Depression is a disease of civilization, by Stephen Ilardi

Depression is a disease of civilization, by Stephen Ilardi

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Depression is a disease of civilization
by Stephen Ilardi
April 2013

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Dr. Stephen Ilardi

I believe depression is one of the most tragically misunderstood words in the entire English language and here’s the problem. Depression has two radically different meanings depending on the context. So in everyday conversation when people say they’re depressed, they use the word depression as a synonym for sadness. It’s the normal human reaction to the slings and arrows of outrageous fortune. In that sense, all of us know the pain of depression.

And yet in a clinical context, depression is shorthand for a devastating illness we refer to it technically as major depressive disorder. This is an illness which robs people of their restorative sleep, robs them of their energy, robs them of their focus, their concentration, their memory, their sex drive, their ability to experience the pleasures of life. For most individuals, it robs them of their ability to love and work and play. It may even rob them of their will to live. And I’ll tell you why.

Because we now know depression lights up the pain circuitry of the brain, to such an extent that most clinically depressed individuals, if you talk to them and they let their guard down, they will tell you as they’ve told me hundreds of times. It’s torment, it’s agony, it’s torture, and many begin to look to death as a welcome means of escape.

Depression is the main driver behind suicide which now claims over one million lives every year worldwide. Now I know what you’re probably thinking at this point. Man, this talk is going to be really depressing. So I am going to give you a friendly little spoiler alert. It’s not. It’s truly not.

Depression – yes, it is a treacherous foe. But what I found in my 20 years of clinical research and clinical work is this is a foe that can be defeated. That’s the good news, and that’s the news that I am going to focus on for most of the talk tonight.

First, a little more bad news. Depression is now a global epidemic. In fact, if we look in the U.S. we now find that nearly one in four Americans will experience that agonizing debilitating pain of depressive illness by the time they reach age 75. And it gets worse. The rate of depression seems to be increasing generation after generation. So every successive birth cohort is having higher rates of depression than the one that preceded it.

Now I want you to look at these lines. We’ve got four different generations on this graph. The green line on the right, that’s the oldest Americans and by the time they’ve made it out into their 60s and 70s they have a lifetime rate of depression of 10%. That’s horrible but it’s much lower than every succeeding generation.

Now take a look at the line that really upsets me the most is the one on the far left: that’s our youngest American adults. Do you see what’s happened? By the time they are in their mid-20s they already have a rate of depression up 25%. Remember, we’re talking about a potentially lethal debilitating illness. Left unchecked, it’s an illness that can cause brain damage. And if we extrapolate that line, by the time they reach middle-age, their lifetime rate of depression will already be over 50%.

So what in the world is going on? What’s driving the epidemic? What can we do about it? What causes depression?

Well, on one level when we ask this question, we’re going to face the answer – it’s really complicated. There have been literally thousands upon thousands of published studies that have identified a dizzying array of factors that are implicated in the onset of depression: biological, psychological, cultural, social, behavioural but if we wade through this complexity what we begin to find is there’s a common underlying pathway, a primary driver, a primary trigger, I call it, the brain’s runaway stress response.

Now we all know the stress response. We think of it probably as the fight-or-flight response in its most extreme form. I want you to think about that response and especially how it was evolved and adapted to serve us.

The fight-or-flight response was designed primarily to aid our ancestors when they faced predators, other physical dangers, that required what? Intense physical activity that would go on for a few seconds, for a few minutes, maybe in extreme cases for a few hours. It’s a very costly response but fine if it shut off when it’s supposed to.

Here is the problem. For many Americans, Europeans and people throughout the Western world, the stress response goes on for weeks and months and even years at a time and when it does that, it’s incredibly toxic to the body and to the brain. It’s disruptive to neural circuits in the brain that use neurochemicals you’ve heard of, like dopamine and serotonin, acetylcholine, glutamate and this destruction can lead directly to depressive illness.

It also can actually damage the brain when left unchecked over time, especially in regions like the hippocampus which is involved in memory consolidation and a frontal cortex. And it also triggers an inflammatory reaction throughout the body and brain.

And here is what we’ve learned about depression. The inflamed brain is a depressed brain. Now this is really intriguing because epidemiologists have now identified a number – a big consolation of illnesses that are rampant and epidemic throughout the entire developed world. You can see the list: atherosclerosis, diabetes, obesity, allergies, asthma and many forms of cancer. These are all inflammatory illnesses. They’re all illnesses that are epidemic in the industrialized modernized world and largely non-existent among modern day aboriginal groups.

I believe we need to add depression: clinical depression to this list. It shows all the hallmarks of being a disease of civilization. And you know what that means? It’s a disease of lifestyle.

So consider the experience of the Kaluli people, of the Highlands of Papua New Guinea. They’ve been studied extensively by the anthropologist Edward Schieffelin. He spent over a decade among the Kaluli. One of his research questions was: How often do the Kaluli experience the same kind of mental illness that we do, and he certainly found some forms of it. He interviewed over 2,000 members of the Kaluli and extensively queried them for their experience of clinical depression.

And you know what he found? One marginal case out of 2000. That gives them a rate of clinical depression that’s probably about 100 times lower than ours. I will tell you why I find that really remarkable.

Because among other things, the Kaluli lead really, really hard lives. Really. They have high rates of infant mortality. They have high rates of parasitic infection. They have high rates of violent death. But they don’t become clinically depressed. They grieve absolutely. They don’t get shut down.

What’s protecting them? Lifestyle. Specifically, the Kaluli live a lifestyle very similar to that of our ancestors over the entire Pleistocene epoch that lasted for 1.8 million years.

Did you know that 99.9% of the human and pre-human experience was lived in hunter-gatherer context. So what does that mean? Most of the selection pressures that have sculpted and shaped our genomes are Pleistocene. We’re still really well adapted for that sort of environment and that sort of lifestyle. I’m not saying there hasn’t been any change since then, because of course 10,000 to 12,000 years ago, we had the invention of agriculture. And there has been some genetic selection over that period of time that’s been more minor.

But what happened 200 years ago with the industrial revolution, it’s been termed radical environmental mutation. I like that term. It’s as if modern American and Western life is radically discontinuous from everything that came before. Our environment has radically mutated.

But how much has the human genome changed over the last 200 years? It hasn’t. It hasn’t. That’s 8 generations. It’s not enough time.

What does that mean? There is a profound mismatch between the genes that we carry, the bodies and the brains that they are building and the world that we find ourselves in. I’m going to put it for you as pithily as I can.

We were never designed — we were never designed for this. We were never designed for the sedentary indoor, socially isolated, sleep-deprived, fast-food laden frenzied pace of modern life. The result: an epidemic of depressive illness.

Now I’m a depression researcher. I was trained in a traditional form of psychotherapy. I was trained in a context where I learned all about antidepressant medications and I want to tell you right at the outset: I am NOT anti-medication. I believe in fighting depression with every possible tool that we have.

But you know what? If we only throw medication at this epidemic, we are not going to fix it. At least we haven’t so far.

How much do you think antidepressant use has gone up over the past 20 years? Would you care to guess?

Audience: 1700%.

Dr. Stephen Ilardi: I like that guess – 1700%. It’s gone up over, over 300%. So you’re close. Over 300% and what’s happened to the rate of depression in the interim? It’s continued to increase. 1 in 9 Americans over the age of 12 is currently taking an antidepressant. 1 in 9! Currently 1 in 5 according to some estimates have tried it at some point.

Have we solved the epidemic? No, we haven’t made a dent. The answer I believe is a change of lifestyle.

Now you’ll see behind you a list of six lifestyle elements. When my research team and I, seven years ago, had this epiphany. We got together and we started scouring through the depressive literature, asking the question: What are the Kaluli doing that’s protecting them, specifically based on everything we know about depression. What did our ancestors do that protected them and we quickly found six factors that changed Neurochemistry. 6 factors that are known to be antidepressant. 6 factors that we can reclaim and weave into the fabric of our day-to-day life in the present, to protect ourselves from this devastating illness.

And so we designed a new treatment program. It was really ambitious; I admit that. Did I think it would work? I really wasn’t sure. You know what? I was not trained as a psychotherapy – as an interventionist researcher I was doing basic neuroscience psychopathology. But I had a passion to see this epidemic brought to its knees. I had a passion to treat individuals whom I knew, who had tried everything and were still depressed.

And so with great trepidation, we set out to design this program. The results have exceeded my wildest dreams.

There are six major elements that — I’m going to run through them as quickly as I can in our remaining time.

The first is exercise. Now exercise is good for us. How many of you – can I see, show of hands, how many of you came in here today knowing that exercise is really, really good for us, right? Every hand goes up.

Now has it changed your behavior? For some, yes. Everybody knows that exercise is good for us. Here’s the problem. Many people have trouble making it happen. And you know what? A lot of people don’t realize just how good exercise – I’m going to say something that may be a little bit controversial – I’m going to go ahead and say it. And I’m not speaking metaphorically. Exercise is medicine. Exercise literally is medicine. It changes the brain and the body in beneficial ways that are more powerful than any pill you can take. Yeah, I said it. More powerful than any pill you can — In fact, I’m going to say something even more controversial.

If you could take the neurological and physiological effects of exercise and capture them in a pill, all the beneficial effects on neural signaling in the brain, the anti-aging effects all the way down to the level of chromosomes in every cell of your body, the mental clarity enhancing effects, I believe — tell me if you think I’m crazy – I believe that pill would become the best-selling drug of all-time. And I think people would pay any price to have it.

There’s a problem though. We don’t exercise. We don’t. CDC again tells us that 60% of all American adults get no regular physical activity. And yet if we look at hunter-gatherer groups, they get four or more hours of vigorous activity every day. In fact, they looked like elite athletes even when they’re in middle age and beyond.

Here’s the thing I love though. If you ask them, they will tell you they do not exercise. They don’t. They do not workout. Working out would be crazy to them. What did they do? They lived. They lived.

Here is – yeah I know. I like it too.

Here is the dirty little secret in the business. And I really want you to — if you remember nothing else in this talk — exercise is not natural. We are designed to be physically active in the service of adapted goals. We are not designed to exercise. When you put a lab rat on a treadmill and crank that thing up to the point where it’s moving faster than it wants to move, you know what it will do – if you let it, it will squat down on its haunches and the treadmill starts to wear the fur and the skin right off its backside.

So it kind of feels our pain, right? When you stare at a piece of exercise equipment, there is a piece of your brain that’s screaming out: Don’t do it. You’re not going anywhere on that thing.

So how do we solve this conundrum?

In our treatment program, we’ve done two things. We’ve made exercise natural and we’ve made it social. What’s the most natural activity in the world? Walking. And guess what? Brisk walking, you know the kind like you’re late for the bus, like you might miss your plane, that kind of walking will get your pulse up in the aerobic range and that’s where it needs to be, based on your age, depending on your age, it needs to be with – your pulse needs to be between about 120 and 150. That’s enough to enhance signaling in your dopamine circuits, your serotonin circuits. It’s been tested head to head against Zoloft twice in long-term it won. At what dose? 30 minutes, three times a week. That’s a low dose. It can change your life.

Now I wish I had time to cover everything else that we need to cover. But I am going to tell you about one more thing: Omega-3 fats.

Omega-3 fats

Did you know that your brain is mostly made out of fat? Did you know the brain is 60% fat by dry weight? So if somebody calls you a fathead, they might be paying you a compliment.

All right. Here’s the thing.

Our bodies can make all the fats that we need with two exceptions. They are called essential fats. You’ve heard of them. Omega-6s, omega 3s, they play complementary roles in the body and the brain. Omega 6s are inflammatory, omega 3s are anti-inflammatory. We need them in balance. We’re designed to have them in balance. Omega 3s come from grasses and plants and algae and the animals that eat them. Omega 6s from grains and nuts and seeds and animals that eat them, which is by the way most of our meat supply.

Our hunter-gatherer ancestors got omega 6s and omega 3s in the optimal balance, which is roughly one to one. We can do fine at 2 to 1. We can probably even do okay at 3 to 1. But guess what? The modern American diet, which is riddled with fast food and processed food and grain fed meat, you see the ratio there. 17 to 1. 17 to 1, things are way out of balance. It’s very heavily inflammatory. It’s very heavily depressant. And that suggests to us of course that if we could supplement with omega 3s that might just be antidepressant, guess what? Over a dozen controlled research trials have now shown this to be the case.

What’s the anti-depressant dose and I am going to leave you with this hopefully, an important tip.

The best research suggests that there is a specific omega 3 molecule; it’s called EPA. And at a dose –it is a pretty high dose – of 1000 milligrams to 2000 milligrams per day, it’s shown to be antidepressant. And many of our patients have benefited remarkably, not just with respect to their depression but other inflammatory conditions as well.

My own story – when I began supplementing with omega 3s several years ago, the tendinitis in my knees went away. And I could start running full court basketball again. The dryness in my eyes cleared up and I could keep wearing my contacts. It’s remarkably health-promoting in many different ways.

Now for those of you who want to get more details 5about this treatment program, I’m just going to zip ahead, because I’m out of time. There’s a lot more to share with you. I don’t really talk about cals. We are designed as a very social species, we’re designed to connect. Did you know that FaceTime, time and the physical presence of our loved ones actually puts the brakes on our stress response? Did you know that our ancestors spent all day every day in the company of their loved ones, their friends? Think about the extensive FaceTime they share with the people that matter most. And what have we done? We’ve traded FaceTime for screen time, FaceTime for Facebook, and the result is devastating. The result is devastating.

We’re born to connect. We need that connection. In our treatment protocol, we work very very hard to help each depressed individual resist the urge to withdraw because when you’re ill your body tells you to shut down and pull away. When you’re physically ill with the flu, that’s adapted, when you have clinical depression, it’s the worst thing in the world you can do, even though every fiber of your being is telling you exactly the opposite.

We’ve got lots of good data on our outcomes. And as I have said they’ve exceeded our wildest expectations. Most of the patients that have come to us have tried meds and they haven’t gotten well. Most of them have tried traditional therapy and it hasn’t been the answer. The majority have gotten well as they’ve been willing to change the way they live. We had a man a year and a half ago who had been fighting depression for 41 years consecutively. And it was one of the happiest days of my life when he came into a session after 14 weeks and he looked around the room with tears in his eyes and said, “This is what I remembered it felt like to be free”. It can happen.

Now we’re still working to improve this program. We’re still working to make it better. I wish I had time to share with you some of the things we’re learning. For those of you who want to learn more about it, I’d invite you to go to our website. We have lots of details. I wish you all a joyful and depression free life.

Thank you.
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