If I asked you what serious health condition Americans are at greatest risk of developing in their lifetimes what would you answer? (Forget for a moment that you just read the title of this blog post). I’m guessing that you might say cancer, heart disease or diabetes. As a doctor I have certainly been trained to think that way. These conditions are scary, they are at epidemic proportions and as a nation we are probably more concerned about them than all other diseases combined. They are, however, not the most common serious health conditions affecting us.
According to the Centers for Disease Control, about 9% of adults are suffering from some form of depression at any given time. About 18% of Americans are suffering from an anxiety disorder of one type or another (such as generalized anxiety, panic disorder, post traumatic stress, obsessive compulsive disorder, phobias, etc.) By comparison, rates of coronary heart disease are about 6.5%, diabetes rates about 8% and cancer rates are about 4% of the population.
When I first saw these statistics, I was really astounded. Nearly one in ten adults in our country is depressed and nearly one in five is suffering from some form of anxiety. Our nation might claim “the pursuit of happiness” as one of its founding principles but I’m afraid that many of us are just not finding it.
Depression, anxiety and other mood disorders are placing a huge burden on us as individuals and as a nation. They affect not only those with the condition, but those that live with them, love them and care for them as well. Virtually everyone in our country is impacted in some way by depression and anxiety.
The Current Treatment Model
For the most part the original treatment approach to these conditions was psychotherapy and counseling, and while these therapies are still in broad use, prescription medications have increasingly taken center stage as the primary treatment for both depression and anxiety. Currently, about 75% of patients seeking conventional treatment for depression are prescribed antidepressant medications. Only about 40% receive some counseling and that percentage is declining. I’m not sure of the reasons for this, but I do know that while most insurance plans will pay for antidepressant or anti anxiety medications indefinitely, they will only pay for a limited number of visits with a psychotherapist.
Appearance of the newer classes of antidepressants, the SSRI’s (selective serotonin reuptake inhibitors) and later, the SNRI’s (serotonin norepinephrine reuptake inhibitors), was treated with much fanfare and helped to create positive public sentiment towards these medications. For a time, these drugs appeared to be safer and more effective than previous generations of antidepressants. Their reputation for safety was damaged in the early 1990’s when it came to light that GlaxoSmithKline, the maker of Paxil, had suppressed research data that showed the drug increased suicide rates in teens and young adults by 800% compared to placebo. All SSRI’s and SNRI’s now carry “black box warnings”, bold statements placed at the beginning of package inserts for drugs that have the greatest potential for dangerous or fatal side effects. Having said that, these drugs still appear to be relatively safe for adults older than age 24. Efficacy is another issue, which I will address shortly.
Anti-anxiety medications such as Xanax and Valium (the benzodiazepines) have been available since the early 1960’s. While they have never had quite the level of popular acceptance as the antidepressants (they have long been known to be addictive), they have certainly become an accepted part of our social landscape as well. The Rolling Stones even wrote a song about Valium, the first widely prescribed benzodiazepine. (Extra credit if you know the name of the song).
SSRI’s and SNRI’s are generally regarded as effective by many consumers, psychologists, and medical doctors and it’s true that many people have an improvement in depression and anxiety symptoms when they take these medications (SSRI’s are often used for anxiety as well as depression). Here’s the interesting thing: several reviews of the available research literature have concluded that for the majority of depressed patients antidepressants are no better, or only slightly better than a placebo (the inert pills given to some study participants to differentiate the true drug effect from the effect of the patient’s belief in the therapy).
A recent analysis of antidepressants in the Journal of the American Medical Association concluded that “True drug effects . . . were nonexistent to negligible among depressed patients with mild, moderate, and even severe baseline symptoms”. They did conclude that substantial benefit over placebo does occur in patients with “very severe symptoms”. Another review estimated that, on average, the placebo effect accounted for 82% of the clinical response of patients to antidepressants.
These findings are fairly consistent with my clinical experience of antidepressants. In my practice, I occasionally come across someone who is doing very well on these medications. In other words, they feel good and they are no longer depressed. Most patients, however, say that they feel somewhat better than before starting an antidepressant, but they don’t report that they actually feel good or that their depression is gone, they just feel less depressed than before. In addition to the lack of a robust response, the main complaint I hear from patients taking these medications is that they “just don’t feel like themselves”. Patients have used words like “flat” or “disconnected” to describe how they feel.
I see a similar picture with regard to the benzodiazepine anti-anxiety medications. A small percentage of people have a robust reduction in anxiety or panic attacks, but the largest number of people see only a modest reduction in their symptoms or no effect at all.
This gets to the real purpose of this blog post. For the most part, people don’t really thrive on depression and anxiety medications (no matter how happy they look in all those pharmaceutical ads), they just get by. And, while it is sometimes better than life without any support at all, there is much more that can be done for these patients.
Taking a broader view
The basic supposition of the pharmaceutical model is that depression and anxiety are a result of imbalances in a small number of neurochemicals and that correcting the levels of these chemicals will resolve the problem. While I do believe that neurotransmitter imbalance is a factor, as a stand-alone treatment it is a decidedly narrow approach and ignores both the question of what is driving a person’s neurotransmitters out of balance in the first place as well as ignoring many other factors that can have a profound affect on mood.
What does it take for someone with a long history of anxiety or depression to really thrive? There are many answers to this question. For some, depression or anxiety symptoms can be purely physical in their origin. For others, current or past stress and trauma are the cause. For many people, the cause is a combination of factors.
It is important to realize that happiness and wellbeing are not “peak experiences” – they are our natural baseline state when our bodies and brains are in balance, and when we feel confident and comfortable with who we are. The key to thriving is to understand the factors that are driving our bodies and minds out of balance and to provide the support needed to restore that balance. Here’s a quick look at some of the elements that are commonly a part of the depression and anxiety picture and some of the therapeutic approaches we use to address them:
Hormones are messengers. They facilitate communication between the various organs and tissues and influence the functioning of almost every cell in the body. Any woman who’s ever been pregnant or suffered from PMS knows how powerfully estrogen and progesterone can affect mood. Other hormones can have a powerful effect on mood as well. An excess or deficiency of thyroid hormone, which is often missed in standard lab screening tests, can cause or contribute to both depression and anxiety. In addition, imbalances in insulin and cortisol can promote anxiety or panic attacks and declining testosterone levels can lead to disinterest, loss of self esteem and depression.
In my opinion, many hormone imbalances that are contributing to depression or anxiety are missed because they either aren’t being looked for or the assessments that are done are not adequate. Once a doctor sees that the patient’s lab test results fall into the “normal range” they will often look no further. I have treated many patients who were informed that they were perfectly fine because their lab values were “normal” even after telling their doctor many symptoms that clearly suggest a hormone imbalance!
I believe that the possibility of hormone imbalances need to be adequately assessed in all depression and anxiety cases. And, while I do often use lab testing to check hormone levels I place greater weight on what patients tell me because symptoms always reflect underlying disturbances in function. They just don’t appear out of nowhere.
We all know that the standard American diet makes the body sick. We consider less often the impact that a poor diet can have on the mind. What we eat influences how we feel in ways that are far too numerous to detail here, however, here are a few interesting tidbits to consider:
- Science has identified about 50 specific nutrients that the body needs for health. Almost half of those can have a direct effect on mood. Deficiency of even a single key nutrient can lead to depression, anxiety and other psychiatric conditions as well.
- Excessive consumption of refined carbohydrates and sugar almost always leads to imbalances in brain chemistry and for some people can be the primary cause of depression and/or anxiety.
- Different bodies need different balances of nutrients. Often people are eating foods that are generally healthy, but they are eating them in proportions that don’t match their physiology. This leads to biochemical stresses that can ultimately affect mood.
- Food sensitivities are non-allergic, adverse reactions to specific foods. Such reactions can affect the mental as well as the physical sphere. Wheat is probably the best known offender, but there are many others. Common effects on mood due to food sensitivities include: depression, foggy or unclear thinking, irritability, impulse control problems, agitation and anxiety. You probably know at least one person who fits that description!
- Food additives can have a drug-like effect on the brain. MSG is a classic example. The G in MSG stands for glutamate, an amino acid that also happens to be an excitatory neurotransmitter that can cause nerve damage at high levels! Other additives (particularly food dyes in my experience) can affect mood and cognitive function as well.
Supporting brain function with targeted nutrition
Part of the goal in helping people recover from depression and anxiety is to restore a healthy balance of neurotransmitters and other key neurochemicals. As I have mentioned, this is the approach taken by antidepressant and anti-anxiety medications. One of the limitations of the pharmaceutical approach, however, is that these medications work by trying to reduce the loss of neurotransmitters from the inter-neuron space after they have already been secreted. If our neurons are not able to make enough neurotransmitters in the first place, slowing their degradation is often not enough to regain a balanced mood.
Using nutrition, we can approach the problem from the opposite direction. All neurotransmitters are synthesized within the brain from nutritional building blocks, such as amino acids (the building blocks of proteins), vitamins and minerals. We can help the body to achieve adequate levels of neurotransmitters by providing it with the specific nutritional building blocks it needs. In clinical practice this approach is often highly successful in alleviating depression and anxiety symptoms (not to mention ADHD and many other psychiatric issues) and can work safely and synergistically in patients still taking antidepressant or anti anxiety medications.
Not all cases of depression and anxiety result from low neurotransmitter levels, however. Perhaps surprisingly, these same imbalances in mood can sometimes result from levels that are too high. This is often the case with patients who have unusual adverse reactions to antidepressant and anti-anxiety medications, such as an antidepressant making one’s depression or anxiety worse, or causing agitation. In these cases, using nutritional therapies to lower the expression of neurotransmitters will actually bring improvement, even resolution, to patients’ symptoms.
Our bodies are complex, and our brains are no exception. Specific nutrients are needed for many aspects of proper brain function and in this modern world, even a healthy diet doesn’t always provide everything we need. We use each patient’s specific symptoms and order lab tests, when indicated, to determine if there are deficiencies of key nutrients that are needed to support optimum neurological function.
The Role of stress and trauma
We all recognize to some degree that our experiences shape the way we think, act and feel. Perhaps we have even made a conscious effort to change the way we respond to certain situations and discovered just how stubborn some of our behavioral and emotional patterns can be. We may even believe that our inability to change is due to some weakness in ourselves.
In reality, what we feel in a given situation, the things that appear important to us and even the thoughts we tend to think are shaped by the way our brains are organized, and that organization is profoundly shaped by our experiences. I remember reading a research study years ago in which rat pups who were not allowed physical contact with their mothers during nursing were found to have lower serotonin levels as adults (remember, serotonin is one of the key neurotransmitters that antidepressants are attempting to raise). This has profound implications for our understanding of how, as a colleague of mine likes to say, “our biography becomes our biology”.
Our experience influences the physical functioning of our brains and bodies in many ways and sometimes they are quite positive. For example, the smells of favorite foods from childhood can bring back a flood of pleasant memories and emotions. When experiences are overwhelmingly stressful, however, they tend to result in changes to brain function that impair our ability to maintain a balanced mood and respond creatively and appropriately in future challenging circumstances.
I sometimes use the example with patients of a person who is mugged by someone wearing a red plaid shirt. A year later, they are walking down the street and they pass a clothing store with a red plaid shirt on a mannequin in the window. Suddenly they begin to feel anxious. They may not even be consciously aware of the shirt in the window, or connecting it to their prior experience, but the brain identifies the shirt, connects it with the past trauma and responds with thoughts, emotions, physical sensations and even actions associated with that trauma. For example, they might begin to feel tightness in the chest, clammy palms and unconsciously begin to walk faster. To the person in this example, red plaid shirts have become associated with a frightening and potentially life threatening situation. The brain and body respond accordingly.
These associations occur in deep, primitive regions of the brain that are not readily available to our consciousness. To unwind habitual patterns that lead to emotional and psychological distress we need to do more than alter our thinking. We need to literally alter the way the brain responds to stress triggers.
Healing From Stress and Trauma
We all experience periods of stress in life and not all of these experiences have lasting negative impacts. Indeed, challenging periods of life where we discover inner resources we didn’t know we had and successfully negotiate difficult circumstances can leave us feeling energized and more self confident. Stressful experiences, however, that overwhelm us in some way, perhaps because we can’t find a way to overcome them, or perhaps because their sheer duration ultimately wears us down, do tend to leave lasting impacts on us that can affect our mood, our outlook on life and even our very thought processes.
There are many ways that we can heal from these stressful, and sometimes traumatic, experiences. Talking it through with an understanding friend or family member or seeking the help of a psychotherapist that you have a good rapport with can be invaluable. Early in my practice, as I became increasingly convinced of the profound influence of brain health on emotional and physical health, I began to seek out ways to help patients who’s symptoms appeared to be related to past psychological stress or trauma. Among other things, this search led me to travel back and forth to Canada for two years to study something called Self Regulation Therapy.
“Self regulation” is a psychological term that refers to the the ability of the human nervous system to respond fluidly to stress and life challenges and then return to a state of balance and wellbeing. SRT is based on research over the last 30 or so years about how stressful life experience can produce lasting changes in the function of the nervous system.
These changes can lead to anxiety, depression, loss of enjoyment in life, low self esteem and a whole host of other psycho-emotional manifestations. It can also contribute to physical disturbances such as hormonal imbalances, digestive disorders, certain cardiac arrhythmias, insomnia, fatigue and chronic pain. The brain is the master controller of all bodily functions and a chronically stressed brain cannot govern the body well.
SRT facilitates two important processes for people with a history of overwhelming stress or trauma. The first is to assist primitive brain centers most involved in chronic stress responses to alter the way that past experiences are held so that they no longer have such a strong influence on current emotions, thoughts and behavior patterns. We could call this “coming to peace with the past”, but in a physiological, as well as psychological sense. The second is to help individuals to discover or restore inbuilt, internal resources that help them more effectively deal with stresses and challenges that occur as they move through life. We could call this “coming to peace with the present”.
As these two processes deepen, self regulation is restored. Patients find that they are less reactive and more creative in situations that would have previously caused them great distress. Over time, patients generally report experiencing more contentment, empowerment, optimism and enjoyment of life.
There is much about our modern world that contributes to the development of depression and/or anxiety: inadequate or distorted nutrition, the increasing stresses of modern life and their effects on both psychological and physiological function, the often ignored and unaddressed toll of abuse, violence and trauma, the over use of alcohol and other mind altering substances and side effects from some prescription medications.
Restoring emotional health and balance must address the full range of contributing factors. The current medical model is, in my opinion, overly simplistic and offers only modest relief, leaving many people suffering from these conditions with little hope for a full recovery. I have worked with many patients who had been on antidepressant or anti anxiety medications for years, were still depressed or anxious and had never been offered any other treatment option!
There are alternatives and they are often quite effective. It is possible for people with depression and anxiety to thrive again. The road to recovery will be relatively short and easy for some and longer and more challenging for others. This depends on the specific factors involved and the level of commitment of the individual, but in my experience there are very few people who will not respond well over time if they commit themselves to a path of recovery.