Placebo: What Your Brain Can Do for You

The placebo effect is the measurable, observable, or felt improvement in health not attributable to treatment. This effect is believed by many people to be due to the placebo itself in some mysterious way.

So states this article on placebos and depression from the Skeptic's Dictionary, and appropriate resource. Like this UCLA article about placebo usage, it discusses how, when a patient is told they are receiving a placebo, the effectiveness often goes away. Is this because the treatment was all in their heads? Or that the depression was?

Many studies try to compensate for the "placebo effect." Others, more recently, have specifically studied this factor as a healing process. A study by Dr. Arif Khan showed, according to the New York Times, that:

It turns out that the more severely depressed people are, the less likely they are to respond to a placebo. And people with more mild depressions get better with just about all treatments, including placebos. Since most clinical trials enroll less severely depressed patients, the observed difference between the response to an antidepressant and a placebo can be misleadingly small.

Other studies, including one by Dr. Irving Kirsch, suggest that medications are nearly useless because the placebo effect is so high in depression treatment. Meanwhile, doctors wrestle with the ethics of "tricking" patients with placebos.

I think the point is not quite being realized by the scientific community. Depression is a disease that is has an effect upon the body as well, because the brain controls all things. Placebo is the brain's natural ability to repair damage to all the human systems. This process is easily interrupted by doubts and limiting beliefs. At this point in our development we have identified the process, and we recognize that it can be encouraged by presenting patients with a physical talisman, if you will, of healing; the pill. More severely depressed people need more than a sugar pill because they are so very sick their limiting beliefs extend deep into the unconscious, metastasizing like cancer. They need medications to bring them to the point where the placebo process can recover enough to even try to work.

I foresee a time when the scientific community will focus serious research on placebos, not to remove them as a variable or identify what is "in a patient's mind," but to determine how to harness our own healing ability and hone it. This research will not be conducted by drug companies, because it would not be advantageous to cure such a lucrative market for maintenance medications. It will be research into areas currently sidelined as psychology or superstition, and will tap into the true potential of the human brain.

The lucky depression patients have found other avenues to unlock these secrets, either through sugar pills or prayer or exercise or therapy, and they have been given a chance at true healing, y allowing their brains to overcome depression naturally. It's time the scientific community figures out a way to give the rest of the victims that opportunity.

Self-Care Options

This article reinforces my position on the paradox of depression: you aren't going to get better if you can't learn to do it yourself, but depression keeps you from believing that this is possible. Drugs and therapy can be important tools for recovery, but neither of them will succeed without your help, and neither of them should be considered for a lifetime. If you plan for a day when you won't need them you're much more likely to reach that day.

Either of those treatment options may give you the needed push to get to a point where you can do something for yourself, crawl just far enough out of your own personal pit that you can take at least a small amount of responsibility for your own recovery. If they can't get you to that level, and you aren't functional enough to make it there without further help, you should find that help. Never forget that the worst symptom you have is the belief that you are going to stay this way, that nothing you do can change it, that it's pointless to even try. Don't give in to that crap, because if you expect the worst you're rarely disappointed. Do you have anything to lose by trying for more? Can it really get worse than it is? Really?

Some thoughts on the five suggestions given:

• Keep Active: yep, I've mentioned how important even a little bit of exercise can be. Don't want to get out of bed? Consider having a friend drag you out if necessary.
• Eat well. A well-balanced eating strategy will help you feel better now and later. Good thought. I've had comments here from depression victims that eat like crap, and it shows in the writing that they're just making things worse. Your body needs good fuel to do a good job.
• Get adequate sleep. I would modify this to say, "Get appropriate sleep." Insomnia is a symptom of depression, but I was more prone to the fourteen-to-sixteen-hour power nap. I psychiatrist I knew said that the best way to regulate sleep is to get up at the same time, every day, without fail. Your body will take care of the rest.
• Control stress. Coping with depression is stressful enough, so try to limit other sources of stress. And depression does a marvelous job of amplifying the other stress, doesn't it?
• Stay connected. Make relationships a priority. Social ties give you a sense of purpose and meaning in life. I can't emphasize this more. You need to be around people, even if you don't feel like it, because even if you believe you're alone in a crowd it is better than being alone alone. Do it even if you don't want to.
  

Fun and Games

My post on gifts for a depressed person has been really well-received, so I know I hit a nerve there. I thought I would follow up with some talk about board games, why you should buy them, give them, and play them.

Board games are a really wonderful way to bond with other people, even people with which you (think you) don't have anything in common. As an angry young teenager I would willingly play Trivial Pursuit with all sorts of people that I thought were absolutely horrible, even my parents. I learned that Dad, even though he was a complete idiot, was really pretty smart, and so was my brother-in-law and even my grandmother. Better still, I learned that I was pretty smart, too.

Board games depend somewhat on chance, so there's a good possibility of doing well even if your heart isn't in it. I think the games that require teams are best, because you reinforce belonging as well as accomplishment. Team board games are also especially good at bringing people together across age barriers.

Win or lose you generally have fine in spite of yourself. If your team loses and you, the depression victim, tries to blame yourself, the fun of the game usually trumps the desire to win and you find that your teammates won't let you blame yourself. Now if you are friends with a serious competition junkie and poor sportsman, this won't be the case. We can talk about self-esteem and destructive relationships another time, however. I'm talking about normal human beings here.

If you're still at a loss for how to spend your holiday budget, I think a good board game like Apples to Apples should appear beneath your tree, or wherever your gifts are stored until opening time.

Recruitment!

Depression Stinks would like to find out more about how depression affects all people. If you are a current or former depression victim, or work with depression victims on a regular basis, and have a blogger account, please leave a comment if you would be interested in becoming a team member of this blog.

Application comments should include:

• The type of experience you have had with depression (personal or professional)
• Areas of treatment of particular interest to you
• Any types of depression that you have a particular knowledge about
• A stated commitment to a minimum posting frequency (although daily would be tremendous, honesty would be preferred)

Team members will be expected to chronicle experiences, comment on research, and discuss the cultural, political, and religious issues that affect and are affected by depression.

Cleaning House

Is a messy home a caused by depression, or is depression caused by a messy home? I've heard passing references to a link between disorganization on the outside and fogginess on the inside, but I wasn't able to find any research on the subject. I know that I'm no stranger to having a bit of untidiness in my life, and there are plenty of other people I know who fall into both the categories of "depression victim" and "house cleaning challenged."

However, as my mother would say, "Dull women have immaculate homes."

There might be some wisdom to the axiom linking an orderly environment with an orderly mind, but until someone does a study I'm not making any pronouncements. However, I think it's fair to say that a messy home feeds really well into the cycle of I'm-not-good-enough that depression creates and builds upon. If you don't have the energy or focus to clean, it's pretty certain you'll put it off. As the mess builds, so does the guilt. The problem gets bigger as the guilt feeds the depression, which diminishes the energy levels and reinforces how impossible the task is. You know the drill, you've probably done it to yourself. Charming little cycle of self-recrimination and self-fulfilling prophecies. You expect that you can't clean the place up, and your mind works overtime to make sure that it doesn't make a liar of you. Didn't think you had that much mental energy, did you?

As with everything depression-related, small victories add up. Commit to not adding to the mess today. You will not create another dirty dish without washing it. One dish isn't so tough. And those socks? Just force yourself to put them in the hamper; you'll be glad you did. Keep up on not adding to the mess, and you'll see you can control your world after all. Then you'll be ready to take a step or two towards the bigger mess.

I would keep making small victories. Don't try to clean every dish in the kitchen, but do try to wash all the ones in the sink. Maybe picking up all the dirty laundry is a bit much right now, but how about just the stuff that you piled on your bed? Each time you succeed you're teaching yourself that you are capable and you are in charge.

Who Is Terence?

I've been asked to talk a little bit about who I am and what I'm doing with this blog.

I suffered off and on from depression from before puberty until my early thirties, with periods of suicidal thoughts. I have tried treatments ranging from therapy to drugs to prayer to exercise to pets to, most effective for me, belief in myself. I'm amazed to this day that a disease that has had such a profound effect upon my life was able to insinuate itself without me noticing.

Depression Stinks is my way of giving a gift to other victims. I know that this disease can be conquered and I want to help others find the right way for them.

Depression is a disease that encourages solitude, and I hope that this blog makes people realize that they're not alone. I also welcome contributors to share their own experiences and viewpoints in posts of their own as well as comments; there is no one correct treatment any more than there is just one way to suffer from this insidious disease.

Memory Loss

If being depressed isn't enough with the lousy attitude, lack of desire to act, and complete disinterest in doing just about anything, a lot of victims have to deal with memory loss as well. It came to my attention just last night that a lot of people aren't aware of this complication from depression; perhaps they're just forgetting? What a sick and twisted thing to have happen . . . a symptom that prevents itself from being noticed!

I found a study on depression and anxiety for starters, so I was quickly able to confirm that there has been research in this area. It's interesting that the study found that while anxiety alone does not have an effect on memory, it can significantly compound with depression. It suggests that other studies that did not control for anxiety levels were frustrating to analyze.

I then discovered that there is a newsletter devoted to memory loss, and they had a wonderful article specifically addressing memory loss and depression a few years back. Salient points include:

• Memory loss, like motivation and focus, are likely affected by the levels of neurotransmitters in the brain.
• The mind filters memory to match mood; depressed people are much more likely to remember times when they're sad than they are to recall happy experiences. "It also reinforces the person's drab and negative view of life, fueling the depression."
• Long term memories are not actually being lost so much as they are never forming at all due to the lack of focus and attention.
  
• Treatment of the depression alleviates the memory problems.
  

I'm able to wrap my mind around the memory loss more comfortably now. Essentially, depression victims aren't able to pay enough attention to form as many memories, and the depression filters those so that the ones that reinforce the disease come more easily to mind. It's one more way that this disease becomes invisible, comfortable, and usual in the mind of its victims.

Goal for today: write down a good thing as soon as it happens. Many treatments suggest some sort of journal; if you want to make this part of one then by all means go ahead. If not in a journal, put it someplace you will see it, like on your refrigerator. You're experiencing happiness despite your depression, and you deserve to know about it.

Giving Perspective

One of the ways that depression works to gain control of a person's life is to instill a perception of changelessness. You always felt this way; it's not a disease so much as it is who you are. Nobody ever cared and you should not waste anybody's time by telling them your problems. Happiness is not meant for your life. The dark cloud that surrounds a depression victim makes it impossible to see things that are positive, helpful, promising.

Now comes a tool from the Families for Depression Awareness that can help remove that metaphorical blindness. It allows a victim to see progress that is made in treatment by carefully tracking it. It's a simple concept but a very important one. It breaks that perception that nothing has ever changed and nothing ever will change by showing, in the victim's own words, what things were like yesterday, last week, last month.

By involving family it also helps break down the belief that you're alone in this journey. Solitude is depression's friend, and it withers if you convince the victim that they are not alone. Mind you it takes a consistent effort to make that point, and even minor setbacks can bring you all the way to Square One, but this tool is a good way to involve the people that care about the victim and help them reinforce that fact.

Tasteful Research Opens Doors

Scientists have discovered that, not only do depression and anxiety have a measurable effect upon the sense of taste, it is even possible to determine which chemicals are most out of balance by how taste has been diminished. This is exciting for a couple of reasons.

This is the first research I have seen that shows physical evidence of anhedonia, the inability to experience pleasure. Anything that reinforces the physical nature of depression is very important. Research that demonstrates the physical symptoms of this disease go a long way towards dispelling the myth that it is "in your head." That phrase makes it sound like depression victims make a decision to suffer, which is not true. Ironically, the very nature of the disease does cause those selfsame victims to make a decision to continue suffering, but this doesn't occur until the will is compromised. Scientific research can demonstrate the physical nature of this disease, although I am of the belief that it will never discover a physical organism, a "depression virus," if you will. The root is not in the body, although much of the damage ends up there.

Diagnosis by taste-test is really just a fancy way of suggesting that we should listen to what our bodies are telling us. We are given a plethora of clues about our health, day in and day out, and either we ignore them or we just don't understand what they mean. Now we have an additional level of understanding, and another tool to use in the evaluation of our health. Another piece of the puzzle is slipped into place as diminished taste is coupled with diminished appetite in some people. We have been given one more solid tool to use to to sweep away the miasma; something corporeal with which to document a disease that prides itself on being as vaporous and insubstantial as a hunting vampire.

Medical Reinforcement (sort of)

Dr. Neubauer has located some studies that support what I have stated previously, namely that there are steps you can take to improve your mood and your sense of accomplishment, including caring for pets and exercise. I understand that his training is scientific and so he will only support any treatment option so far as the scientific method can document its success, but I take exception of his downplaying the value of these treatments, as well as herbal remedies like St. John's Wort, which I will discuss more in detail in a future post. For now, suffice it to say that there have been studies that demonstrate this herb's efficacy, just not, apparently, published in any journal the doctor respects.

I'm also not surprised that he does not include such vehicles as prayer and self-affirmation, as these are exceedingly difficult to document in a laboratory. Being unverifiable is not the same is being unsuccessful, however. Expectation is often half the battle.

Will Employers Actually Help?

This is an interesting study - careful tracking of employees through screening and treatment, even accounting for various levels of quality of treatment, to see how much productivity could be improved by working to overcome the depression. I'm more amazed with the process than with the results. The keys to such an enhanced depression screening program working would be twofold:

First, the employers must recognize that the cost of replacing an employee with another, which would not include the cost of depression treatment, would still be higher. Training and development, even for a relatively low-challenge job like fast food, can amount to thousands of dollars. The investment would be a crap shoot if you consider that a lack of depression screening could land another underperforming individual on the payroll.

Second, it must be mandatory, or it will be a failure. Nobody submits themselves for depression screening, or nearly nobody. Half of the depression victims don't realize they have a problem and the other half are too ashamed to admit it. Most of the people with a need would never be identified, so the cost would have no offset in value.

Employers are very results-oriented, so hard data such as these are promising. It is still likely only to be implemented by employers that are independent enough not to have to answer to stakeholders that are so shortsighted that they resist anything without an immediate benefit, and only in industries where employees are likely to stay more than the five years projected by the study as the point at which savings develop.

Gift For a Depressed Person

Holidays can be a very difficult time for the victim of depression. As I've discussed in the last post, it is very easy for well-intentioned holiday activities to completely overwhelm the depressed person. If you know someone who's depressed (some warning signs can be found here if you're not sure), you might want to prepare a gift that takes their disease into consideration. Here are some ideas:

Presence, not presents: present them with an invitation or a certificate that requests that they spend the holiday or a specific time with you. Make it quite clear that no gifts will be exchanged, no food is to be prepared, and nothing special is required. If they tell you, "I'm afraid I won't be very good company," tell them, "That may be true, but I will be." If you sincerely care about this person and are willing to see who dwells beneath the cloud of gloom that their disease has helped them make for themselves, this may be the best gift you could give. If you and they are lucky, they will be able to tell you it made them happy. If not, trust that it did.

Focus on the positive: Put together a photo album, a slide show on a CD, or a letter or scrapbook that centers on positive things you have shared. A well-depressed person doesn't see themselves as having any value, and this kind of effort serves to remind them of things they've almost certainly forgotten. Depression can cause memory loss, and you can bet that the good ones go first. This is a gift that will be cherished.

Ask for help: This may or may not work, depending on the level of the depression. My mother has suffered from depression on and off for most of my life. The holidays have always been important to her, and I knew that being at a loss for things to suggest to her for gift ideas wouldn't sit well with her. Since I didn't have any wants particularly, I requested that she create a needlework piece for me. Mom has always been an avid needlework artist, ranging from knitting to crewel to embroidery to counted cross stitch. Her hands knew what to do even though her mind didn't see the point, so the act of creation served as a reminder of the value she held to me.

Bright Blessings: If you share a religious belief with the victim, or at the very least he or she isn't a diehard atheist, offering a tangible blessing may be helpful. Depressed people have very often lost their faith, and cannot pray for themselves, even if they know that prayer is a very important part of their ability to overcome the disease. Give them a promise, one you intend to keep, that you will pray for them daily or weekly for a set amount of time. Put it in writing. As an alternative, find an appropriate candle and either bless it yourself or have it blessed by someone who has taken religious orders or their equivalent. Specifically focus the blessing on light, be it the Light of Jesus or the return of the sun or the oil that burned for eight days, or whatever makes sense in your tradition. Tell them to burn the candle at their lowest point in the day.

Use Holidays Properly

Why are there so many holidays in December and January? We have Hanukkah, Christmas, Yule, Kwanzaa, New Year's Eve, St. Lucia's Day, and all manner of variations on those, as will as ancillary celebrations (such as Advent). In one form or another, these celebrations focus on happiness or light. Celebrations of light, all clustered around the longest night of the year? Surely this is not a random occurrence. Obviously the human spirit craves light and the life it brings, and the dark times of less activity and more eating are being offset by singing, candles, parties (okay, that's also a handy excuse for eating), and opportunities to spend time with other people: cultural and religious offsets to the physiological reactions to winter. We understand that times of cold and darkness can wear away at our resolve, and we fight back by creating a flurry of activities aimed, purportedly, at joyfulness at this darkest time. Hopefully it's enough to carry us through the remaining ice and snow as the days grow longer.

Enter depression, subtle twister of goodness.

Looking at the world through the unwholesome filter of depression can make a good thing into a painful experience. Holidays are designed to bring people together; you just want to be left alone. They encourage you to give; you're overwhelmed by the idea of shopping, or terrified that you'll choose the wrong item. Indoor creative crafts flourish; your mind is a pile of mush and you're sure you can create or decorate anything.

If you've read this blog for any amount of time you know that it's my firm belief that depression has physiological, psychological, and spiritual components, and gleefully will attack you on all those fronts. This is a time of year when it can use the forces of nature (less sunlight and warmth) as its strength, overwhelming the forces of culture (social activities, giving and happiness). Well if it will use the momentum of the year, you can too.

Go to the parties, even if you sit by yourself. Joy is also an infectious disease, and if you expose yourself to it you may find that you catch it. Surround yourself with people that won't judge you for your failings - there is no better time of year to find the goodness in your fellow man than right now. Sing and don't care how you sound. If buying gifts is too expensive or you hate the crowds, try making your own and (here's the trick) stop caring if they're perfect. Spend some time volunteering as a Santa or Salvation Army bell-ringer. Force yourself to be in situations where you will be exposed to the goodness of humanity.

All the drugs in the world will not get you out of bed. Your therapist and your gods cannot do this for you either. Depression is working very, very hard to convince you that you have no power, no worth, no purpose. Set yourself a schedule of things to do, things that intellectually you know are good at this time of year, and stick to it no matter what. You will find many, many excuses to avoid positive, social activities, because the more of them you engage in the more the depression will fight back and try to suck you back in. That's why I suggest literally writing down (or getting a friend to, if you must) your holiday activities and going through the motions. Sooner or later the habit will find its way in deeper, helping out whatever treatments you might have going for you.

And then you'll discover the most amazing gift of all - that you can.

Wellbutrin and SAD

I think the most promising thing about this discussion of Wellbutrin is that it's only recommended to be taken during the dark months. It's very easy to get into a maintenance program with depression, and it's often not necessary. Long-term medication creates a dependence in a way that isn't defined by the scientific community; it's a belief that develops that one cannot be well without a drug, which becomes a self-fulfilling prophecy. If you're depressed you're already extremely susceptible to the belief that you are simply not a strong person, and drugs can easily reinforce that by becoming a security blanket. Properly used, a medication for most depression victims should be a trainer, showing their minds what health looks like so that they can reproduce it in themselves.

That being said, I'm glad that Wellbutrin might be useful for SAD sufferers. If it gets you through the darkest times, and allows you enough energy and motivation to modify your behavior for health (exercising, exposing yourself to more sunlight), then it could be a godsend for many. Only for a very small percentage of depression victims is a permanent drug solution logical. And I know how you think if you're depressed, so let me make this clear: you're not one of that small percentage. Don't believe it. The light is inside you, and the drug is only a tool that can bring you back to the level where you can find and use what you've had all along.

Dark Times Ahead

Seasonal Affective Disorder is really only the beginning. You don't have to be crippled badly enough by the season alone to have it really affect you negatively. "Winter blues" leads to a lack of energy and a desire to eat more in all of us to some extent, and if you're otherwise depressed this can compound your symptoms.

The metaphor of darkness and light works well with depression because darkness and light have very significant physiological effects upon us. Diurnal is the standard behavior cycle for most living things, and even though we humans can act against type, we are generally responsive to having light in our lives. Darkness is a time of hibernation, introspection, preparing for the light to return. Sunlight encourages us to think, to act, to experience outwardly rather than inwardly. Both are perfectly normal and healthy and we need a balance between focusing on within versus focusing on without. With depression, though, darkness takes precedence, and the darkness that is created within magnifies the darkness in the world until it's unbearable.

You might be eating more and feel guilt over the weight you're gaining, or think you're gaining. Or you're less motivated to exercise. Or when the sun sets at 4:30 in the afternoon it feels like all the light in your life is vanishing with it.

The light box described in the link is probably not necessary for someone who is depressed but not specifically prone to SAD. However, daily walks in the daylight will get your blood flowing, expose you to sunlight, and get you the exercise you need anyway. You don't want to exercise if you're depressed (since depression discourages you from doing anything that might benefit you), and this is just compounded by the time of year.

The sunlight is going to be diminishing for a few more weeks. Make an extra effort to get outside, even if it's cold out. Buy a full-spectrum bulb or two if you can. Set your alarm for the same time every day and get up, no matter how much you don't want to. It's going to turn around soon, and before long you'll see that the light creeps in a little earlier and lingers a bit longer than it had been. Don't be afraid to make a note of the time so you recognize the increased light more quickly. The light always returns. That's a promise.