Depression: Time for a rethink

Contributing Columnist

National treatment of depression is distressingly poor. It is time to rethink how we do it. Even the public agrees.

Is that true because ten percent of Americans are depressed this very moment? That depression is ranked one or two worldwide for destroying work effectiveness and economic productivity? Is it because such serious illness cuts twenty years from sufferers’ lifetimes, including our 39,000 successful yearly suicides?

No. It’s because someone wonderful died.

I expected Robin Williams to die young. Friends in LA explained to me five years ago that his heart disease was severe. He had been addicted to alcohol and cocaine a very long time – a fairly common experience for those with manic-depressive illness, or what Robert Lowell termed manic-impressive illness. (Williams knew far more than prolonged depressions. To observe hypomania in its gloriously inventive form,  watch Williams in “Good Morning Vietnam.”) To all this cumulative misery was added the ravages of Parkinsonism. Here is the chronicle of a death foretold.

But could his depression have been treated more effectively? And what can we do to help the other few hundred million people also afflicted?

First, get depressive treatment out of its academic and commercial silos, and then start thinking differently about how the body actually works.

Talk to patients about treating depression and you hear two common options: drugs or psychotherapy.

Academic psychiatric departments trumpet the latest psychopharmacologic cocktails. Academic Psychology departments tell you drugs hardly work, and if they do work, their side effects are terrible. Cognitive-behavioral therapy or interpersonal and other therapies are always better than drugs, they claim, just like Thai Boxing is better than Kung Fu.

The ironies: 1. The combination of medication and psychotherapy is generally more effective 2. Most drugs for depression are given out by non-psychiatrists who know little or nothing about psychotherapy; the drug companies long ago learned long ago internists and GPs were a much bigger market for their wares3. The many other modalities for treatment of depression are hardly discussed 4. Prevention of depression doesn’t come up.

The end result – haphazard, uncoordinated, inefficient care; haphazard to non-existent health care coverage; silo blinkered research, with public health rarely invited to the table.

If health is health care’s product, we have not yet glimpsed the ballpark.

The human body reinvents itself rapidly and inexorably. We are regenerative information systems that never stop learning.

Depression helps halt much of that learning. It kicks the body into non-adaptation, an inability to adjust that places people’s brains inside cul de sacs that grow thinner and deeper. Depression makes more of itself.

To get out of depression you need the body to properly regenerate.

In theory, that should not be hard. Most of you is replaced in a period of weeks. The heart is mostly remade in three days, beyond its skeletal parts; you are partially reborn every time you wake from sleep. But depression is nefarious, ruining or stuttering much of the machinery of biological regeneration.

How to get this fixed? Begin by trying a four part model: health as physical, mental, social and spiritual well-being. Then apply it depression and its treatment:

Physical treatments: Yes, you can use drugs to change brains. But you can also use light, from the sun and lightboxes (see the work of Dan Kripke); repetitive exercise (both moderate and with studied intensity); improved sleep (see the work of Rachel Minber); regularity of daily patterns, particularly those of resting, eating, and moving; and the unexpected pleasure and effectiveness of moving through nature, which particularly aids those who are depressed.

Mental treatments: an overall cognitive approach to life – seeing the world in terms of solutions rather than problems – may do a lot more than help treat individual depression. It might also prevent a lot of it, both its first appearances and return. As with many physical treatments, people can do these themselves, and can be taught to do them in groups.

Social treatments: Different cultures prioritize social techniques for treating mood, and not only in East Asia. But depression itself makes people socially withdraw – and that helps make them worse. The data go back to Berkman and Syme in the 1970s – more social connections means less depression. Here is another opportunity for prevention and treatment. When depressed, people often need social support more than when well.

Spiritual treatments: take “spiritual” to mean connecting with an entity or idea larger than oneself, and the critical importance of meaning and purpose reappear in treating depression. This is much more than mindfulness training. For many, the most effective component of depressive treatment is work – remaining on the job and getting the job done even when one feels bad. When people lose jobs because of depression, the family, economic and community fallout often proves overwhelming. Further, people need meaning to live. When people loss meaning on becoming depressed, they suffer horribly – and make their treatment harder.

Treatment silos may make life “easier” for pharmacy benefit companies, academic departments and health insurers, but they don’t do a lot for people who might or do become depressed. There are few good reasons for treatment exclusivity when treatments work so fitfully. You need to do what works – in physical, mental, social and spiritual realms – and do them together.

Just as you can combine psychotherapy with medication, you can add friends to morning walks in natural settings. Keeping depressed people working can help far more than individual patients – it can aid their companies, families, communities and local economy. Nudging depressed people to greater social engagement may take considerable effort, but can help them reacquire skills forgotten with depressive episodes, and simultaneously aid their helpers. Doing something purposeful and meaningful helps both givers and receivers.

There will certainly and necessarily be new drugs, new electrical devices, new psychotherapies. Most should be viewed not as panaceas – not too many of those around – but extra technical advantages to a much larger process, that of healing people physically, mentally, socially and spiritually. Getting the different techniques to work together can provide a different way of viewing depression, treating depression, and preventing depression.

Robin Williams and many millions more deserve that. We loved them. We love them still.

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