Later On

A blog written for those whose interests more or less match mine.

The depression epidemic and why the medical profession is failing patients

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William Leith reports in the Times:

In 1989, a trainee physician called Edward Bullmore treated a woman in her late fifties. Mrs P had swollen joints in her hands and knees. She had an autoimmune disease. Her own immune system had attacked her, flooding her joints with inflammation. This, in turn, had eaten away at Mrs P’s collagen and bone, noted Bullmore, who was 29, and whose real ambition was to become a psychiatrist.

He asked Mrs P some routine questions about her physical symptoms, and made a correct diagnosis of rheumatoid arthritis. Then he asked her a few questions he wasn’t supposed to ask. How was she feeling? How would she describe her mood? Well, said Mrs P, she was feeling very low – she was tired, listless and losing the will to live. She couldn’t sleep.

At this point, Bullmore made another diagnosis. “She’s depressed,” he told his boss at the hospital.

“Depressed?” said the consultant. “Well, you would be, wouldn’t you?”

Both of these doctors understood that Mrs P had an inflammatory disease. They knew that it had wrecked her joints. They understood the basic process that caused the joints to be wrecked. And they also knew that Mrs P was depressed.

But still, there was something about Mrs P’s symptoms that Bullmore and his boss had missed – something they didn’t see. That’s because they had been trained not to see it. As Bullmore puts it, they had a “blind spot”.

This blind spot was, and still is, part of the medical mindset. What Bullmore and his boss couldn’t see concerns inflammation, and the way it is connected to depression. It might even solve the mystery of why a quarter of the population of the developed world gets depressed. Why do hundreds of millions of people who are safer, better fed and richer than humans have ever been in their entire history suddenly lose the will to live?

——————————

Ed Bullmore is now 57, a professor of psychiatry at the University of Cambridge. Sitting in his office at Addenbrooke’s Hospital, he will, over the course of an afternoon, tell me some extraordinary things. He will say that Mrs P was probably depressed because she was inflamed. He will say that he believes inflammation in the body can cause depression in the mind. This is the subject of his new book, The Inflamed Mind. We sit at his round table, with a life-size plastic model of a brain between us, and by the timeI leave his office, I will see human history in a different light.

“Of course!” That’s what I will keep saying to myself over the next few days. Bullmore says that inflammation causes depression. And stress causes inflammation. And the modern world is full of things that make us stressed. We are the product of ancient genes, many of which were designed to help us survive in the African savannah tens or even hundreds of thousands of years ago. In those days, we weren’t stressed by mortgages or PowerPoint presentations. We were stressed by different things – for instance, when we thought we might be wounded in a fight. That’s because, for most of human history, a wound might easily become infected and kill you. When you’re stressed, your body is flooded with inflammation. It’s getting ready to save your life.

And what happens in the modern world? Mostly, the wound never comes. Instead, the PowerPoint presentation comes. The mortgage comes. And the emails. And the texts. And the beeps and buzzes emanating all day from the phone in your pocket.

Stress, I will think, is chronic. So the body is chronically inflamed. The inflammation gets into the brain. The wound never comes. Sometimes the depression does.

So what do you do? You go to a psychiatrist. Because you think your problem is a mental one. It’s not physical, you think. It’s in the mind. And the mind is different, isn’t it?

——————————

Mrs P – she was inflamed. She was depressed. The consultant had said, “You would be, wouldn’t you?” He thought she was depressed because she was thinking about being inflamed. Her physical problems had made her reflect on the future, which looked bleak. So naturally she was depressed. As the consultant said, you would be, wouldn’t you?

“There is quite a lot under the surface of that remark,” Bullmore tells me. “He said it almost without thinking. It was like an automatic response. But it did mean, frankly, as far as we were concerned, as her physicians, if that’s what we thought was the cause of her depression – that she was reflecting on her arthritis, that she was thinking too much about it – that was equivalent to saying, ‘It’s not our problem.’ ”

If Mrs P was depressed, the doctors felt, it was not a medical problem at all. It was a problem for a psychiatrist to solve.

But what would a psychiatrist do?

——————————

Shortly after Bullmore treated Mrs P, he started training as a psychiatrist at the Maudsley Hospital in south London. By now he was 30. One day, in 1990, he treated a patient, Mr Q. “He wasn’t much older than me,” says Bullmore. “He told me he’d got depression.” To look at “you wouldn’t think he had psychiatric problems”. His condition was not immediately visible. Like Mrs P, his mood was low. He was tired, listless, losing the will to live. Nothing gave him pleasure any more.

The young Bullmore diagnosed Mr Q with depression. “When I told him he was depressed, he wasn’t very impressed by that,” says Bullmore. “Because, in effect, he’d told me that himself. I’d just written it down and translated some of his ordinary language into some of this neoclassical gobbledegook that doctors tend to talk. Like, he told me he’d lost pleasure in simple things, and I told him, ‘You’ve got anhedonia.’ He told me he was feeling gloomy, and I told him he had major depressive disorder. Although I was putting it in different words, I wasn’t telling him anything he didn’t already know.”

That’s one thing a psychiatrist would do. Bullmore suggested drugs. That’s another. “He asked me how they worked. I told him all about how they changed the serotonin level in the brain, because there was supposedly a serotonin imbalance the drug could correct. He said, ‘How do you know that about me?’ And it was quite a shock, actually.”

This was the world of psychiatry in 1990, and there are several things that might shock you about it. A man tells a doctor he feels extremely low and has lost the ability to feel pleasure. The doctor tells him he’s suffering from depression and anhedonia. He then prescribes an SSRI drug – a selective serotonin reuptake inhibitor such as Prozac or Seroxat – in order to raise the level of a substance called serotonin in the patient’s brain. But he has no idea whether or not the patient’s levels of serotonin are too low. He’s just guessing.

Also, he has no idea whether or not the drug will work. It works, or seems to work, for some patients. Sometimes it works for a while, and then stops working, at which point some patients respond well to increased doses. Others don’t. Sometimes there are side-effects. SSRIs can make patients gain weight or lose interest in sex. Sometimes the patient might find the side-effects another set of reasons to be depressed.

“I realised,” says Bullmore, “that there was quite a lot we didn’t know about why and how we were using these treatments.”

And now he says another shocking thing. “There still isn’t a good answer to that question. The crucial thing is: anybody prescribing SSRIs to anybody for depression or anxiety – nobody knows that that particular patient has a problem with serotonin in the first place. There is no biomarker.”

In medicine, drugs are usually prescribed to respond to biomarkers. For instance, a doctor might diagnose an inflammatory disease by analysing a blood sample, and then decide to prescribe a steroid to treat the inflammation. It was shocking that, in the world of mental illness in 1990, doctors were prescribing drugs that might or might not work, without responding to a biomarker. It’s even more shocking that they’re still doing it now. Nothing much has changed for almost 30 years.

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I’ve never been depressed, although I’ve suffered from anxiety, a disorder that shares some characteristics with depression. But we all know at least one person who has suffered from depression. At any one time, 10 per cent of us are depressed. Sometimes it creeps up; sometimes it happens suddenly. It happens to more women than men, but more men commit suicide as a result of it. Several studies suggest that it happens to people whose status is low – underlings are more depressed than their bosses. It’s been linked to obesity and diabetes. It happens to people with heart disease more than people without heart disease, all else being equal. There is a genetic component – if members of your immediate family have suffered, you are more likely to suffer. People are always depressed for a reason, or several reasons. But often we can’t say what those reasons are. For a long time, depression has seemed to be one very big mystery.

It’s reasonable to ask what, if anything, depression does for us. Why hasn’t it been selected out of our genome? After all, depressed people live shorter lives, are less likely to prosper and have fewer children. Think of all those lost work days, all that time and money spent on recovery. It knocks billions off the national GDP, says Bullmore, if you want to think of it that way. But think of all the broken relationships. Think of all those people who fall, quite suddenly, to depression. Think of the futures they never get to have.

According to the writer Andrew Solomon, depression is emotional pain beyond sadness. Sadness such as grief, he writes in his brilliant book The Noonday Demon, is like being attacked by rust, which weakens the structure of your mind. Depression is what happens when the structure collapses. Solomon describes his own depression as a living force trying to take him down. “Its tendrils threatened to pulverise my mind and my courage and my stomach, and crack my bones and desiccate my body. It went on glutting itself on me when there seemed nothing left to feed it.”

Solomon says that depression is what happens when things go catastrophically wrong with the mind. He says it’s the price we pay for being creatures who are able to love. Creatures who love must also be primed for loss. To Solomon, “Depression is the flaw in love.”

And Bullmore says something that most of us, until now, hadn’t thought of. Depression can be a product of both the mind and the body. The mind picks up sensory signals that cause stress, the body becomes inflamed, and the inflammation enters the brain, and this in turn affects the mind. It’s a hall of mirrors. It’s not something a doctor would think of; a doctor treats the body. It’s not something a psychiatrist would think of; a psychiatrist treats the mind. It exists in the blind spot.

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About halfway through our afternoon together, . . .

Continue reading.

Interesting factoid: Obesity causes inflammation. If inflammation can cause depression, moving from being obese to being normal weight might reduce (or even cure) depression.

Written by LeisureGuy

23 April 2018 at 9:29 am

2 Responses

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  1. Where can I read the rest of this article without having to pay the Times UK?

    musanim

    24 April 2018 at 3:00 pm

  2. I have no idea. But I think you can read two Times articles a week without subscribing, so you might try clicking the link next week. And, of course, the book referenced in the article, The Inflamed Mind: A Radical New Approach to Depression, is readily available, so you might try your local library for that. (Link is to Amazon.com, it’s also available from Amazon.co.uk and Amazon.ca.)

    LeisureGuy

    24 April 2018 at 3:45 pm


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