A Mind of Your Own: The Truth About Depression and How Women Can Heal Their Bodies to Reclaim Their Lives

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, a topic we’ll get into in Chapter 3 (#u3ee4227e-2da8-5b13-b30d-73799d008e0e).

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.

AN EVOLUTIONARY MISMATCH

Take a look around you and appreciate the world we live in today with its technologies and conveniences: computers, cars, cell phones, and supermarkets. But also consider the mismatch between this scenario and the days when we had to forage for our food and sleep under the stars. Our caveman days are still very much a part of our DNA because evolution is slow; what seems like ages in cultural time (20,000 years ago) is but a blink of an eye in biological time. Which brings me to ask the question: Is all this depression simply a sign of an evolutionary mismatch?

This is the term that encompasses the source of most modern ills. We are engaged in lifestyles that are not compatible with what our genome has evolved over millions of years to expect. We eat a poor diet, harbor too much stress, lack sufficient physical movement, deprive ourselves of natural sunlight, expose ourselves to environmental toxicants, and take too many pharmaceuticals. Our wayward departure is marked by two specific revolutions in the history of mankind: the Neolithic, or agricultural, Revolution and the Industrial Revolution. For 99 percent of our existence, we followed the so-called Paleolithic diet, which is devoid of inflammatory and “insulinotropic” foods like sugar, grains, and dairy. Our body’s microbial ecology has been one of the primary victims of this shift—­the 90 percent of our cells that are non-human in nature and that account for the majority of our body’s activities, which in turn impact the expression of our genes. I’ll be going into greater depth about the human microbiome in Chapter 3 (#u3ee4227e-2da8-5b13-b30d-73799d008e0e), but I’ll give you a short primer here because this discussion is important and will be carried throughout the book.

Although we’ve learned to think of bacteria as agents of death for the most part because certain strains can cause lethal infections in compromised hosts, new science is compelling us to consider how some of these microscopic bugs are fundamental to life—­and mental health. As you read this, some 100 trillion microbes are colonized in your intestines alone.

They outnumber your own cells by a factor of about ten, covering your insides and outsides. And they contain estimates of more than 8 million genes of their own, which means that fully 99 percent of the genetic material in your body is not your own. It belongs to your microbial comrades. These microbes not only influence the expression of our DNA, but research reveals that throughout our evolution microbial DNA has become part of our own DNA. In other words, genes from microbes have inserted themselves into our genetic code (mitochondrial DNA being the prime example) to help us evolve and flourish.

A great many of these invisible creatures live within your digestive tract, and while they include fungi, parasites, and viruses, it’s the bacteria that appear to hold the proverbial keys to the kingdom of your biology, as they support every conceivable feature of your health. In the future we’ll likely see how the other microbes contribute at least as much to our health as bacteria do. The microbiome is so crucial to human health that it could be considered an organ in and of itself. In fact, it has been suggested that since without it we could not live, we should consider ourselves a “meta-organism,” inseparable from it. This inner ecology helps you digest food and absorb nutrients, supports the immune system and the body’s detoxification pathways, produces and releases important enzymes and substances that collaborate with your biology (including chemicals for the brain, such as vitamins and neurotransmitters), helps you handle stress through its effects on your endocrine—­hormonal—­system, and even ensures you get a good night’s sleep. Put simply, your microbiome influences practically everything about your health, including how you feel both emotionally, physically, and mentally.

What compromises a healthy microbiome? Not surprisingly, your microbiome is vulnerable to three antagonizing forces: exposure to substances that kill or otherwise negatively change the composition of the bacterial colonies (these substances include everything from environmental chemicals and drugs like antibiotics to ingredients such as artificial sugars and processed gluten-containing foods); a lack of nutrients that support healthy, diverse tribes of good microbes; and unrelenting stress.

I’ve devoted an entire section to the amazing features of the microbiome, so you’ll gain plenty of knowledge about how it plays a role in your physical and mental well-being and how you can maintain an optimal colony of tribes. We have coevolved with these microorganisms throughout our journey on this planet, and we must respect them for what they are: the body’s—­and brain’s—­best friend. And they are as much a part of our survival and mental well-being as our own cells are.

DESIGNED FOR DEPRESSION

Have you ever stopped to wonder if depression has benefits? I know, it sounds a little outlandish to even suggest such an idea. But it’s an excellent question to ask and an even better one to answer. This conversation, however, is best couched within the topic of stress in general. So let’s go there next.

Most of us can recognize the symptoms of stress. We feel it inside and out. We become irritable, our heart races, our face may feel hot, we get a familiar headache or upset stomach, our mind is incessantly chattering, there’s a sense of impending doom, and we’re annoyed by the smallest things. For some ­people, stress has little outward effect. For these individuals, what they feel at the surface is internalized and sometimes expressed as disease. In fact, many of these ­people don’t believe they experience stress—­but they do; they just don’t consciously recognize it until it builds up to a certain point and seeps out in other ways.

The term stress as it is used today was coined by one of the founding fathers of stress research, Hans Selye, who in 1936 defined it as “the non-specific response of the body to any demand for change.”

Selye proposed that when subjected to persistent stress, both humans and animals could develop certain life-threatening afflictions such as heart attack or stroke that previously were thought to be caused by specific pathogens only. This is a crucial point, because it demonstrates the impact that everyday life and experiences have not only on our emotional well-being but also on our physical health.

The word stress as it relates to emotions became part of our vocabulary in the 1950s. Its use became common with the onset of the Cold War, which was an era when fear ruled. We were frightened of atomic war, so we built bomb shelters. As a society, we could not say we were afraid; instead, we used the word stress. Today we continue to use the word to describe anything that disrupts us emotionally—­we’re stressed, stressed out, under stress, and so on. Stress can also be described as the thoughts, feelings, behaviors, and physiological changes that happen when we respond to demands and perceptions. And if those demands placed on us overwhelm our perceived ability to cope, we experience “stress.” In our frenzied minds, we begin to pant silently like an animal and look for an escape.

Since Selye, researchers have broken stress down into several subcategories. Stress physiology has come a long way in the last fifty years in particular, and so have the stressors. A key concept to enter the medical vernacular more recently is what is known as allostatic load. Your allostatic load refers to environmental challenges—­the “wear and tear” on the body—­that cause it to begin efforts to maintain stability (allostasis, also known as homeostasis). It also represents the physiological consequences of adapting to chronic stress that entails repeated activation of the body’s stress response machinery involving many systems—­immune, endocrine, and neuronal. Researchers Bruce McEwen and Eliot Stellar coined this term in 1993 as a more precise alternative to the term stress.

The key players of the stress response, cortisol and epinephrine (adrenaline), have both protective and adverse effects on the body depending on when and how much they are used. On one hand, these hormones are essential for the body’s ability to adapt and maintain balance (homeostasis), but if they are flowing for a prolonged period or needed relatively frequently, they can accelerate disease processes. The allostatic load, as it’s called, becomes more harmful than helpful. This load can be measured in physiological systems as chemical imbalances in the activities of the nervous, hormonal, and immune systems. It can also be measured by disturbances in the body’s day-night cycle (what’s called the circadian rhythm, another concept we’ll explore later), and in some cases, changes to the brain’s physical structure.

Stress is actually a good thing, at least from an evolutionary and survivalist perspective. It serves an important function: to protect us from real danger by equipping us with a better means to escape a life-threatening situation or face it head on. But our physical reaction doesn’t change according to the type or magnitude of a perceived threat. Whether it’s a truly perilous stressor, or just the to-do list and an argument with a colleague, the body’s stress response is the same. Let me give you a quick lesson on what goes on when your body senses stress so we can come full circle back to, dare I say, the secret value of depression.

First, the brain sends a message to the adrenal glands that results in the release of adrenaline, also called epinephrine. This triggers your heart rate to increase as blood is directed to your muscles in the event you need to flee. When the threat is gone, your body normalizes again. But if the threat doesn’t go away and your stress response intensifies, then a series of events take place along what’s called the HPA axis, short for hypothalamic-pituitary-adrenal axis, and which involves multiple stress hormones. The hypothalamus is a small but key governing region of the brain that has a vital role in controlling many bodily functions, including the release of hormones from the pituitary gland housed inside. It’s often referred to as the seat of our emotions because it commands much of our emotional processing. The moment you feel nervous, anxious, extremely overwhelmed, or simply worried that you can’t deal with life, the hypothalamus releases a corticotropin-releasing hormone (CRH), a substance that starts a cascade of reactions, ending with cortisol flowing into your bloodstream. While this process has been well defined for a long time, newer research reveals that perceptions of stress trigger inflammatory signaling from the body to travel to the brain, priming it for hyper-response.

You’re probably already familiar with cortisol, the body’s main stress hormone that aids in that famous fight-or-flight response. It also controls how your body processes carbohydrates, fats, and proteins. Because it’s the hormone responsible for protecting you during times of stress, its actions increase your appetite, promote more fat storage, and break down complex molecules and tissues that can be used for quick forms of energy, including muscle. For this reason, continual exposure to excess cortisol over time can lead to increased abdominal fat, bone loss, a suppressed immune system, fatigue, and a heightened risk for insulin resistance, diabetes, heart disease, and full-blown depression. Cortisol does, however, serve a positive role. It directs and buffers the immune system and primes the body for attack. This would all be great if the attack were short-lived and easily resolved. The attack of our modern-day lifestyles is unrelenting.

The scientific study of the impact of stress on the body from the inside out, and even the outside in, has made tremendous advances in the fifteen years starting in 1998 when Harvard University researchers conducted a joint study with several Boston-area hospitals designed to examine the interactions between the mind and the body, specifically the skin. They called their discovery the NICE (neuro-immuno-cutaneous-endocrine) network.

In plain speak, it’s a giant interactive network consisting of your nervous system, immune system, the skin, and your endocrine (hormonal) system. All of these are intimately connected through a dialogue of a complex array of biochemicals.

The Boston researchers studied how various external forces influence our state of mind, from massage and aromatherapy to depression and isolation. What they discovered confirmed what many in the scientific community have known anecdotally for centuries: our state of mind has a definite impact on our health and even our appearance. ­People suffering from depression, for example, often look older than their chronological age. They don’t appear healthy and vibrant, as the stress of coping with depression has accelerated the aging process and damaged their health.

Since the NICE network entered our vocabulary, dozens of other studies have been performed to confirm the powerful interplay between psychology and biology or, put simply, mind over matter. An analogy I like to use in my practice goes like this: If you’re walking down a dark alleyway at night and hear footsteps behind you, you might be alerted in uncomfortable ways, and your body will prepare to fight or flee. But if you then hear your friend’s voice, everything in your body’s physiology changes in that one instant. Yet the only thing that’s changed is your perception!

So going back to the question “Can depression be good for us?” Was depression once an adaptive response to the environment? I subscribe to the idea that the body doesn’t make mistakes after millions of years of evolution. A 2014 review in the Journal of Affective Disorders attempts to answer the question of why we get depressed, rather than just looking at how, and what to do about it. Often the best approach to root cause resolution of symptoms comes from an understanding of the reasons why the body is responding in the way that it is. Speaking to the concept of evolutionary mismatch, the authors of the paper state: “. . . modern humans exist in environments that are critically different from those in which we evolved, and that our new environments interact with our ancient genomes to lead to disorder . . .”

The authors discuss how depression may have served a purpose at some point, but the nature and intensity of today’s modern-day triggers may be leaving more of us depressed (up to 41 percent of us!) more of the time than seems reasonable. This perspective encompasses the inflammatory model of depression, which posits that both psychological stress and bodily inflammation result in brain-based changes that would serve us if they were brief, but may kill us if they are persistent (something like that).

The researchers of the review go on to explain how antidepressants are missing the mark, and why their prescription should be reconsidered, citing side effects including:

. . . headache, nausea, insomnia, sexual dysfunction, agitation, sedation, hyponatremia, stroke, cardiac conduction defects, and increased risk of mortality. The long-term use of antidepressants may be associated with additional adverse effects. For instance, some antidepressants may be weakly carcinogenic or cause osteoporosis. Antidepressants have also been associated with an increased acute risk of suicide in younger patients while they may decrease the risk of suicide in older patients or with longer-term use. Also, all major classes of antidepressants have been associated with unpleasant (and sometimes dangerous) symptoms when they are discontinued abruptly. Discontinuation of antidepressants is associated with relapse and recurrence of MDD (Major Depressive Disorder). In a meta-analysis, this risk was shown to be higher for antidepressants that cause greater disruption to neurotransmitter systems . . . [And] there is a growing body of research suggesting that when they are used in the long term as a maintenance treatment, antidepressants can lose ­efficacy, and may even result in chronic and treatment-resistant depression. Such reactions may be due to the brain’s attempt to maintain homeostasis and a functioning adaptation in spite of the medication.