A modified model for understanding depression and anxiety ought to involve a whole person, integrative approach.
by Gary Kaplan, DO
Article reprinted from US News and World Reports, May 12, 2015
Public acts of violence seem to fill the news media streams these days and are typically followed by outcries for greater access to mental health care for those that need it most. And although most individuals with serious mental illness are not dangerous, many of the perpetrators of these heinous crimes later turn out to have a documented history of depression or mental illness, which often went untreated. So, what can we do to stop the anguish? What is it that we are missing?
The Cost of Failure
Unfortunately, the number of Americans affected by serious depression and anxiety disorders is enormous, as are the costs to society due to failure to treat and/or treatment failure. The National Institute of Mental Health reports that each year, approximately 57 million Americans suffer from depression, including chronic, low-grade depression (dysthymia) and anxiety, and some 14.8 million of those are dealing with major depressive disorder, the leading cause of disability for people ages 15 to 44.
The cost of failing to effectively treat these conditions is not just the individual’s inability to complete college, hold a job or cultivate positive relationships; it also includes the toll taken on an entire family and community when a despairing person takes their own life. And in the most extreme cases, the costs of acts of public violence – in terms of suffering, municipal expenses, personal medical and legal expenses, and lost human potential – are immeasurable.
Several months ago, Michael, a 17-year-old high school student, came to see me. Michael had a long history of hospitalizations after attempting to take his own life, and despite undergoing intensive psychiatric treatment, he remained depressed and suicidal. Like 40 percent of those who suffer from major depressive disorder, Michael was not responding to treatment.
When contemplating a situation like Michael’s, the question “What am I missing?” is never far from my mind. Statistics show that only about one-third of patients with MDD respond to antidepressant medication, with about the same number responding to psychotherapy alone. If we combine the two approaches the numbers improve slightly, but the fact remains that most people with MDD respond only partially to medical interventions, with almost half remaining entirely unresponsive.
A Central Nervous System in Turmoil
A mountain of scientific research over the last 10 years has demonstrated that neuropsychiatric conditions such as depression, anxiety disorders and possibly bipolar disease are, in a very high percentage of cases, the result of inflammation occurring in the brain. In the past few years, there’s been a great deal of publicity linking generalized inflammation to heart disease, chronic pain and obesity. Inflammation in the body takes many forms: When we have an allergic response to pollen or food, our bodies’ inflammatory response includes the release of histamine, which makes our eyes itch and noses run; we see the inflammation associated with a skin wound when the white cells of our immune system respond to a bacterial infection. Inflammation in our brains, however, is unique in that it is mediated by tiny cells called microglia.
Microglia are the innate immune system of the central nervous system. Their job is to respond to trauma and damage to the brain. In response to brain injury, the microglia release a virtual symphony of chemical mediators that orchestrate the destruction of bacterial invaders, the elimination of damaged neuronal tissue and the initiation of the repair process.
After responding to an assault on the brain, microglia typically return to a resting state. But ongoing and cumulative assaults to the brain (e.g., fever, physical assault and emotional trauma) will cause the microglia to remain chronically up-regulated, causing them to continuously spew out inflammatory, tissue-destroying chemicals. This brain inflammation produces a wide range of symptoms including depression, anxiety, chronic pain, difficulty focusing and concentrating, fatigue and sleep disturbances. Further compounding the issue is the fact that a solid understanding of the role of microglia in brain health is sadly lacking among most medical professionals, with the result that they continue to treat what are in fact “symptoms” as separate and unique “diseases.”
Looking Beyond the Symptoms
A new framework, where physicians look beyond the symptoms, would involve giving priority to discovery of the root causes of an individual’s depression or anxiety. This would primarily require an understanding of what caused the microglia to up-regulate. Research has shown that anything that can damage neuronal tissue can be a trigger. So, an exploration of a patient’s depression may include asking them about possible traumatic head injuries, psychological traumas (acute events and chronic stress), infections (e.g., tick-born diseases, other bacteria and viruses), and even biotoxins that may have entered the body from exposure to toxic molds, celiac disease and hypoxia (usually related to sleep apnea). The list of triggers is long, and as such, the process of identifying the possible underlying causes of the disease requires putting together a thorough medical health timeline for each patient. With this new approach, treatment options expand due to the greater understanding of the origin of the illness, thereby increasing prospects for recovery.
As for Michael, my 17-year-old patient who was depressed and suicidal, it turned out that he has celiac disease. Now gluten-free, he is no longer depressed, he has re-engaged in life and he’s looking forward to going to college. He is still taking antidepressant medications, but under medical supervision is slowly weaning himself from them (it takes time for the brain to heal after the assault is removed). His life has been changed, for the better, forever.
It is my hope that, with a modified model for understanding depression and anxiety, involving a “whole” person, integrative approach, more patients will be correctly diagnosed and treated, as Michael was. In his case, and I suspect in many more, we’re learning that all too often, depression is not just depression.