Causes of Mental lllness - Still a Mystery

This post is dedicated to the memory of Diane, her valiant fight, and her gentle spirit. May she rest in peace for eternity.

Yesterday morning, I awoke to the sound of my husband's iPhone as it blared the NPR morning news. This isn't anything out of the ordinary, but the story was particularly appropriate. I later looked it up. It was entitled "When It Comes To Depression, Serotonin Isn't The Whole Story" by Alix Spiegel (re-printed in full at the end of this post). According to this particular story, all the hype about chemical imbalances and correcting levels of serotonin and dopamine aren't flying with current research about mental illness anymore. 

I admit I was a little disheartened. As someone who currently takes medication for treatment of depression and anxiety, I could not help but feel a little out of the loop. Misinformed. Behind the times. Then again, the research does not rule out taking anti-depressants for help with and treatment of depression. Rather, it says serotonin and other brain chemicals may not be the sole cause of mental illness. 

Okay then, so what is? 

The last paragraph of the article states that "the real story is complicated, and in a way, not all that reassuring. Researchers don't really know what causes depression. They're making progress, but they don't know. That's the real story."

Okay, so we don't know. Maybe we don't even know as much as we thought we did. But science continues to surge ahead. Many brain scientists on the front lines have already moved beyond the serotonin theory and have begun to look for other underlying issues, such as identifying what genes might put people more at risk for developing mental illness than others. While this is an exciting development for the field and I am eager to see where it leads, it still leaves those of us currently fighting battles with depression in the lurch. After all, it is only natural for us to want to understand what is happening to our minds and bodies - and why. 

At the moment, we will just have to continue to wait. But that's not all we can do. We can still be advocates of mental health - for ourselves, and for others. We can continue our own individual journeys toward wellness. We can reach out. We can help others. We can stay informed. We can keep the conversation going, and more importantly, keep it open. We can make every day we are given a chance to better ourselves in mind, body, and spirit.

To our health,

h.

~     ~     ~

When It Comes To Depression, Serotonin Isn't The Whole Story

by ALIX SPIEGEL

When I was 17 years old, I got so depressed that what felt like an enormous black hole appeared in my chest. Everywhere I went, the black hole went, too.

So to address the black-hole issue, my parents took me to a psychiatrist at Johns Hopkins Hospital. She did an evaluation and then told me this story:

"The problem with you," she explained, "is that you have a chemical imbalance. It's biological, just like diabetes, but it's in your brain. This chemical in your brain called serotonin is too, too low. There's not enough of it, and that's what's causing the chemical imbalance. We need to give you medication to correct that."

Then she handed my mother a prescription for Prozac.

That was the late '80s, but this story of a chemical imbalance brought on by low serotonin has remained very popular.
"The problem with you," she explained, "is that you have a chemical imbalance. It's biological, just like diabetes, but it's in your brain. This chemical in your brain called serotonin is too, too low. There's not enough of it, and that's what's causing the chemical imbalance. We need to give you medication to correct that."
So to address the black-hole issue, my parents took me to a psychiatrist at Johns Hopkins Hospital. She did an evaluation and then told me this story:
When I was 17 years old, I got so depressed that what felt like an enormous black hole appeared in my chest. Everywhere I went, the black hole went, too.

Then she handed my mother a prescription for Prozac.

"I don't know of any story that has supplanted it," says Alan Frazer, a researcher who studies how antidepressant medications work. He is also chairman of the pharmacology department at the University of Texas Health Science Center at San Antonio.

"It definitely continues to live — absolutely," agrees his colleague Pedro Delgado, the chair of the psychiatry department at UT. "If you go to your community doctor, you're likely to hear some version of that."

But for many scientists who research depression, this explanation is no longer satisfying.

"Chemical imbalance is sort of last-century thinking. It's much more complicated than that," says Dr. Joseph Coyle, a professor of neuroscience at Harvard Medical School. "It's really an outmoded way of thinking."

Coyle, who is also the editor of the journal Archives of General Psychiatry, says that though serotonin plays a role in depression, low serotonin is likely not the cause of depression. Scientific thinking has clearly shifted, he says.

Still, the story of serotonin remains. Why does it continue to have such a powerful grip on the popular imagination?

The Link

According to Frazer, to understand how the story of low serotonin came to dominate our understanding of what causes depression, you need to go back to the late '50s, to a psychiatric hospital in Switzerland.

That's where psychiatrist Roland Kuhn gave a newly developed drug to 10 patients who had been paralyzed by depression for years. Over the course of three weeks, he watched a near-miracle occur.

"There was this lightening of their mood," Frazer says. "They became more energized, more interested in things around them."

This was the birth of the very first antidepressants, called tricyclics. And with that birth came a question: How could these drugs possibly be working? Researchers had some ideas, but it really wasn't until the mid '60s, when the cause of Parkinson's disease was discovered, that a real narrative began to take shape.

It turned out that Parkinson's — a brain disorder — was caused by a deficiency of a chemical in the brain called dopamine. This discovery influenced the way scientists thought about depression.

"There is no doubt in my mind that the Parkinson's story had a strong impact on the way that people were thinking about depression," Frazer says. "It became easy to speculate that depression was due to a deficiency."

The question, of course, was what was deficient? Which chemical was too low? For decades researchers argued this question, but no one candidate took the lead. And then came Prozac.

Prozac's Pull

Almost as soon as it was introduced in 1987, the antidepressant Prozac, which selectively targets the chemical serotonin, became a blockbuster. "Prozac just blew everything else out of the water," Frazer says.

This had less to do with the efficacy of Prozac (it is not better at treating depression than tricyclics, the earlier generation of antidepressants) than with the fact that the drug had relatively few side effects.

"It was very free of side effects," says Pedro Delgado. "And so it began to be used very widely, and there was a lot of enthusiasm for it."

That understates the case. In a very short time, Prozac became wildly popular, and again, Prozac worked on just one chemical in the brain: serotonin.

And really, it is because of the popularity of Prozac that the low-serotonin story took hold, even though, Frazer argues, the scientific research has not borne that out.

"I don't think there's any convincing body of data that anybody has ever found that depression is associated to a significant extent with a loss of serotonin," he says.

Delgado also makes this argument. In the 1990s, he carried out a study that showed that if you take a normal person and deplete them of serotonin, they will not become depressed. He says he feels this demonstrates that low serotonin doesn't cause depression.

Coyle is less absolute in his dismissal of the evidence on serotonin. His take is that while low serotonin probably doesn't cause depression, some abnormality in the serotonin system clearly plays a role. But most researchers have moved on, he says, and are looking at more fundamental issues like identifying the genes that might put people at risk for developing depression.

"What's being looked at are processes that are much more fundamental than just serotonin levels," he says. "We need to move beyond serotonin, and I think the field is."

Serotonin Sticking Around

So why are so many people still talking about low serotonin causing depression?

Frazer says it's probably because it has had, and continues to have, important cultural uses. For one, he says, by initially framing the problem as a deficiency — something that needed to be returned to normal — patients felt more comfortable taking a drug.

"If there was this biological reason for them being depressed, some deficiency that the drug was correcting," Frazer says, then taking a drug was OK. "They had a chemical imbalance and the drug was correcting that imbalance." In fact, he says, the story enables many people to come out of the closet about being depressed, which he views as a good thing.

Still, there's no question that the story also has downsides. Describing the problem exclusively in biological terms has convinced many people to take antidepressants when other therapies — like talk therapy — can work just as well.

One critic I talked to said the serotonin story distracted researchers from looking for other causes of depression. But Delgado agrees with Frazer and says the story has some benefits. He points out that years of research have demonstrated that uncertainty itself can be harmful to people — which is why, he says, clear, simple explanations are so very important.

"When you feel that you understand it, a lot of the stress levels dramatically are reduced," he says. "So stress, hormones and a lot of biological factors change."

Unfortunately, the real story is complicated and, in a way, not all that reassuring. Researchers don't really know what causes depression. They're making progress, but they don't know. That's the real story.

It's not exactly a blockbuster.

A Life in the Making: Two Years Later

This past weekend, I celebrated a unique anniversary.

Two years ago last Sunday, I acknowledged that the way I was living my life was not working anymore.

I was unmotivated, doing only the bare minimum to get by in my classes and at my job. I was fearful of everything: that I would never graduate, that I would be a failure, that my friends didn’t like me, that the people I loved would leave me. Despite the presence of all of the people in my life, I felt alone and slept my days away to avoid this feeling of emptiness. I was either agitated or anxious most of the time. The changes in my mood came on suddenly and were often unpredictable. I got worked up over the most miniscule things. Sometimes a perfectly good day would be ruined because someone looked at me the wrong way.

Somewhere, deep down, I knew this was no way to live my life.

Two years ago last Sunday, I stood face to face in a local bookstore with the man who would later become my husband. We were in the middle of an argument and were about to walk away from the whole thing when he asked me, “Do you think you’re depressed?” I tearfully replied, “Yes. Things that seem easy for other people just aren’t easy for me.”

And so began the journey. We even nicknamed 2009 the “Year of Health.”

Two years ago last Sunday, I named my depression for what it was. There would be no turning back, no more denying. I took the first step toward getting my life back.

And now?

Do I still struggle with depression? Yes, of course. But now I have the tools and the resources to separate the disease from the real me, hence the title of this blog: “I Am Not This Disease.” The art of self-awareness has been an invaluable tool for me in this journey. This might be the most important thing I took away from my time spent in Cognitive Behavioral Therapy. I had to re-learn how to think: how to logically process my thoughts, how to use situational evidence to uncover rational information, how to recognize when I am falling back into the old, destructive thought-patterns of my past.

And medication? Once I found a combination of drugs that worked for me, I can honestly say in amazement that my brain chemistry has changed. To think that I used to feel guilty and ashamed for taking anti-depressants is astounding. Now, I look at that little pill in my hand and feel nothing but thankfulness. I’m thankful for developments in science and medicine. I’m thankful for my doctors. I’m thankful that I’m insured and can therefore afford my medications. We all know that this simply isn’t the case for all people living in this country, and I eagerly await the day when universal health care will be able to touch the lives of people who so desperately need mental health care.

The greatest gift this journey toward mental health has given me was quite unexpected. I have emerged from this experience with a greater appreciation for the people in my life. I now find myself reaching out to others in ways I would not have during my illness. Lately, I notice I have within me a new-found desire to help others. Recalling how so many people sat and waited quietly with me through some of my darkest hours, I now want to be that kind of support for others. I want to give back because I spent so much time on the receiving end.

I also think my depression has made me a better listener and therefore a better partner and a better friend, or so I hope. Now that my life is not consumed with my anxiety and depression, I have the capacity within me to consider the needs of others in ways I have not been able to before. Finally, I am present. Really present. To myself and to others.

I am currently reading a wonderful book written by Methodist minister Susan Gregg-Schroeder called “In The Shadow of God’s Wings: Grace in the Midst of Depression.” I came across a chapter entitled The Gift of Living with Paradox. I had never thought about my depression in this way. She explains that our culture thrives on instant gratification, so living within a paradox, or a mystery as some might call it, does not come easily to us. But this is exactly what living with depression is like. We constantly find ourselves between two polarities: sickness and health, rationality and irrationality, darkness and light, until we can learn how to achieve a balance in our lives. This doesn’t always come easy for a depressive because so often we think in black or white terms, or what some therapists might call “all or nothing thinking.” But this isn’t a life at all, is it? All of us, depressed or not, must learn to accept what Susan calls the “intermingling of the darkness and the light and learning to appreciate the areas of gray.”

Anyone who has gone to battle with a major illness knows that the journey toward health is never fully upward. We take a few steps forward, and a few steps back. Wash – rinse – repeat. And yet this is how we learn. We must come to appreciate all the steps of the journey. Perhaps Susan sums this up best when she goes on to say that:

“The paradox lies in the fact that the parts of ourselves that we have buried in the shadow of subconscious are essential to our becoming integrated, whole persons. When brought into the light, these qualities we have rejected are transformed by God’s grace. They, in turn, strengthen our whole personality.”

So, here’s to living with paradox.

Here’s to two years of journeying toward sound mental health.

And here’s to you and your journey, wherever you might find yourself at this very moment.

May 2012 be another “Year of Health” for us all.

To our health,

h.

Listen to me!

It was now early spring, just a few weeks before Easter. It became clear to me that my elevated anxiety was at the heart of my most recent and lengthy depressive episode. For some time, I had suspected that my medications might be at the root of my problem. Maybe my system had built up a tolerance to them overtime? Maybe they were never the right combination of meds to begin with? Whatever the case, I was at a point where I knew I was feeling no different. It made me wonder why I was taking them at all.

At this time I was taking Wellbutrin, a unique anti-depressant that I had been on for over a year. I was also on Buspar – an oldie but goodie – for my anxiety, but looking back now, it never worked that well for me. If I took the highest recommended dose, I felt sick to my stomach. I tried to tell my psychiatrist on more than one occasion that I didn’t think my meds were helping me like they should. His next step was to prescribe Levothyroxine – a thyroid hormone that when taken at a very low dose was said to help elevate mood. When I contacted him again after several weeks hoping for yet another option, he told me we were running out of choices. Knowing that my body did not respond well to SSRI’s (Prozac, Lexapro, Zoloft), he said our next step might be a low dose of Lithium.

I never called him again.

I may have been depressed, but I knew there had to be other options out there before we pulled out the big guns. Lithium? Now that IS crazy!

I asked my therapist for a referral, explaining to her that I just couldn’t believe Lithium was my last option. She agreed. I knew there had to be another way. I knew my doc just wasn’t listening to me. I was screaming out to him: “Treat my anxiety! Treat my anxiety!” and his solution was to prescribe a drug normally given to patients with bi-polar depression. I had always known I was not bi-polar. My depression just never worked that way. It didn’t happen in extremely high and low fits. I never had the urge to stay awake for days or find myself maxing out my credit cards. It was more like a constant, undulating pulse that weighed me down – some days more than others. I only wanted to sleep. Besides, my therapist assigned me a formal diagnosis of Major Depressive Disorder (MDD) back in February. (For more information on MDD, check this out: http://www.dbsalliance.org/site/PageServer?pagename=about_depression_overview).

My therapist eventually put me in contact with a psychiatric nurse at a local mental and behavioral hospital. Finally – a new plan! The only drawback was that she was booked until mid-May. One evening when my anxiety was particularly horrible – racing thoughts, short of breath, pacing, etc. – I gave in and drove myself to an immediate care center. I told them every med I was on and my entire mental health history. I asked to be put on something that would help calm me down until I could get in to see this new psychiatric nurse.

No help whatsoever. They wouldn’t prescribe me any anti-anxiety medication and proceeded to inform me that if I needed further treatment I would have to go to the local hospital, admit myself, and stay overnight for evaluation. I was seething mad and completely discouraged – again. I just needed some help. I felt like no one was listening to me – again. Even after the doc inquired if I was suicidal, which I have never been even in my darkest moments, she still turned me away. Unbelievable. I knew I couldn’t go home. I would be alone with my thoughts and I wouldn’t be able to calm myself down. When I managed to finally pull myself together again, I took myself to a concert at the music school. A three hour event, it helped soothe my anxiety and lifted me up to a better place. I knew I could return home to an empty apartment and maybe get some sleep. I was going to be okay.

*                       *                       *

Since seeing my psychiatric nurse, who took my complete mental and family health history in handwritten notes, I was prescribed a drug called Cymbalta. Ads for it run on TV all the time: “Depression hurts. Cymbalta can help.” In my case, this is true. Cymbalta is in a class of drugs known as SRNIs, which target serotonin and norepinephrine. I began at 30mg daily, and eventually worked my way up to the full 60mg dose without any problems and minimal side effects. At 60 mg, Cymbalta is said to treat the symptoms of GAD, or Generalized Anxiety Disorder. She also prescribed me a daily low dosage of Klonopin, commonly known as a “benzo,” to further aid in the treatment of my anxiety since I told her I thought this was my most immediate problem. I was told to take a pill in the evening before bedtime; the idea being that I would wake up a little less frazzled and edgy.

So I had a new med cocktail that overtime proved to be effective for the treatment of BOTH my depression and anxiety. All of this arrived at a very providential time in my life. By early May, I had been on my new meds for about two and a half weeks. I also graduated from school – finally – after nine years of work. I even attended the ceremony, which I didn’t do as an undergrad. I felt it would help bring closure to what seemed like an unending chapter of my life. I woke up every morning and could breathe just that much easier knowing that I would never have to go back to this particular school. No more pressures of academia, no more constant evaluation, no more grades assigned to my art. This chapter was done. Over. FINITO!

Some weeks later, my husband and I decided to relocate to the small town in which he was teaching. We found a small house to rent, which for someone who has lived in apartments for the last nine years, this was very exciting! Around this same time, I found a great part-time position at a Methodist church about 35 miles away from where we had chosen to live. I felt so lucky to have found meaningful work during this time of transition. Moving to a small town immediately begs the question: “What the hell am I going to do around here?” But I had been given an opportunity, and for that I am grateful.

Most importantly, it was summer, and I decided to make it a REAL summer vacation. After all my husband and I had been through, after all I had been through between doctors and meds and recitals and this and that, it was time for my mind and body to heal themselves over. This meant no recitals. No conferences. No special projects. I limited myself by taking a very part-time job at a local ice scream shop to give myself a little something different to do during my last few months in town. I spent time with friends and family. I read and caught up on all the stupid TV that I missed during the school year. I joined the local YMCA. Some days, I gave myself permission to stay in my PJs until dinnertime. Big deal, I thought. I earned this. I also kept up on my therapy through individual and couples sessions, still journaling like crazy. I even tried writing some poetry. On the whole, it was a great summer. Without challenges? Of course not. But these challenges were all the more bearable now that I had an advantage over my depression. I had finally – with the help and support of my doctors, my husband, and my family – found a combination of drugs that worked for me.

It took over a year and a half, but we found each other.

To our health,

h.

"The moment you can visualize being free from the things that hold you back, you have indeed begun to set yourself free."---Unknown

Sculpture by: Zenos Frudakis "Freedom"