To fight a rising tide of depression and suicide, psychiatrists need to do more than just fill patients up with pills
The New York Times recently published an important investigative report shining a long-overdue light on the painful, sometimes disabling experience of withdrawing from antidepressants – drugs that millions of Americans have been taking, sometimes for decades
The recent deaths of Kate Spade and Anthony Bourdain threw into stark relief the human toll that depression can take. But the problem is complex, with multiple factors. We are seeing a striking increase in the number of Americans diagnosed with depression, and an accompanying increase in suicides. This is coupled with the promiscuous and sharply increasing prescription of antidepressants to 34.4 million Americans in 2013-2014, up from 13.4 million just 15 years earlier. And this pervasive prescribing continues despite the lack of proof of the drugs’ long-term effectiveness; their mixed results even with short-term treatment; the frequent side-effects – weight gain, gastrointestinal problems and sexual dysfunction – that are themselves depressing. Meanwhile, we are paying the prohibitive financial costs of depression – an estimated annual average of $210.5bn in treatment and lost productivity.
These numbers raise critical questions: why are so many Americans becoming depressed? Why do rates of suicide, depression’s dire and irreversible consequence, continue to increase – by 25% since 1999 according to a recent Centers for Disease Control and Prevention report? Why are we treating vast numbers of these depressed and suicidal people with drugs that are of limited effectiveness? How can we do better?
Depression is characterized by low energy and despondency, negative self-esteem, pervasive pessimism, difficulties with eating, sleeping and sexual functioning, and helplessness and hopelessness. It is caused by biological, psychological, social and economic and spiritual challenges which are increasing in number and severity and often compound one another. These include decreases in social support and the loneliness that follows; high levels of stress about the economy, and the future; the hyper-competitiveness and hypercritical self-assessments of youth; sedentary lifestyles and poor diet; and our addiction to our digital devices.
The prevailing psychopharmacological treatment is based on the theory that depression is a neurotransmitter disorder. Pharmaceutical manufacturers and physicians are fond of making an analogy between depression and type-1 diabetes. The bodies of type 1 diabetics do not produce enough insulin, so diabetics receive insulin by injection. Depressed people, the analogy goes, are incapable of producing adequate amounts of neurotransmitters and must be prescribed drugs to increase them.
This is incomplete and misleading. Some depressed people may have lower levels of serotonin or norepinephrine. But no one knows how many, and doctors rarely measure these levels before prescribing drugs. A variety of emotional, social, nutritional and environmental factors affect a person’s fluctuating neurotransmitter levels, which in turn affect how a person functions. In other words, low levels are likely to be the symptoms, not the cause, of depression. Unfortunately, the prevalent view of depression as a “Prozac deficiency disease” prevents many Americans from seeking out a more comprehensive, safe and effective approach, grounded in self-care and group support.
Meditation is fundamental to this approach. Slow, deep breathing relaxes our body, quiets our mind, and lowers the stress which often precipitates depression. It quiets activity in the amygdala, a portion of the emotional brain responsible for fear and anger, and enhances activity in the hippocampus, which mediates stress and memory and is damaged by depression. Meditation thereby promotes functioning and increases tissue mass in the frontal part of the cerebral cortex, where depression has inhibited judgment, self-awareness and compassion. Meditation also makes it easier for us to connect with others who may provide comfort, intimacy and support. It gives us perspective – helping us see that what seemed insurmountable is manageable. It promotes compassion, and facilitates finding mood- and life-enhancing meaning and purpose.
Physical activity complements meditation. As a depressed person moves, she overcomes her inertia, releases tension and reclaims and enjoys a body that seemed alien, even hostile. Jogging, tai chi, yoga and dance all lower stress and stress hormones, may help rebuild the hippocampus and enhance activity in the frontal cortex. Exercise by itself can be at least as effective as drugs in relieving depression.
These self-care tools enhance the production of the neurotransmitters that drugs are aimed at – serotonin, dopamine and norepinephrine – without damaging side-effects. And the active engagement that self-care requires may itself be the most effective antidote to depression’s hallmark symptoms of hopelessness and helplessness.