What if depression was not an illness of the brain?

At med school, I learnt that depression is an illness of the brain. When we properly treat it with the correct medication, we restore imbalances and patients get better.

Depression as a brain illness is a useful model. Many of my patients come seeking help, deeply ashamed of their depression, as if it is a character flaw. When I say that the brain is an organ and can get sick like any other organ in the body, it often helps to get past all the judgemental, self-critical chatter.

The longer I am in this game, the more I realise that while it is true that the brain can get sick, it is perhaps not the whole truth. The brain is an organ in a body in a spiritual being living in the real world. To try and localise depression as just having one origin is simplistic. There are other variables at play.

Inflammation

Inflammation is your body’s response to insult and injury. It is normal and necessary. It’s when a part of your body gets swollen, hot and red. Think of when you knock your knee, and it gets inflamed, you wouldn’t want to move it too much thus giving it time to heal. Or of the fever and malaise of flu which keeps you in bed for a few days. Inflammation is part of your body’s defence mechanisms.

The problem comes in when there is chronic inflammation. In the brain chronic inflammation results in the release of inflammatory SOS signals called “inflammatory cytokines”. Inflammatory cytokines are higher in people with mood and psychotic disorders. These cytokines disrupt the normal production of serotonin and glutamate – key neurotransmitters involved in psychiatric disorders.

What is causing brain inflammation in the first place? The modern lifestyle of high stress, low exercise and unhealthy diet.

When we consider depression as a symptom of an unhealthy lifestyle, then the cure has to be in addressing lifestyle and not just in taking medication.

I do get worried when well-meaning folk tell depressed people to stop their antidepressants and rather live a healthy lifestyle. It somehow implies that patients are responsible for their illness. If they just lived cleaner lives, they wouldn’t be depressed. This is not true. Depression is an illness; it is not anybody’s fault. However, a healthy lifestyle helps the outcome of any chronic illness, depression included.

The gut biome

Our gut, the small intestine and the large intestine, is filled with over a kilogram of bacteria, the gut microbiota. That’s almost the weight of an average brain. These bacteria carry more than a hundred times the genes of the human genome. It is comprised of 150 common bacteria and thousands of less common bacteria.

In 2011 McMaster University in Canada started doing interesting experiments with mice. They bred bacteria-free mice and started transplanting gut microbiota between mice. (Gut microbiota, by the way, is essentially poop.) They had fascinating results. Shy mice became adventurous when they got the gut microbiota of adventurous mice and vice versa.

Now, in 2019, the evidence is mounting that our gut biome not only influences how we feel but also how we behave. Obese patients with unbalanced microbiota crave carbs, unlike obese people with balanced microbiota. Patients suffering from depression have unbalanced microbiota, whether it is a cause or effect of the depression, is uncertain. Experiments are underway researching faecal transplants as novel treatments for depression.

Modern society

One of my patients recently asked me: what if living in depressed state is correct? What if it isn’t an “imbalance” or isn’t something “wrong”? What if being depressed is the only natural state to be in for an intelligent, empathetic, compassionate, informed, thinking individual to exist in the current state of our world?

Is depression a natural reaction to an insane world?

The problem with depression is that you are biased to see things negatively. So I think my patient’s world view was tinted by her depression, and that she could not connect with the joys of the world. However, despite there being more treatments for depression than ever before, the incidence rates of depression keep rising. Modern society is relentless in it’s pace and it is making people sick.

Depression as a spiritual crisis

When I think of someones spiritual life, I do not necessarily refer to their religious life. I rather mean that sense of purpose and belonging which is so essential to mental health.

One of the most difficult aspects of depression is the feeling that life isn’t worth living. Very often, my patients and I get into a loop of treating symptoms and problems. However, when we begin to speak about values and meaningful experiences, then healing and resilience begins.

Victor Frankl, psychiatrist and holocaust survivor puts it like this: If a man knows the ‘why’ for his existence, and will be able to bear almost any ‘how.’ 

Depression continues to be a challenge for its sufferers and treating clinicians. The treatment of your depression will be as unique and individual as you are. If you are suffering, find a clinician who tries to understand you. You do not have to do this alone.