Out of the Blue: Six Non-Medication Ways to Relieve Depression (Norton Professional Books) (21 page)

PROMISING NEW POSSIBILITIES FOR RELIEVING DEPRESSION

Here I want to do a quick survey of some promising avenues I see on the horizon for helping to relieve depression. However, as physicist Neils Bohr famously said, “prediction is very difficult, especially if it’s about the future,” and it is with this caution I that I offer these possibilities.

Gamifying Recovery From Depression

As I hinted before, one promising new approach to relieving depression is to make a game of it. One problem for depressed people is that they have trouble motivating themselves, and another is that they have trouble sustaining positive feelings. Gaming is designed to increase both. The brain has a reward system that releases dopamine, the reward and motivational chemical in the brain. This is why some people get hooked on games. That little reward chemical just keeps squirting into their brains as they win a level or hear some motivating game sound.

I first heard about this approach from Jane McGonigal, a gamer who has advocated gaming as a way to solve the world’s problems. At one point in her life, she suffered a severe concussion that caused brain damage. She had trouble thinking, remembering, reading, writing, and doing anything. She had constant pain. She was told not to be active. It wasn’t clear if she would recover. After a month, she wasn’t any better.

She sank into a deep depression and begin to consider ending her life. She finally decided that she would either kill herself or make a game of crawling out of her depression. She immediately enrolled her twin sister and her husband as her game allies and created both a game structure and a new secret alternate identity for herself in the game.

The game she created was called “Jane, the Concussion Slayer,” and it was designed to help keep her motivated, moving forward toward recovery. Using this game, she did, in record time, almost fully recover from her disability and depression.

When she began to share how she did this during her talks (see her TED Talks video on gamifying recovery at http://www.ted.com/talks/jane_mcgonigal_the_game_that_can_give_you_10_extra_years_of_life.html), others wanted to use her system for recovering from whatever disability, illness, or challenge they faced. So she created a more generic game structure and made it available for free for anyone to use. She called it SuperBetter. Your clients can find it and sign up to try it at www.superbetter.com.

The game has several elements, which, if you have ever played an action/adventure game, will be familiar:

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Secret Identity: To start the game, you adopt a hero identity/avatar, who is stronger and braver than you feel at the moment.

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Quests: These are daily steps you take to get better.

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Allies: These are online or real-world friends who support or encourage you or help you win your quests or get to your goals and celebrate your progress.

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Future Boosts: These are things you look forward to and want.

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Power Ups: These are things that give you energy and strength. (McGonigal’s Power Ups were things she could do to move forward even on her worst days, such as cuddling her dog for ten minutes or getting out of bed and walking around the block just once.)

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Bad Guys: These are the obstacles you face on your way to recover or change.

The game is designed to builds four kinds of strengths for the player: Social, Emotional, Mental, and Physical. Players get an ongoing “Resilience Score” as they stay active in the game and move forward toward their goals and do their Power Ups. They set stretch goals, called Epic Wins, along the way to being “superbetter.” McGonigal’s Epic Win was to run a half marathon, something she had never done before having her brain injury (hence the name “SuperBetter”). The goal is to make one’s life even better than it was before the problem or challenge.

People have used the SuperBetter game structure to get better from such conditions as depression, anxiety, obesity, nicotine addiction, unemployment, knee surgery, asthma, diabetes, chemotherapy, autoimmune disease, and chronic pain. If you have a client who is oriented to gaming (or was before becoming depressed), I suggest you encourage him to sign up for SuperBetter and give it a try. Even if your client wasn’t a gamer, you might recommend it to him if he seems like a good candidate for it. To become familiar with the format and its power, you might even try it out for one of your own issues that you would like to change.

Another game was designed in New Zealand to help teenagers recover from depression. The designers had noticed that many adolescents were reluctant to seek therapy for their depression, but that they were happy to play games and sought them out. So, they decided to design a game to teach kids about depression and help them gather resources to get better.

The game is called SPARX (an acronym for Smart, Positive, Active, Realistic, X Factor thoughts). Again, to start the game, the teen chooses an avatar. In the game, the player is confronted by GNATs (another acronym that stands for Gloomy, Negative, Automatic Thoughts). To help combat the GNATs, players can find the Bird of Hope and grab a Power Staff. They are given various landscapes to conquer or complete a journey within, such as a Cave, Ice, Mountain, or Volcano. Along the way, they learn to manage their anger, anxiety, depression, and unhelpful thoughts and beliefs.

There is already some research showing that the game helps relieve depression in twelve- to nineteen-year-old kids (Fleming, Dixon, Frampton, & Merry, 2012). You can learn more about this gaming intervention at http://sparx.org.nz.

Nutritional Pathways to Preventing or Relieving Depression

Something we haven’t discussed much is nutrition, partly because I’m a psychotherapist and my training has more to do with the brain, emotions, behavior, and actions than nutrition, but like you, I suspect that nutrition has a strong influence on depression and may have a powerful impact on relieving it.

Indeed, there is intriguing evidence for at least a couple of nutritional associations, although it is not yet definitive. For instance, it has been noted that people who are depressed have lower levels of Omega-3 fatty acids and DHA in their bloodstreams (Frasure-Smith, Lespérance, & Julien, 2004). Now, it’s hard to tell whether this finding is a cause or an effect. Does a deficiency in those fatty acids precipitate depression, or does being depressed deplete Omega-3’s? Either way, it might be worth having your clients try some daily high-dose Omega-3 supplements to find out whether they help them feel any better.

In one controlled trial, participants who were depressed but not anxious experienced relief when they were given Omega-3 supplements (Lespérance et al., 2011). Why people with co-occurring anxiety didn’t benefit is unknown. Of course, more research should be done to discover more about this non-medication pathway to recovery.

There are probably other nutritional elements that have a role to play in bringing on depression and in alleviating it, but this is still a big territory to be explored and full of “experts” who will tell you their firmly-held beliefs and put them forth as fact. It would be nice to have more science to give those opinions more grounding in fact, and I expect we will find out more as time goes on.

The Inflammation-Depression Connection

Related to the nutritional aspect of depression is some newfound awareness of the role that inflammation plays in many diseases and conditions. For instance, there is a surprising connection that has been discovered between gum inflammation and infection and heart problems. Inflammation has also been implicated in cancer, arthritis, dementia, and many other ailments. Stress can increase or bring on inflammation and, as we saw in Chapter 7, may impede brain cell growth.

So, is there a stress-depression connection? It appears so.

Psychiatrist Richard Shelton and his co-author Miller review evidence for this connection in their article “Inflammation in Depression: Is Adiposity a Cause?” (2001). Here is their summary:

Mounting evidence indicates that inflammation may play a significant role in the development of depression. Patients with depression exhibit increased inflammatory markers, and administration of cytokines [small signaling molecules used by the nervous system] and other inflammatory stimuli can induce depressive symptoms. Preliminary findings indicate that antagonizing inflammatory pathways may improve depressive symptoms. One primary source of inflammation in depression appears to be adiposity. Adipose tissue is a rich source of inflammatory factors including adipokines, chemokines, and cytokines, and a bidirectional relationship between adiposity and depression has been revealed. Adiposity is associated with the development of depression, and depression is associated with adiposity, reflecting a potential vicious cycle between these two conditions which appears to center around inflammation. Treatments targeting this vicious cycle may be especially relevant for the treatment and prevention of depression as well as its multiple comorbid disorders such as cardiovascular disease, diabetes, and cancer, all of which have also been associated with both depression and inflammation.

Another study found that having higher-than-normal blood levels of C-reactive protein (CRP), an indicator of inflammatory disease, increases the risk of depression two- to threefold (Wium-Andersen, Ørsted, Fallgaard Nielsen, & Grønne Nordestgaard, 2013). Exercise has been shown to decrease inflammation levels, so the strategies for exercise and brain growth put forth in the last chapter may be using this anti-inflammation mechanism to help alleviate depression.

Vagus Nerve Stimulation and Deep Brain Stimulation

There are two newer treatments that are still unproven in scientific studies, but they have worked for some depressed people and I think they are worth mentioning here.

Biological psychologist Stephen Porges has been writing about the connection between the vagal nerve system and mood, stress, trauma, and illness for some time. He calls his theory the Polyvagal Theory (Porges, 2007). Other practitioners have begun to investigate whether using electrical impulses to stimulate the vagus nerve can alleviate depression, especially for people who don’t respond to traditional medication treatment, and so far they have found that it can (e.g., Sackeim et al, 2001).

Another promising possibility is called deep brain stimulation (Mayberg et al., 2005). This involves stimulating parts of the brain that appear to be metabolically overactive in depressed people so as to modulate the activity of that region (in the main study that has been done, the target has been the subgenual cingulate region, or Brodmann area 25). While the studies that have been done are preliminary, this kind of treatment may become more common and better established scientifically as a treatment for depression as we develop more refined tools to examine the brain in action and perfect methods of using light and electricity to do subtle interventions that have few if any side effects. Deep brain stimulation has been used to great effect with Parkinson’s patients and is now a standard treatment for that disease, so perhaps it will be the same with depression one day. Now it is used mainly to treat severely depressed people who haven’t responded to any other treatments.

However, much more needs to be known about it. Indeed, one woman who was treated with deep brain stimulation actually seemed to develop a serious depression as a result (Bejjani et al., 1999).

Better Medications With Fewer Side Effects

One of the problems with earlier antidepressants was that people experienced unpleasant and sometimes intolerable side effects. The newer SSRI medications became more popular in part because they resulted in fewer side effects and were better tolerated by depressed patients. I suspect that in the future, as we learn more about the brain, more targeted drugs with even fewer side effects will be discovered and developed.

One of the problems with current antidepressants is that they typically take weeks or months to have their full helpful effect, so the development of drugs that work more rapidly would be welcome. One drug that is currently used in hospital settings and sometimes has a stunningly rapid effect is ketamine. Ketamine can relieve suicidal impulses rapidly as well. (As a former hippie, I remember hearing about ketamine being used as a recreational drug in my college days, and if memory serves, it was a hallucinogenic drug, so it must be carefully administered and monitored when used for depression, I am sure.) Ketamine has also been used in medicine as an anesthetic.

For depression, ketamine is administered by injection, and while it can have a rapid and dramatic effect in lifting depression, its effects typically don’t last long, and not much is known about the long-term effects of multiple administrations of ketamine (Mount Sinai Medical Center, 2013).

Another fast-acting experimental drug called AZD6765 works, like ketamine, on the glutamate system in the brain, and also shows promise for rapid relief of treatment-resistant depression (Zarate et al., 2012).

Drugs to stimulate brain cell growth will be developed in the future, either combating the die-off of brain cells that accompanies long-lasting depression or preventing it in the first place. So, while this book is about drug alternatives, I would be happy if better drugs that worked for more people were developed.

PREVENTING DEPRESSION

Another area that is important is prevention. One explanation for why there has been a decades-long rise in depression is that there is more and more fraying of the social net that connects people in industrialized countries. The Internet has been bad and good in this respect.

It is easier for people to live much of their lives, and even much of their social lives, online without having actual face-to-face interaction with others. Yet the web has helped people who are feeling isolated find like-minded people more easily as well.

So, perhaps future depression prevention efforts will identify people who are at risk of developing depression and take steps to help them connect with others more.

Another prevention effort might find people who have had depression and have come back from it so that we can investigate the process of “resilience,” as it is called in the mental health and sociological literature these days. In this book I have put forth some ideas about what helps people bounce back, but it would be nice to see as much effort going into researching resilience from depression as we see going into studying its causes and biochemistry. Let’s study people who come back from depression more quickly than others, or people who don’t develop serious depression despite being at risk genetically or because of chronic stress exposure.