simply try cutting out sugars for a couple of weeks to see if they notice any effect. (I also ask them to cut out simple starches - like crackers and white bread - which the body converts directly to sugars). A few have had the courage and determination to given it a go: they're reported remarkable improvements in mood, energy, and mental clarity.

OCD Treatment: As Good As It Gets?

Stephen Ilardi, Ph.D. — Mon, 20 Jul 2009 19:47:14 +0000

I got a call from a psychiatrist colleague of mine a while back. He was an old-school Freudian psychoanalyst who had his patients come in twice a week to lie on a couch, talk about their dreams, free-associate about childhood experiences, and so on. Although this type of treatment might be useful for some patients - especially those who wish to better understand and change troublesome personality patterns - it has not always been strongly supported by research.

As it turned out, the psychiatrist was calling to ask if I would take on one of his patients who suffered from obsessive-compulsive disorder (OCD) - a debilitating mental illness that afflicts about 2% of the population - wonderfully depicted by Jack Nicholson in the film, As Good As It Gets. The psychiatrist had already been treating this distraught young man for over 4 years, but his OCD symptoms actually worsened over that span of time. Since there's no good scientific evidence that Freudian psychoanalysis is an effective treatment for OCD, I wasn't terribly surprised.

Fortunately, during my grad school training at Duke, our instructors and supervisors emphasized the importance of asking, for each form of mental illness: which of the hundreds of possible treatments are most strongly supported by the research evidence?

For OCD, this is a no-brainer: a form of behavior therapy called exposure and response prevention (sometimes called exposure and ritual prevention) has outperformed other treatments (including meds) in the clear majority of relevant outcome trials.

To get some idea of the potency of behavior therapy for OCD, consider the results of the largest OCD comparative outcome study to date, sponsored by the National Institutes of Mental Health. The study pitted behavior therapy against a drug called Anafranil (clomiprimine), arguably the most effective OCD medication currently on the market. Here were the observed rates of favorable treatment response:

Behavior Therapy: 86%
Anafranil: 48%
Placebo: 10%

Notice that OCD is such a severe disorder that it has a minimal placebo response . . . it takes much more than placebo-induced positive expectancies to cure this particular illness. And even though Anafranil certainly outperformed the placebo in this study (48% to 10%), behavior therapy was considerably more effective (with a whopping 86% response rate). In fact, it wasn't even a close call.

There's a genuine tragedy, though, embedded in these numbers: many OCD patients will never even know that behavior therapy exists. While some will waste their time and money on ineffective forms of psychotherapy, most OCD patients will simply be told that they have a 'chemical imbalance', handed a prescription of Anafranil or a similar medication, and told in effect, "this is as good as it gets".

Sadly, it's hard to get the word out about behavior therapy for OCD. Few mental health reporters understand the field well enough to do the story. Drug companies have multimillion dollar budgets to promote their products - for better and for worse - whereas psychotherapists skilled in behavior therapy for OCD are small in both numbers and financial resources. (To find such a therapist near you, try contacting the Center for Anxiety and Related Disorders.)

In case you're wondering . . . within 4 months of my taking on the aforementioned OCD patient and treating him with standard behavior therapy, his symptoms were in remission. I've seen it repeatedly over the course of my career, and I'm not a particularly gifted psychotherapist (clinical research is my main gig), nor is OCD my area of specialty.

So lately, whenever I see an antidepressant commercial, I find myself thinking, "If only someone had the money for a series of slick commercials about behavior therapy! We've got to find a way to tell the 6 million OCD sufferers that there's a potentially more efficacious treatment out there - one (alas) that many have never even heard of."

Social Isolation: A Modern Plague

Stephen Ilardi, Ph.D. — Tue, 14 Jul 2009 00:23:33 +0000

The best research confirms it: Americans are now perilously isolated. In a recent comprehensive study by scientists at Duke University, researchers have observed a sharp decline in social connectedness over the past 20 years.

Remarkably, 25% of Americans have no meaningful social support at all - not a single person they can confide in. And over half of all Americans report having no close confidants or friends outside their immediate family. The situation today is much worse today than it was when similar data were gathered in 1985. (At that time, only 10% of Americans were completely alone).

How could this happen? It's hundreds of little things. You can probably think of several off the top of your head: the longer work hours, the Internet, the ubiquitous iPod . . . and don't forget all the time spent sitting in traffic.

According to Robert Putnam, sociologist and author of the influential book, Bowling Alone, for every 10 minutes added to commute time, there's a roughly 10% decrease in social ties.

But we're truly not designed to live like this. For the great majority of human history, people resided in small, intimate hunter-gatherer communities. And anthropologists who spend time with modern-day hunter-gatherer bands report that social isolation and loneliness are largely unknown among them: group members spend the bulk of their time - virtually all day, every day - in the company of friends and loved ones.

Even Americans of a few generations ago used to benefit from a richness of community life that has all but disappeared, as we've witnessed a long, slow retreat into the hermetically sealed comfort of our fortress-like homes . . . deep friendships replaced by screens, gadgets, and exhausted couch-potato stupor.

The toll? Increased vulnerability to mental illness. Social isolation is a huge risk factor for the onset of major depression, which has more than doubled in prevalence over the past decade. And there's growing evidence that isolation increases vulnerability to various forms of addiction, as well.

In a future post, I'll discuss several strategies for enhancing social connection that I've outlined in a recent book. But here's a useful first step: Resolve to live each day as if your relationships are your highest priority. We all say that our loved ones matter to us far more than our work, our status, our things; but it's important that this sentiment truly be reflected in our allocation of time and energy.

Depression: Tragically Misunderstood

Stephen Ilardi, Ph.D. — Sun, 05 Jul 2009 17:52:00 +0000

Depression is one of the most tragically misunderstood words in the English language. Why? The term has two starkly different meanings, depending upon the context.

Among clinicians, depression is shorthand for a debilitating syndrome - major depressive disorder - that robs people of their energy, their concentration, their memory, their restorative sleep . . . their ability to love and work and play. The disorder actually lights up the brain's pain circuitry, inducing a state of suffering far exceeding that of any physical discomfort. As one of my patients told me, "if I could give up my right arm - literally, have it amputated - to escape the pain of depression forever, I would take that deal in a heartbeat."

To make matters worse, depression is neurotoxic. By suppressing levels of a key neural growth hormone (BDNF), the disorder leads to the eventual death of neurons in critical memory and reasoning areas of the brain, including the hippocampus and prefrontal cortex. Simply put: depression causes brain damage.

And yet when people refer to depression in everyday conversation, they usually have something far less serious in mind. In fact, the term typically serves as a synonym for mere sadness. For example, I've heard people talk about feeling "depressed" after ripping a hole in a new pair of jeans, or even after missing an episode of their favorite TV show. Such dysphoria - while unpleasant - is simply part of the human condition, a hard-wired reaction to negative life events. But it has little effect on our ability to function, and it rarely lasts for long. A little encouragement and support from loved ones is normally all it takes to restore our emotional equilibrium.

In contrast, clinical depression often persists for months on end, and a friendly word of support is simply not enough to loosen its suffocating grip. That's where the tragic confusion ensues. For when those suffering from depression confide their diagnosis to friends and family, they're often met with relative indifference, born of the assumption that the patient is afflicted with mere sadness - a condition from which they can quickly and easily recover. As a result, depressed patients are often encouraged to snap out of it. No one would dream of offering such cruel and ridiculous "advice" to someone diagnosed with cancer or heart disease; the admonition is equally inappropriate in the case of depression.

A few years ago, one of my patients suggested, "You shrinks really need to come up with a better name for this disease. Depression doesn't begin to describe what it's like, and the word is just way too confusing for people." I couldn't agree more. At least back in Freud's day - despite the field's many obvious shortcomings - clinicians actually had a precise technical term for depressive illness: melancholia. Perhaps it's time we brought this venerable term back into vogue - or coined an even better one. Such a simple step might go a long way toward increasing compassion for the millions who battle this devastating disorder.