Sunday, February 7, 2010

Release the Kraken!!

Well, it's one of those weeks in a remitting/recurring disease. "Release the Kraken!" -- my favorite line from Clash of the Titans, a 1981 movie to be remade and released this summer.  Oh, you gotta check out that link to the trailer!

My apologies to regular readers who are looking for a new post.  It's an interesting one, Shadows.  Maybe I will be able to write it next week.  Come to think of it, the image on the right would fit that post, too. (Anonymous, in the public domain for copywrite expiration). For now, here is a reprint from last July:

What is Depression, Anyway?

When I thought the meds would work, I didn't ask this question (referring to the title, not the caption!) Depression is a disease of the brain and also of the mind. The best results are obtained by working on both fronts. Take your meds. Talk to your therapist. Simple.

Then I discovered that the meds made me worse. Whenever I say that, I rush to say that, my experience notwithstanding, for most people they work. They can save your life. And then I rush to say, but not for everybody. If you think they make you worse, you might be right.

The rhetoric keeps shifting on this point, depending on what the speaker is selling. I
think the current prevailing stats are that the meds help half of us, harm a quarter of us, and for another quarter, they just don't work. And for most of us in any of those groups, the disease does go away on its own anyway, though it leaves its wreckage behind. But that is what I am gleaning from the research. Nobody in the scientific community has summed it up so simply.

Me, I am in the serious harm group, which has turned me into a dog with a bone. The bone is this one question, What the hell happened to me. I can't let it go, because I don't know what will happen next.

The popular understanding is that depression is a "chemical imbalance" in the brain. This simple formulation is the simple sales pitch for the simple solution, Prozac, to be specific, and then other selective serotonin reuptake inhibitors (SSRIs), and later serotonin norepinephron reuptake inhibitors (SNRIs). These meds (siblings and cousins -- they all address the same mechanism in the brain) were thought to be the single bullet solution for the single bullet problem, not enough serotonin.

SSRIs worked wonderfully for a while. They emptied the psych wards. They still work wonderfully for many. But over time the evidence accumulated, and eventually doctors started to believe their patients who claimed that the meds were not working, or had stopped working, or were driving us over the edge.

The people who believe in SSRIs have solved the pesky problem of the quarter of us who are screaming by coming up with a new diagnosis. We don't have regular depression, they tell us, we have Bipolar II. Which is a very effective way to shut us up, because Bipolar is a scary diagnosis that first flattens us and then drives us underground. While depression has less stigma than it used to have, Bipolar is as scary as ever, even if you add that "II." Plus, it opens up a whole other set of medical options, with side effects that are even less appetizing. Other options for the alternate label are anxious depression or depression, mixed state. They all mean the same thing: we fit the diagnostic criteria for major depression, but we go crazy when we take the meds for major depression. So the problem must be us, because it can't be the meds, which reduce suicidality, not cause it, notwithstanding the reports of people who are, after all, mental patients, and at risk of suicide anyway.

Here is the issue. Depression is a physical and objective illness in the brain that is diagnosed on the basis of symptoms that are subjectively experienced in the mind. Remission is defined in the same way, by self-report of subjective experience.

But it turns out, according to fMRI's, the brains of people who have been depressed
but currently have no symptoms work differently than those who have never been depressed at all. The physical manifestations of the illness in the amygdala and the pre-frontal cortex persist, even when the mental aspects have temporarily abated.

Regarding that chemical imbalance, if you artificially reduce the serotonin in a depressed brain that is on meds and in remission, you will cause a return of the symptoms. However, if you artificially reduce the serotonin in a brain that has never been
depressed, there is no depressive effect. So the physical evidence and the mental experience do not always coincide.

So what is depression, anyway? And why does it go away? And why does it come back? I might let go of this bone, if only it didn't keep coming back.

The brain is a complex system with communications channels and feedback loops that maintain homeostasis and interacting mechanisms that make it work well when it works well, and even repair itself when it is injured. The experiences of relapse and of "Prozac poop-out" seem to indicate that these mechanisms also maintain homeostasis when the brain does not work well, when the set points are set in ways that make us sick.

There are set points other than the amount of serotonin in the synapses. The early success of SSRIs led researchers to place all their eggs in the neurotransmitter basket and neglect the development of other approaches. We all loved that "chemical imbalance" idea that gave so many people permission to seek treatment, because it is so objective and suggests that there is physical evidence. The downside of the simple explanation is it has caused a lot of suffering for those who follow instructions and "keep trying" to find the med that works, when the whole idea behind the meds may be off base. And that suffering is compounded by suspicions of malingering from people who believe the sales pitch, that depression has been solved.

And what about therapy? There is evidence that it works, that it prolongs remission. But remember, remission is defined as the current absence of subjectively reported mental symptoms, not what is actually going on inside the skull. So how does therapy work? And then why does it stop working? My therapist thought I was still depressed because I wouldn't stop thinking certain thoughts. I said I couldn't stop thinking certain thoughts because I was depressed. Maybe that is the mental feedback loop. Sometimes my efforts to interrupt it work, sometimes for a long time. And then homeostasis reasserts its grip.

I like to think that each time I go under I learn new tricks for how to come back up. That's the good news. The bad news is that I can keep going down deeper, where the new tricks I learned last time don't work. I need a different relationship with my brain and the places it takes me.

I expect that scientists will spend the rest of my lifetime trying to make brains like mine work like the brains of non-depressed people, that some people will be helped in that ongoing chemistry experiment, and some people will be harmed. But the mystery will not be solved. And in the end, brains like mine will persist in being different.

Depression comes from a brain that works differently than the norm. I have a suspicion that it will be easier for me to find a way to survive being different than to find a way, whether through drugs or therapy or surgery or whatever, to get my brain to conform.


  1. Hey, Willa. Great repost. As you know, I've been asking a lot of questions on my blog along the lines of Is it depression or is it something else? I really think it would be useful if we eliminated the term depression entirely and broke it down according to source (such as "stress disease") or prominent symptom (such as "lack of motivation disease" or "feeling sad disease") or what we really may have (such as, heaven forbid, bipolar II or bipolar NOS).

    Then, having sorted out the stress people from the unmotivated people from the sad people from the BP people and on and on, maybe we could actually come up with tailor-made treatments and therapies that work. No more stupid SSRI's for everyone nonsense.

    Please keep pursuing this line in your blogs. I'd love to see what you come up with.

  2. Last night the image came to me, "If fever is the symptom, leeches are the cure," Yeah, we're still at the leech stage.