Runaway stress helps explain why depression is linked to so many physical ailments.
by Lisa James
The dark thoughts started when she was in high school. But it wasn’t until she was in college that Laurie Coker, 53, of Winston-Salem, North Carolina, had a bout of depression “bad enough that I had to withdraw for a while.” Coker’s mood problems continued off and on through her twenties and into her thirties, when “I would have really dark periods, especially after I had my second child,” she remembers. “I would not answer the telephone. I had so little focus; I felt passive and detached.”
Today, Coker directs the North Carolina Consumer Advocacy Networking and Support Organization, which helps patients cope with mental illness. As someone who has experienced depression first-hand and as a former psychiatric nurse, Coker knows how this disorder can derail someone’s life. “One of my patients said that it’s like you’re in this dark hole and the harder you dig to get out the deeper you feel that you’re digging yourself in,” she says. “I remember times when I was not depressed but fearing when the next depression would hit. It’s absolutely frightening. You start fearing that the next thing that happens is going to make life worse.”
Coker is far from alone. According to the National Institute of Mental Health, one in every 13 adults experienced at least one bout of major depression in 2007. Depression rates are on the rise, and research indicates that being depressed increases one’s risk of physical ailments such as heart disease.
The news about depression isn’t all bad, however. “People can get better and hope to be well, not just better but well,” says David Hellerstein, MD, of the Depression Evaluation Service (www.depression-nyc.org) and the Columbia University Department of Psychiatry (www.columbiapsychiatry.org). What’s more, a healthy lifestyle may help keep depression at bay.
More Depression, Younger Ages
“Depression rates have been going up across many different societies since the early 1900s,” says Hellerstein, author of Heal Your Brain, to be published by Johns Hopkins University Press next year. “And the age of onset has gotten earlier: early adulthood, teenage years, even childhood.”
The idea of depression affecting more people at younger ages troubles many researchers. “It appears that every successive generation is experiencing depression at a higher and higher rate,” says Stephen Ilardi, PhD, professor of clinical psychology at the University of Kansas and author of The Depression Cure (Da Capo Press).
What’s not clear is exactly why depression rates are increasing. “It’s hard to pinpoint,” says Michelle Riba, MD, associate chair for Integrated Medicine and Psychiatry Services and director of the Psycho-Oncology Program at the University of Michigan Comprehensive Cancer Center (www.cancer.med.umich.edu). “It could be better diagnosis and screening—there might be more information about depression and less of stigma attached to it. The economy could also be contributing.”
Job loss is one of the many setbacks that can cause someone to feel down for a week or two. True depression, though, is marked by not only low mood but also low self-esteem and energy, memory and sleep disturbances, poor concentration, poor appetite or overeating and loss of interest in pleasurable activities.
In major depression, symptoms are severe but relatively short-lived. Low-level chronic depression, though, can last for years—even decades. Other types include bipolar disorder, marked by mood swings, and seasonal affective disorder (SAD), triggered by reduced light levels during the fall and winter. Depression has a high rate of relapse.
Primed for Depression
Even if scientists could determine why depression rates are rising, that would not explain why if two people are laid off, one will become depressed and the other won’t. “There are a lot of different types of depression and we don’t fully understand which are genetic and which may be linked with other conditions,” says Riba. “We still don’t have a biochemical test or imaging study that clearly explains what is going on.”
Family history plays a crucial role. “Children of depressed mothers have a higher risk of developing depression themselves,” says Kathi Kemper, MD, MPH, FAAP, who chairs the Center for Integrative Medicine at Wake Forest University School of Medicine and is the author of Mental Health, Naturally (American Association of Pediatrics). She says familial risk includes genetic factors and exposure to poor health habits, such as not exercising and eating low-nutrition fast food.
Women in general are more prone to depression, mostly for hormonal reasons, although “we know that men with depression don’t always come to medical attention,” notes Riba. Having a social network seems to offer protection. However, Ilardi warns that toxic relationships—a harsh parent, an abusive spouse—are risk factors.
One depression fighter is resiliency, the ability to bounce back from bad experiences. “Someone who is resilient will see adversity as a challenge,” says Hellerstein. “Those who are sensitive to setbacks are more at risk.”
One factor in reduced resiliency is a poor response to stress. ‘We’re not well adapted for 21st century living, a lifestyle of social isolation, fast food and being sedentary indoors,” says Ilardi. Kemper believes that the 24/7 nature of today’s electronic media can make the world feel like a threatening place, which is also stressful. “I call CNN the ‘all disaster, all the time’ network,” she says.
The Brain-Body Link
Mood troubles often go hand-in-hand with physical ones. “I have fibromyalgia and many of the people I know who have it have either bipolar disorder or depression,” says Coker. “A lot of my peers have many physical symptoms. There’s a lot of hypertension, heart disease and respiratory disease.”
“People with chronic depression use a lot of medical services,” says Hellerstein. “They also run a higher risk of alcohol and drug problems; if you feel bad all the time it’s natural to reach out for something that makes your feel better.” Riba, who deals with many cancer patients at the University of Michigan, says, “Depression, anxiety, and other psychological issues affect up to 35% of patients during the course of their cancer.” Depression is so common among heart patients that the American Heart Association recommends they be screened for it.
Heart disease and cancer are only two of the ailments associated with depression. It has been shown to increase the risk of being diagnosed with dementia (Neurology 7/6/10). Being depressed increases the risk of obesity and can intensify pain (Archives of General Psychiatry 3/10, Biological Psychiatry 6/1/10). One study group found that depression is as deadly as smoking (British Journal of Psychiatry 8/09).
Stress helps explain why so many depressed people suffer physically. Under stress the body “increases its output of adrenaline and cortisol,” says Hellerstein. “In high-stress urban areas there is a lot of depression, along with illnesses such as obesity, diabetes and heart disease.”
Stress hormones promote the sort of low-level inflammation that has been associated with chronic disease. Researchers “have seen that aboriginal groups almost never get things like diabetes or atherosclerosis,” says Ilardi. These groups don’t have problems with depression, either.
Cortisol suppresses BDNF, a substance needed to fix damaged neurons. As a result, “depression causes brain damage over time if not treated effectively,” Ilardi says. It is known that depression is also related to levels of neurotransmitters such as serotonin, which help relay messages between brain cells. Hellerstein explains that scientists had long proposed the “deficiency model” of neurotransmitters in the depressed brain. This model assumes “there isn’t enough gas in the tank; many antidepressants work by essentially putting more gas in the tank,” he says. “But the chronic stress model suggests that when your stress response system is constantly turned on, you use up your neurotransmitters at a faster rate. It’s as if the car is getting poor mileage.” The idea is to tune up the brain to keep neurotransmitter levels from falling—and to keep stress, and the inflammation it promotes, from burning out the engine.
There are as many ways of healing depression as there are depressed people. Knowing exactly which type you have “is less important than understanding your own experience and getting individualized help,” says Kemper. (Consult a trained healthcare professional, especially if you are currently taking a prescription antidepressant; seek help immediately if you are having suicidal thoughts.)
One of the best ways to improve mood is through exercise. Scientists have found that physical activity increases BDNF, the substance that promotes neuron growth.
Eating a healthy diet is vital because so much of the food we consume these days is nutrition-poor. “Most Americans are failing to meet their need for one or more nutrients through diet,” says Kemper. “It’s hard to function well if your brain isn’t getting optimal nutrient levels to make the neurotransmitters it needs.”
Foods such as whole grains, fresh produce and fish provide several key brain nutrients. “People who eat diets rich in omega-3 fatty acids have much lower rates of depression,” says Kemper.
“Thiamine (vitamin B1) is necessary for optimal function of the brain.” She says that niacin (vitamin B3) helps the body process omega-3. Adequate niacin supplies allow the body to hold onto tryptophan, an amino acid needed for serotonin production, which also requires pydrioxine (vitamin B6). (Tryptophan is available as milk protein concentrate.) Kemper says that deficiencies of another B vitamin, folate, are “fairly common and contribute to a variety of mental and emotional symptoms,” including depression. “Vitamin D is an anti-inflammatory,” says Ilardi. “It’s also a genetic regulator.
There’s thousands of genes in the body regulated by vitamin D and 500 of them are in the brain.” Minerals that help improve mood include calcium, which tends to be lacking in people with depression; chromium, which helps brain cells use fuel properly; iodine, deficiencies of which impair brain function; iron, which helps the body deal with stress; and magnesium, another stress fighter.
Alternative practitioners have long recommended SAM-e, a substance believed to enhance neurotransmitter function, for its anti-depressive effects. Kemper says that a review by the government’s healthcare research agency “concluded that it was as effective as anti-depressant drugs.” St. John’s wort, the best-known herbal mood regulator, appears to be helpful for mild to moderate depression (European Neuropsychopharmacology 8/12/10).
SAD may not be the only type of depression that responds well to light therapy, which, according to Ilardi, stimulates serotonin production. Kemper recommends music to lift one’s spirits and reduce stress. A number of complementary health practices, including acupuncture, massage and yoga, have also been used to help improve mood.
Coker believes in the power of making the right choices to fight depression. She says, “There needs to be much more emphasis on knowing yourself, to know when your moods are slipping, and on making sure you do what you need to do.”
Self-Help for Mental Health
One of the most distressing aspects of depression is the feeling that, between the illness itself and a here-take-this-pill therapeutic approach, you’re not quite in control of your own life. But now there’s a movement in the mental health world to allow people with depression and other mental disorders to reclaim their own capacity for healing by letting them help themselves. “Self-help groups have had some of the highest quality results,” says Patrick Hendry, senior director of consumer advocacy for Mental Health America.
Part of the problem, Hendry says, is that mental illness is often exacerbated by poverty. People suffering from depression and other ailments often “become unable to work and they apply for Social Security disability or Social Security supplemental income,” he says. “People are supposed to live on less than $700 a month; as a result people with mental illness who don’t have private insurance or family support fall into the lowest economic level. They’re told, ‘You have a severe mental illness and will never be able to work again.’”
That pessimistic outlook simply isn’t true, according to Hendry. People can and do recover, and one of the best ways to foster recovery is to have people meet to discuss common problems and solutions. “You’re talking to your peers, to people who have gone through what you’re going through,” Hendry says. “Many of our affiliates have self-help groups they run. We try to find programs that really work and we promote them throughout the country.”
This idea represents a change in thinking about mental health. “Most people want to be involved in their own care but for years the system wasn’t built that way. Doctors would tell people, ‘You’re going to therapy twice a month and take these medications,’” says Hendry. “When going to a community mental health center you often work with a case manager to build a treatment plan. Until very recently the case manager would write up the plan and say, ‘Sign it.’ We’re really tried to change that, so that the individual is the one who drives the treatment. These people are regaining control of their own lives.”
About half a dozen states are even starting pilot programs in self-directed care, in which money that the state would spend on patient care—often to support costly hospitalizations—is instead put into an account that the individual can use for whatever he or she thinks would promote their own recovery. “The money follows the person,” says Hendry, who used to direct such a program in Florida. “They’re getting what they need as an individual, not what a state mental health department thinks they need for depression.” Budgeted items may include everything from psychological evaluations to nutrition counseling and yoga classes to massage and other forms of therapy, along with efforts to improve a person’s ability to get and hold a job.
Laurie Coker believes that widespread acceptance of the self-directed care model could save individuals from needless suffering—and save states from skyrocketing mental health costs. “So much of our public budget is in crisis intervention and crisis services—we have to do things that are wellness- and prevention-oriented,” she says. “The more emphasis that’s on preventive care the fewer resources you have to dedicate to hospital care. You saving both dollars and trauma.”
Hendry agrees. “Over the past five years almost every state has been cutting dollars for mental health care, and the ones they tend to cut out are in prevention,” he says. “So you wind up with more people in hospital, which is much more expensive.” To compute the savings from self-directed care, Hendry compares the cost—4,000 to $12,000 per person a year—to the $100,000 or more it costs annually to hospitalize someone for mental illness.
Coker has started a self-help group in her Winston-Salem community. “We’re starting to plan activities, to get out and do things,” she says. “We’re tired of talking about our illnesses. You don’t grow unless you take risks.”
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