Episode 48

empathy is knowing your own darkness
without that connection you don’t have
anything what’s the opposite of
addiction just freedom
dr elardi yeah plea please call me steve
steve
uh the title of your book the depression
cure
seems like a pretty bold title uh it
certainly caught my attention
uh when brandon first uh handed it to me
i was wondering if you could speak to
that because i’m sure that’s with some
intention
it’s actually been the source of a lot
of conflict
between
me my literary agent my publisher
they love the title
um
i
really don’t like it
and
my wife and i have actually had lots
lots of talks about i mean i want to
change it um
i’ve been in talk with the publisher
about doing a revision of the book and
um
you know that
what my agent said
well actually let me back up what i said
to my agent is look depression is this
treacherous illness
um it robs people of so much
that they value in life and for so many
it actually robs them of their will to
live
and i don’t want to have a title of a
book that makes it sound as if there’s a
promise embedded that if you read this
book you are guaranteed to be cured of
this
treacherous illness because that’s not
what any sane clinical researcher would
ever want to promise that sounds
like somebody selling snake oil
um
you know the
the the little grain of truth behind the
title though
is that there are people on the planet
that have been studied
that have often very challenging lives
and yet they don’t seem to suffer from
depressive illness the way we experience
it
and we can go into you know a whole lot
of details about why that would be why
are there people living in the highlands
of papua new guinea
or in the amazonian rainforest that
have hard lives but they don’t get
clinically depressed that doesn’t mean
they don’t get sad it doesn’t mean they
don’t have
bereavement they don’t grieve when they
of course they grieve when they lose a
loved one but they don’t get struck down
by this
senseless illness that just robs people
for month after month year after year of
of their life
um
so
the kernel of truth in that title is
that there’s a way in which people are
living a type of
active cure
that’s both preventive and it turns out
from much of what we know about modern
clinical neuroscience
so many things about the way we live
affect the brain in such a profound way
that they can actually have
antidepressant effects
on brain function so
they they can be curative in that sense
okay
so what would the title of your book be
then if if you were in charge of titling
it i don’t know if you’re comfortable
sharing that sure oh wow uh so it
depends on whether or not my publisher
is going to be listening to this podcast
if it’s going to be a real big hit then
i better be a little more careful but um
i think we’re safe so okay so far yes
this is the first one but you never know
when something’s gonna go viral if it
goes viral then then it’ll help you
solve your problem thank you yeah
exactly okay um
well i you know
one thing i thought about was something
okay every every alternative title that
i came up with
my agent my publisher and my wife all
said that’s boring
so
so things like healing depression
they’re like oh yeah that’s boring um
you know um lifting depression
things that really get at this sort of
the goal of
my clinical work my clinical research i
mean for all of us as clinicians these
are the things that that
that get us up in the morning and that
we have passion about but
we we don’t ever want to over hype or
oversell or you know promise something
now that
we think it might be in doubt
um what i will say is somebody who’s you
know i got my my degree my phd in
clinical psych in 1995 so 23 years ago
i’ve seen hundreds of depressed patients
and
i can tell you i’m more excited about
this particular treatment protocol in
terms of both the short-term
and long-term effects
than any other thing that i’ve ever been
a part of in my graduate school
training i i got a high level of
training
in a type of treatment that most of your
listeners will know about cbt or
cognitive behavioral therapy
um
i got to such a high level of training
that i was actually doing training
workshops in cbt for depression at apa
so i know that protocol really really
well
and it’s it it’s okay it you know some
people do respond favorably
um
in the short term and and some of them
even in the long term but it’s not like
the majority of depressed patients who
do cbt are going to be
permanently in remission it’s just you
know it’s helpful but it’s not
a miracle cure
ditto for the drugs by the way which are
about as effective as cbt
and i took a class at duke in clinical
psychopharmacology
and so i i know a lot about meds my wife
is a full-time
psychopharmacology prescriber she’s a
med maven so you can imagine the
conversations we have around the dinner
table
um
but she’s taken in recently to telling
her patients like she’ll hand them a
script
and say look if you just take this drug
and don’t change anything about the way
you live your life
the odds are not in your favor in terms
of being able to go into complete
remission and stay there
so you know she’s very realistic with
her patients about the data behind these
medications is not all that exciting
it’s like they do
help somewhat for some people
but they’re not like this you know
miracle cure that a lot of people think
and that we all wish they were
so i
kind of ironically i used to work for
eli lilly as a pharmaceutical rep
selling
prozac um
well those were good times back those
were a good time and actually i worked
through the good times to the bad times
uh for that particular company um
and certainly
i mean certainly what stands out for me
was the hyperbole the pharmaceutical
company would use and then their their
studies um
were all like
uh funded by eli lilly he almost had a
pre-arranged outcome before the study oh
it’s incredible yeah and you probably i
don’t know if you you know you probably
know this but some of your listeners may
not
um
when companies like lily and pfizer and
merc and you know all the big players
were um
were trying to get fda approval for
their their drugs they had to file these
studies with the fda
and submit their their data
placebo-controlled randomized
placebo-controlled trials
and the fda was sitting on this big
database
of all these trials of antidepressants
and
um they would you know they wouldn’t
release it to the public because the
drug company said no you can’t release
it it’s all proprietary it’s you know
it’s our it’s our intellectual property
you can’t and the fda is a public agency
they’re you know there
on our tax dollar to protect the public
good
so researchers petitioned the fda under
the freedom of information act to get
these data released and what they found
was absolutely remarkable which was
in about half the trials
of these antidepressants that are being
hyped and marketed as these miracles and
about half the trials that the fda was
sitting on
the drug did not beat the placebo and in
about half of them they did well guess
which half got published
right so every single freaking study
that the fda was sitting on that the
drug company had you know been forced to
connect to get their fda approval
every one where the drug happened to
beat the placebo
then the drug company was really eager
to get that published in a top journal
and then they would promote it and the
drug reps would come around with their
shiny little glossy and hand it out to
all the prescribers and say look how
great our drug is see it did so well
and it would be like but don’t pay any
attention to the man behind the curtain
nobody even knew that there was a
curtain or a man behind the curtain
which was all of these negative trials
that we now discover are sitting there
and once we look at the whole picture
what we find is
this is the separation between the
antidepressant and the sugar pill the
placebo
is like on average for the average
depressed patient about three points
on a 55-item clinical rating scale which
is to say
barely clinically meaningful
for the average pain you know there
there are there are some patients for
whom and i’ve seen it with my own eyes
where these drugs truly are miraculous
in the benefit they bring but for every
one of those there are a lot of patients
where there’s nothing and by the way
there are also patients where the drug
actually makes things worse and we don’t
like to talk about that
but you know there’s activation syndrome
there are people that get really
agitated on the drug they get academia
they get
you know and you’ve seen it i’m sure
absolutely um
so
you know yeah there are all kinds of
things that we sweep under the carpet as
a profession
because we want our i think well there
are all kinds of reasons the drug
companies want to keep selling their
product
i think those of us who are not
on that side of the business we just
want our patients to stay hopeful and to
feel like no they’re you know we have
all these powerful tools
my feeling is as a clinical researcher
i’ve been in this business 27 years now
is we need to be honest with ourselves
about how
much these treatments leave to be
desired
and that really was was
part of the impetus behind so i went
from being nimh funded
doing clinical neuroscience i was
looking at doing like um
basically hemispheric lateralization
research looking at like how does your
left hemisphere process information when
you’re depressed different from your
right hemisphere
because it turns out like the right
hemisphere specializes in negative
autobiographical information so you can
find these imprints of depression in the
right hemisphere if you just like tap
into it there’s a way to do that with
like divided hemifield presentation i’m
not going to bore you with all the gory
details
but i went from that to doing treatment
outcome research
because i finally just got so frustrated
with
like cbt doesn’t have the greatest
long-term outcomes and the meds don’t
and even if you combine them they don’t
even together they don’t have the
greatest and then i read about people
groups like the kahluli and papua new
guinea in new guinea who don’t
suffer from the burden of depression
and i bumped into this
construct for medical epidemiology um
where you know these these physicians
have looked at disease burden of peoples
all over the world and they find oh
people that are in affluent countries
like the us and europe
that are
rich and industrialized and western and
and and um modern
we have our own characteristic diseases
that people who live more like our
ancestors just don’t seem to have
and
i finally had this aha this epiphany
moment a little over a decade ago where
it’s like oh depression fits that
pattern depression just like say
type 2 ob
type 2 diabetes or obesity or
fibromyalgia depression is one of these
diseases
that’s hugely overrepresented
in places like the u.s and
virtually unheard of
in people that live the way our
ancestors live
so then it’s like okay well if we start
thinking of depression as this disease
of civilization
then maybe
it’s it’s foolish for us to think that
we can
get people well
just by throwing a medication at it any
more than say heart disease you know if
we have a typical person with heart
disease and we just you know we give
them an angioplasty and we give them
stent
and we throw some meds at some statins
and if we’re just like well yeah but
just keep eating the way you’ve always
eaten and keep sitting on your couch and
you know doing all the things you’ve
always done it’s like guess what the
modal outcome for that heart patient is
they’re going to die of heart disease
you know even though we’ve treated it
with the best that you know western
medicine has to offer
and we may buy them a little bit of time
but we haven’t cured their heart disease
and yet if they started living the way
the yanomamo live or the kaluli they
would cure their heart disease because
those people don’t get heart disease
because you know it’s a disease of
lifestyle i think depressive illness is
a disease of lifestyle
and that we were never designed for this
isolated screen addicted
fast food laden
sleep deprived pace of modern life and
you know how long before we evolve into
being genetically predisposed to live
this way
because it seems like with virtual
reality and other things heading down
the pike like
it isn’t going to be like it seems like
the trend is toward increasingly
sedentary
it’s true
natural selection
um genetic evolution
normally takes place on pretty
large time scales
you know we might think like a fast
evolutionary change would take place
over 5000 years
so for example
five to ten thousand years ago
some people started herding livestock
and started having access to dairy
and milk products for the first time
after weaning
after age four say for the first time in
human history
but
the the standard issue human being
cannot process
dairy
after age four they’re lactose
intolerant they don’t keep producing
lactase after age four well some genetic
mutants
had variations on some of the lactase
genes that allowed them to keep
producing
lactase till they were 20. and that was
a huge adaptive benefit right so there
was selection pressure
and now we have a whole host of folks
whose ancestors are from parts of the
world that you know were dairy farmers
for ten thousand years or five thousand
years
and they can you know they’re lactose
tolerant
um but that’s like five to ten thousand
years and we view that as like lightning
fast
in evolutionary terms so
so four generations into being sedentary
nowhere two seconds in and in fact i
would say and this is probably not a
rabbit hole you want to chase down right
now
but with
with uh
the the possibility now of real-time
gene editing
uh technologies that some of your
listeners may have heard of like crispr
cas9 and
some other gene editing technologies
where we can actually go in and change
letter by letter in the human genome
and probably within the next 10 years
we’ll be able to do it
to a fertilized zygote in other words
for in vitro fertilization you could
have a fertilized egg go in and gene
edit
that egg
implant it in in the womb
we are going to be directing our own
genetic evolution
way before any evolutionary change is
going to happen naturally on this front
so we could design
sedentary people
we could in principle once we figure out
exactly what what the requisite genes
are yeah i think in principle we could
design
people who would at least be
robustly resistant
to all of the enormously adverse
physiological consequences of being
sedentary we’re designed right now with
these stone age largely stone age
pleistocene genes that expect us to be
moving vigorously for like hours a day
they expect our i mean our bodies are
designed to be moving
and so when we keep them sedentary for
most of the day then we run into all
kinds of problems in terms of like
glucose utilization we develop
metabolic syndrome and insulin
resistance and
all kinds of problems with neural
signaling and we wind up you know with
high rates of obesity and high rates of
illnesses like depression yeah in
principle i think eventually there could
be a genetic fix for that that’s not my
preferred solution i’d rather
i’d rather instead
engineer society in such a way that we
could make
make it the default easy thing for
people to do to be physically active the
way it was for our ancestors because
it’s not like
modern-day hunter-gatherers like the
kaluli or the ghana it’s not like they
have more willpower than we do it’s not
like they’re better people or strong
they they’re active because they they
need to be
if they didn’t need to be they wouldn’t
and we know this how because when
aboriginal peoples are kicked off their
ancestral lands and put on reservations
and given
access to calorie dense foods that we
have
they’re fine with the food they like the
food and you know and then they they get
sedentary
and they quickly develop epidemics of
obesity and diabetes and all of our
illnesses and they get depressed just
like we do
um
so i would rather than
i mean the problem with re-engineering
the genome is there are all kinds of
potential unintended consequences and
there’s just too much we don’t know yet
i don’t think it would be i mean i don’t
think the science
the technology to make those genetic
changes will be there within 10 20 years
the science to do it
safely probably won’t be there for a
couple generations if ever so i’m not
going to be a big fan of that approach
that makes sense like i was just kind of
curious about that
um some other like to transition away
from that a little bit um
something that stood out to me as i was
listening to you speak today is
i i love to backpack and there was a big
part of me that’s like this
feels like is getting as close to some
of these cultures that you described as
you can get where you throw everything
on your back
you pre-arrange meals uh they’re pretty
well thought out they’re meant to be
kind of high protein yep
uh
calorie dense in a way but you’re using
i’m using the calories and
the elation like i i threw hike the
wennuchi wilderness uh 100 miles oh wow
um
a few summers ago and
oh i mean i felt amazing after ditto i
mean i haven’t done that yeah but you
know when i’ve been immersed in nature
and active like at yosemite um
at yellowstone about five years ago i
mean it just i came back at the end of
that week and i told my wife i said
this is the best i’ve felt just and and
i normally feel fine but i just it’s
like
it just took it to a different level i
just it just this deep sense of
well-being like i was just meant to live
this way yeah it was amazing and you
wake up
kind of when the sun starts
don’t need to watch right and you go it
is amazing when it starts to get dark
and you have this powerful sleep drive
yeah like when i backpack with my son
i’m like okay
when we can count 20 stars because we’re
that tired we can count 20 stars we can
go to the because he’s so tired by the
time we’re done and
and uh
well yeah and i i so resonate with what
you’re saying and one of the things i i
say is a little bit of a shorthand for
my students
to help them think about what was life
like
hundreds of thousands of years for your
paleo paleolithic ancestors
it’s like your ancestors were on a
lifelong camping trip
right
they were with their 30 to 50 closest
relatives and friends
they were all in it together
and they spent all their time outdoors
and they were just immersed and
i don’t want to overly romanticize it
because there are things about that i
think are really challenging and like
you know there they had a lot higher
burden of parasitic
infection and illness and that was a big
deal um
you know and and
it’s not like i want to go live as a
hunter-gatherer you know right i don’t
but i think that there are so much we
can learn
from them
well i i’ve done some winter camping and
like
that’s really tough oh yeah like it you
know the nights are so long
so cold and
so cold and i don’t know yeah
i think you burn fat pretty quick too
shaking and cold oh my god yeah no
absolutely so it’s like no i want to
keep my laptop
you know i want to keep
netflix
i want
i want to i want to keep
a lot of things that we just appreciate
about 21st century i want us to have the
best of both worlds you know and i want
our patients to be able to
import the things from the ancestral
milieu into the present
and weave them into the fabric of
day-to-day life in the 21st century
um and and and to be clever about it
because if we did it in a non-clever way
it could feel like oh god this is like
this huge burdensome project it’s going
to take hours of my time every day
and none of us have that
time or energy or effort or willpower
and particularly not clinical patients
who are battling with syndromes like
depression that rob them of their energy
and motivation anyway
so i’m all about looking for life hacks
looking for
little shortcuts ways to like how can we
get the most bang for the the sort of
the you know the metaphorical buck of of
effort
and you you have a
you have a concept when you were talking
about rumination
uh
just just this last week as i was
actually thinking of getting this
podcast going and i was ruminating it
was you know it was probably two in the
morning
and i remembered something somebody had
talked to me about was the grant was
thinking of gratitudes but
um
this woman asked me to do gratitude
alphabet gratitudes just find something
that i’m grateful for that starts with a
oh that’s interesting and i made it to p
and i fell asleep
and it complete because i think you had
talked in your talk about
um priming the pump and like the
alphabet thing seemed to prime the pump
for me to like
give me okay what starts with a what
people start with is where i started but
i couldn’t think of anybody in that
moment and then
um what were you grateful for like
aardvarks yeah
that’s a good question
i i don’t even remember in that moment
what it was but i i was amazed at how
quickly the rumination stopped i started
throwing up from my stomach into my
other stomach it’s really
well so for you know
you feel like all your listeners are
going to be really familiar with what
rumination is and why it’s toxic maybe
talk about it
well okay so
you know rumination is just basically
clinical shorthand for
persevering or dwelling on negative
typically negative thoughts right and
that’s what we that’s what we worry
about people ruminating on
if somebody is like infatuated
romantically and they’re ruminating
about their
you know their schmoopy
we’re gonna let that one go probably but
but when people are depressed they
ruminate
usually
about um
upsetting things that have happened in
the past if they’re anxious they
ruminate about things they fear or worry
about in the future potential threats
usually that are down the road like the
podcast yeah all the things that have to
get done
um
and you know there’s nothing
intrinsically
toxic about a little bit of rumination
right after something upsetting happens
it’s you know can be helpful to kind of
get a sense of well why did that happen
and what can i learn from it how can i
make sure it doesn’t happen again all
that but when people are have a clinical
syndrome
they make it a habit and they’re just
dwelling on these thoughts all the time
and then it just amplifies their
negative mood
and it amplifies their stress response
so
you know their their stress circuits are
on overdrive
and it becomes a habit and it becomes a
really toxic habit and a lot of times
people don’t even know they’re doing it
because it’s like so ingrained it’s just
like when you drive that really familiar
route and you pull up in the driveway
and you haven’t even been paying
attention you don’t even know like how
you got there you’re just i mean i think
everybody right you pull in the driveway
yeah
like why because it’s overlearned it’s a
habit
and people ruminate that way
and
you know
it’s really hard to change that that
habit and when we’re depressed what
happens or when we’re anxious
is the mood drives the thinking and we
don’t realize that so much of our
thought process is governed by our
current mood state and if it’s a very
strong negative mood
then it primes all of our memories and
all of our associations that match that
mood so if i’m in a strong
anxious mood then i’m primed with all
kinds of
cues about threats and things that have
gone wrong and all the things that could
go wrong and you know it’s effortless
i’m not primed for gratitude though
right so if i’m ruminating
one thing i know is it’s not gonna be
easy to think about things that i’m
grateful for
but
if i deliberately take a step back and
say i’m going to force myself
to think about what am i grateful for in
this moment and i love this alphabet
thing i haven’t heard that one before
but like you know what am i grateful for
it starts with the letter a
um
i hope my wife doesn’t tune in because i
just thought for some reason i’ve always
thought
the actress amy adams
is particularly
she was great what was uh that was that
uh alien the alien movie what was that
called
like
a rival and thank you it starts with me
too oh yeah
well um
but
like if i’m in a really dark place and
brooding and ruminating and i can get
myself to think about oh
that’s a really talented person who
brought a little bit of joy into my life
and that of other people and then i move
on to bee and it’s like oh well that’s
easy because i love
nba basketball
b for basketball got it yeah yeah thanks
for explaining yeah well i just because
yeah yeah it’s like oh dude no you’re
you’re on head and we’re not there yet
um
i mean i could replay in my mind’s eye
the last five minutes of the 2008 ncaa
championship game where you know i’m at
the university of kansas you know i just
won the national title that’s not nba
but several of the guys played in the me
um all right it’s going to
start slowly
priming
not only the mood that goes with
gratitude but then other thoughts that
are way less congruent with rumination
and it’s going to interrupt it and it’s
just there are lots of ways of
interrupting rumination that’s just one
of about five or six different tools but
it’s a really powerful one it’s one i
mentioned in the talk today
um
i’m a little embarrassed to say i didn’t
think about when when when we first
developed the tlc protocol
it was not in our toolkit it was one
that was brought from a patient
um who
um had gotten it from somebody at her
church
and i don’t know if it just made the
rounds in church circles or something
but um it it’s really powerful
yeah it is i i know my
i remember i think i told you i got
through p
and then i woke up in the morning like
whatever it was like it allowed
me being tired to take back over and i
was like i don’t know what the i don’t
know what happened and i don’t know what
the neuroscience is about but
ruminating stopped and then i could just
be tired and fall asleep well so what it
takes to fall asleep um
is
a tired body
and a quiet mind
and so if we’re ruminating we don’t have
a quiet mind
but
we need to stop
okay
if we’re ruminating we don’t have a
quiet mind
but if if we’re doing something that’s a
little bit mentally taxing like you
talked about
um you know going through an entire
alphabetic series
it’s a little mentally demanding but not
in a way that’s arousing it’s not in a
way that’s going to keep us awake
you basically got yourself to a place
where you had
not only a kind of a
a tired mind but a still mind um
and i’m real familiar with the alphabet
i don’t have to think exactly so you’re
just on autopilot but you had to exert a
little bit of effort and thinking about
what am i grateful for for you know with
this letter
and um and it almost it reminds me a
little bit of some of the ancient wisdom
of people
that do repetitive kinds of uh
meditative things or prayer
like a a prayer wheel or a
a rosary or you know just something
that’s repetitive and rhythmic that we
don’t have to think about too much
it can have a very calming soothing sort
of effect so i think you might have
inadvertently got got a little benefit
from that as well i’ll take it
right the
kind of the last question i had
and then brandon i know i’ve been
dominating the questions but
okay
um i don’t
the people of
i don’t know is tribes the right word i
don’t know what word to use
the the tribes the bands yeah well so
you know that’s a great great so my
understanding and i’m not an
anthropologist but most of the people
who work in this area
prefer the term um for the smallest unit
which would be like sort of immediate
and extended family of 30 to 50 a little
hundred gather band
but that bands are usually not on their
own
it would be almost impossible to survive
a band of 30 on their own
they are linked
by marriage
and
treaty often
defense mutual defense treaties
um with other related
clans that form a tribe okay so when we
talk about say the kaluli people of
papua new guinea
the tribe of the kaluli is about 2 000
but that subsumes several
interconnected bands of 30 to 50 to 70
to you know
so
i mean certainly as a
going through your book like
i think connection with other people was
part of
uh your plan and and certainly
um
the one thing about the claims that i
guess that kept i kept thinking about
was
um how
homogeneous they are monolithic or
whatever where they all i mean they
there isn’t much diversity they all they
they’re all doing the same thing over
yeah that’s really interesting
it turns out i think yes there’s there’s
a lot to that but
there are all kinds of examples in the
um
ethnographic record the anthropological
record
of bands that will adopt
members
that are not genetically related that
may look a little different
that you know may
on the surface not be their genetic kin
but
they are fictive ken
and for them that’s real um
now there’s some really famous stories
of
european settlers in the americas that
were bumping right up against native
american tribes
that would on occasion
have traditions where if they lost one
of their warriors in battle
with these european colonists
they would kidnap
one or more of the children
of
these colonists to raise as their own
as a spiritual replacement for their
warrior son who had been killed
and you might think there would be
some hard feelings some you know
vindictiveness some
vendetta or something but as far as we
can tell um that’s not what happened
they were
fully
embraced as a member of this like if
you’re part of this band
you have our back we have your back
we’re in this together our survival
depends on everyone’s loyalty
and there was this deep feeling of
belonging
that you hear people and i don’t want to
romanticize combat or combat platoons or
the middle you know but
i grew up in that world my father was a
career officer in the air force and a
squadron commander
served in vietnam
and
you do hear
that
when it’s at its best there’s a kind of
sense of belonging
that happens among combat platoons this
band of brothers this you know we’re in
this together
and
sometimes upon returning to civilian
life
i mean yes there’s this feeling of it’s
nice not not to be shot at all the time
it’s nice not to have to worry about
being exploited by an ied but
a sense of loss of something crucial
this loss of belonging this loss of
purpose and meaning and
i i would say we all have a primal
craving to belong to something bigger
than ourselves
and i think that sometimes that’s a very
hard thing for americans to find
i think some people can find it in
religious communities
with the right kind of religious
community and the right
binding ideology maybe um
there’s a way in which some people get
that sense of oh we’re in this together
and you know it’s like um
we belong to this really important thing
that’s bigger than us
but for a lot of americans increasingly
that’s not an option that they find
appealing
and
it’s just really hard to get elsewhere
but i think it’s it’s a gaping hole in
modern american life that we need to be
more wise about
naming and
seeing and addressing and i think those
of us in the clinical community maybe
need to
i think we’ve been under attentive to
how important it is for people
to have that sense of community and
belonging
well and i mean talk about a hard thing
the life hack too yeah like
i’m not sure there’s a quick fix for a
sense of belonging or a sense of
importance there’s not and and um not
that i know of anyway not that i know
now
fortunately i don’t think it’s important
to get that to recover from depression i
think it’s maybe more important to find
that
to get resilient and and and and
protected against future depression
back to religion and one thing we know
is that people who belong
to religious traditions where they have
a strong sense of community
are dramatically less likely to get
depressed again
because they have that social connection
they have that community
um now for our depressed patients you
know while they’re depressed
the thing we work on acutely the hack
that’s so helpful for most people
is while they’re depressed their brain
is telling them to pull away from other
people
in other words the brain is telling them
the depressed brain is saying
hey it’s like you’re sick you need to
like shut down and crawl into a cave
somewhere and cut all your ties
and it turns out to be a really really
poisonous sort of message that they’re
getting
and so if we’re lucky the person with
depression
has social connections that they’ve let
go
maybe not completely but maybe you know
friends that they
haven’t accepted those invitations
they’ve you know friends have initiated
five times hey let’s go do this thing
and they’re like ah
that’s really nice but i just don’t feel
like it
um and then the friend quits asking you
know but those are ties that can be
we’ve found almost always picked back up
um
and so we we focus on those kinds of
connections
a lot more and you know we can work on
the belonging piece
later on in recovery yeah more broad
existential questions like
as you were talking i did
another thing that i constantly feel
like i run into
obviously
depression just metastasizes and spirals
down it seems like as
as i think you alluded to today
um
and then sometimes i use like a physics
term of like overcoming that initial
inertia seems like it takes so much
energy and once once the spiral starts
unwinding itself
it gets easier right exactly when you’re
scheduled
regulated and all that you build
momentum yeah you build momentum but man
that initial inertia where you get
almost no reward exactly for that first
walk you do for a half hour briskly
like how how do you
get people going i guess like that
yeah okay well for myself it’s one of
the
it’s one of the most pressing clinical
challenges especially for people that
are very severely depressed a very low
energy initiative
one thing that we found really helpful
is meeting in groups
um where people have that
social connection to others that are
for one of a better term kind of
cheering them on
the other thing we’ve done
is um
in the middle of every week
so we meet once a week in the group but
in the middle of the week
we let patients know ahead of time
you’re going to get a brief coaching
call
from one of the two group therapists
that are going to we can schedule it if
you’d like
just going to touch base for five
minutes
just you know
not
to nag or you know anything else but
just to touch base and if you’ve run
into any
roadblocks you know anything that’s kind
of you feel like is in the way if you’re
putting this thing into practice because
we have like one new thing that we want
them to implement in the first week it’s
really pretty easy it’s like we want you
to start taking this
omega-3 supplement yeah
and but you know for some people it’s
like oh i keep forgetting it’s like okay
well we can we can we can problem solve
that we can troubleshoot the it’s like
okay well where can you leave the bottle
where you’re gonna be reminded how about
do you brush your teeth every day
you know hopefully the answer is yes
so far it’s always been yes whether or
not that’s true or not i don’t know but
but everybody says they do
um so it’s like well how about if you
put the bottle
the supplement bottle like right next to
your toothbrush so that there’s no way
you can get your toothbrush without
running into it and just when you run
into it you take it then
okay well that’s pretty easy yeah
um
i think
beyond that i’ve got a colleague in
china
in a city
it’s often pronounced in in
english-speaking
parts of the world chun king i don’t i
don’t know the chinese pronunciation but
she’s at a university there and she
contacted me and we’ve been
corresponding and i’ve helped her
develop a therapeutic lifestyle change
program
for
her university there in china
and they have a social media platform
that she thinks is way better than
facebook which doesn’t surprise me
and
that makes it really really easy to have
secure private groups
and so when they have a tlc treatment
group for depression
they have a
a group that everybody has access to
that everybody goes on every day
to write a little encouraging note
to someone else in the group
because
if you think about it when you’re
depressed it’s really you almost it’s
almost impossible to write yourself an
encouraging note because the negative
self-talk is so
loud at first
but virtually everyone with depression
finds it intensely rewarding
to do something that they think might be
a benefit to somebody else
so if somebody posts like hey i remember
three days in a row to take my fish oil
or you know maybe now we’ve moved on to
using a light box there people you know
it’s like oh i got my light box and i’ve
you know i was i figured out where to
set it up and and you know people like
log in and they you know like put a
little heart next to it or they’re like
oh that’s great you know that
you know i was feeling discouraged but
now you’ve inspired me to blah blah you
know and you can see where that could
could be yeah i thought it was a really
brilliant uh
application i’m not a big fan of social
media for all kinds of reasons but
i do think at times it can be harnessed
in ways that can be really helpful
yeah absolutely so there’s a potential
act for you for finding finding a sense
of belonging yeah
through chinese social media
yeah i think i think it was called baidu
as it was i think that was
yeah she sent me a link
let me know if you need it for your
favorite yeah okay
brandon what what’s popping in your head
over there sorry no i i love the
conversation i love the direction of it
i mean um super insightful and i hope
our listeners are listeners are taking a
lot out of it and
i mean just to you know kind of peel
back maybe to the definition of
depression i think
it’s
um as you talked about uh today um
you know when
i think
i don’t want to be too broad stroke and
say it’s american culture anything like
this but it there does seem to be this
tendency to you know buck up or chin up
in the process when somebody’s feeling
uh depressed and it sounds like from
what you you spoke about today and you
speak about in your book that there’s
something very particular happening here
that’s separate from what we might
perceive as sadness absolutely
yeah it’s you know something i
i find myself talking about a lot more
these days is just
the way in which the word depression is
just really unfortunate
because it has its everyday
colloquial use it’s just meaning
basically oh i’m sad and you know
that we all know what it’s like to feel
sad because something upsetting happened
but that we also use it as a shorthand
for
this devastating depressive illness so
you know we still call it depression or
we might say clinical depression or
major depression or unipolar or
major depressive you know but
we still use the term depression except
now people don’t know what the hell we
mean you know they’re like what so are
you saying you know that i’m sad it’s
like yeah i know i’m sad but it’s way
more than
it’s so much more than just sadness
depressive illness is this
condition in which
normal sleep architecture is profoundly
altered so the person doesn’t get their
normal restorative deep sleep and their
hormonal function is altered and their
attentional circuitry is ultra so they
have trouble focusing and their memory
circuitry is altered and their stress
response circuits are in overdrive so
they’ve got way too much cortisol and
the cortisol is interfering with all
kinds of brain circuits and there’s
another hormone called
crh corticotropin releasing hormone
which starts perturbing dopamine
signaling and starts perturbing
serotonin signaling and you know before
you know it you’ve got a person
whose functioning is compromised in
every domain one of the stats i shared
today that seemed to really shock people
is that
depressive illness is now globally the
single leading cause of work-related
disability
in the u.s
it’s the single leading cause of
disability for everyone under the age of
and is on a trajectory
to be
um for any age group the i mean it’s
it’s
and it also leads to tens of thousands
of deaths every year through
depression-linked suicide so
you know it’s it’s a really big deal and
and
sadly most people that are suffering
from this depressive syndrome
don’t fully understand it their friends
and family can’t really see
their suffering they are suffering their
pain circuitry is lit up so they’re in
agony
um but nobody can tell and the other
thing i i i i forgot to mention today
but i’m glad i have a chance to mention
it here is a lot of people with
depression
that’s been going on for a long time
they kind of develop this ability to
fake it a little bit because
they’re just so exhausted from trying to
explain themselves to people
that even though they’re
miserable
they can put on a little bit of a facade
of like they you know might say like
sort of acting okay like
like they won’t let you know
how much they’re hurting
um
and sometimes these folks are suicidal
sometimes they’ll kill themselves
and everybody’s like but but joe seemed
alright like you know he was kind of
like you said sort of putting on this
brave face or sucking it up or whatever
um
it’s really tragic that you know
sometimes
we have no idea the kind of pain that
people are bearing all around us and
if we’re so caught up in our own stuff
that we don’t even notice or we don’t
take the time to even check in
in a real way we’ll we’ll be like oh how
you doing but we don’t actually right
we’re not really asking how are you
doing
yeah
um you know and one thing comes to mind
you know
when i think about depression and a
person truly suffering
um a lot of the times we can you know
turn on the television and there’s some
ad space for an antidepressant or
something that can you know i can uh
you know take a pill in the morning take
a pill at night and i’m gonna feel
better in the process and for somebody
who’s truly suffering that sounds like a
great solution
a tactful solution in that regard but it
sounds like more so that
um
in the case of the depression cure and
what you’re after is that we’re looking
for more of a process
um more of a change rather than
something instant so i can see in this
as well that when somebody hears the
depression cure and although it’s
tactful for your publisher and your
publisher enjoys it that somebody might
be
peeling through the pages quickly and
looking for that golden nugget
golden nugget in the process um what
would you
um well i i’m all in favor of of a quick
fix if it exists right and so you know
when i think about each of so we have
we’ve built this lifestyle based
treatment protocol or i would just say
you know these modifiable domains in our
lives that we can tweak
that have antidepressant effects on the
brain and on the mind
um
i’m thinking for each of them
how long
before it takes effect you know and how
can we
how can we help people get better as
quickly as possible
i’m i’m not philosophically opposed to a
quick fix i’m not philosophically
opposed to a magic pill or a miracle
cure i mean you know we hear a lot of
hype these days about things like
ketamine like oh well you know ketamine
has this really super fast response rate
well
you know when you really dive into the
data on that it’s like yeah maybe a
little bit but it’s not typically a
sustained
response for most people there are lots
of potential downsides to that there are
all kinds of potential addictive issues
and possibly even
neurotoxic
effects of giving somebody high doses of
ketamine week after week it’s not good
for the brain and we know that it’s not
rocket science
um
so i’m not opposed to a miracle cure but
i just think we need to be really really
brutally honest
in terms of things that actually work
and don’t hurt the brain i would say
probably light there bright light
is probably the fastest thing we have
especially if somebody has winter onset
depression due to light deprivation
within five to seven days of getting 30
minutes of
bright light exposure and i mean like
you know you measure light in units
called lux 10 000 lux or more
seven days they should be experiencing
some benefit
uh physical activity uh exercise
for some people
will have some temporary mood elevating
effects right away we’ve had even some
really severely depressed patients
now they can’t initiate exercise but if
you hook them up with a trainer and get
them out they’re moving so they don’t
have to think about it they’re just
doing is following with the person
because they’re not going to want to do
it
but they they’re willing to do it if
somebody will help them take them by the
hand and help them through it
um after their first workout sometimes
they will say
that actually feels good now i’m a big
fan of back to your hiking
you know if you can get them out like so
imagine you take somebody
and you get to take them on a that’s
depressed take them on a brisk hike
out in nature it’s like okay now you’re
getting bright light exposure
you’re getting social
support and connection you’re getting
the exercise and you’re getting
uh immersion in nature which has its own
sort of restorative effects in turning
down
stress response circuitry which is part
of the problem and depressed so like
just with a hike in nature you could get
like
a quadruple whammy
which could have immediate mood
elevating effects it’s not going to cure
them
but it’s going to maybe be enough to
break through their pessimism and their
hopelessness and give them a sense of oh
my god there are things that actually
can move the needle
like maybe maybe this could work for me
because part of the the problem with
depression is people get so hopeless
they get you know they get so
despondent of feeling like well
it’s been going on a long time
you know i’m just i’m i’m done like you
know i just i don’t think i’m ever going
to get better
doctors don’t know what they’re doing i
tried the meds it didn’t help me or the
side effects were too awful like you
know whatever and there are lots of
potential side effects
and they jerked me around from this
media that mad and this mad and you know
i’m done and i tried to do therapy but
my therapist just sat there and listened
to me and i wanted them to give me some
advice about stuff i could do and they
just wanted to sit there like a nod and
say uh-huh and you know tell me more and
you know sounded like
like you know saturday night live skit
um you know
they get hopeless
and you know so many folks that we’ve
worked with have been in psychotherapy
and they’ve been in
in in pharmacotherapy and nothing has
helped
so you can imagine
you know and and and i want to validate
that and say yeah you know
um that’s not unusual and yet here are
all kinds of things that we have really
really nice robust research to suggest
that if we can find a way to help you
start doing these things they will make
a difference yeah they should make a
difference now if they don’t
then
you know let’s treat this as a as a
detective
mystery you know it’s like
yeah there are going to be those outlier
cases where the person has an underlying
medical condition
that’s driving their depression nobody’s
ever picked up you know and we picked up
a sleep apnea one at one time i mean we
pick it up we were just like you know
this person is not getting into
remission they’re doing everything it’s
helping but it’s not getting them where
it should there’s something else going
on
and then you know we started like oh
they’ve got you know they snore and
their spouse says they seem to stop
breathing and we’re like let’s get a
sleep consult and you know once we got
that catch then it’s like yeah
their depression yeah got better
yeah um and i and i think it’s
interesting i’m certainly one who loves
looking at uh reviews and things like
that on literature and what people have
written and when it comes to your book
it’s not only well-read it’s it’s it’s
well reviewed in the process and i do
notice that um some individuals um seem
uh have conflict
um within the reviews um just um
to intend
let me restate it
that
the reviews i see that i i think are
sort of misunderstanding kind of the
direction that you’re taking the book
have conflict with it because it feels
like they’ve opened the book and have
been scrolling for the the golden nugget
in there for the secure process but um i
think in reality and i think the
beautiful thing too that many people are
responding to these conflicts who’ve
read your book and quite positively hey
you know take a look at this page oh it
seems like a paragraph was missed for
you here on this page um and i and i
think it’s great that in the process
that even though there’s this
maybe title that you might want to
change in hindsight or you know go back
on that you did think about it when you
put it together and it doesn’t come out
i think as the end for
many individuals as you
just trying to slap stick it in that way
that there was direction for this there
was thought um and thinking about
omega-3s and all that sort of stuff well
yeah i mean and i i in the in the very
beginning pages of the book the preface
you know i’m very
explicit in saying
there is no one-size-fits-all cure for
you know and anyone who understands this
illness
is not in the right mind if they say
they can promise you a cure
you know but
you know i also said i’ve never seen
someone yet
put this full protocol in
to place without experiencing at least
clinically significant improvement
now that may not take them
to remission which is really what i
would
only be satisfied with sustain stable
remission that would be a cure
i’ve seen many patients get there
but when they don’t then i’m always
thinking about okay well
you know there are a lot of i mean
literally dozens of medical conditions
nutritional deficiencies
medications that they’ve been prescribed
that can actually sustain depression
that people don’t even realize like
they’re you know they’re taking xanax
or maybe they’re you know smoking a lot
of weed
um and it turns out the the marijuana is
actually
sustaining
their depression they don’t realize it
now i’m not saying by the way i don’t
want to i know this is colorado yeah
you’re colorado
but i mean you know marijuana has as you
guys know both thc and cbd cannabidiol
and and they have very different
psychoactive effects
that vary a lot
from person to person and based on the
ratio and
you know a lot of people don’t realize
like no if you
with your neurochemistry if you’re
getting the wrong ratio and you’re doing
this every day it could actually be
making you more anxious it could
actually be driving your stress response
circuits in a way that are going to make
it impossible for us to get you to
recovery
by the way i say this all the time with
anxiety
thc for a lot of a lot of people can
really rev up their anxiety circuitry
cbd i’ve almost never seen cbd seems to
actually have a soothing effect from
most
people that i’ve seen clinically and and
also the research on that seems to
support this this is actually a
discussion that we’ve been having
actually ongoing and
and obviously like
we have to be able to mold and adapt in
our field and obviously our field kind
of comes from collapsing the dialectic
as you put it in like
it’s unhelpful and honestly you know to
back it up even further we’re in the
middle of an opiate crisis and that is
real
and uh
um
and we may need to think of different
things to think of yeah oh absolutely
including how to look at success or what
is how
i don’t know yeah well and and you know
if i can just give one more shout out
for the benefits of uh marijuana um
states that have adopted legalized
marijuana
have seen a drop in opiate overdoses
because many people
find that cbd will give them enough
efficacy and pain management
that they can get off the damn opiates
that they depend on because they’re in
agony
but if if they can have the cbd there
for that transition they can actually
often successfully stop taking the
opiates and
you know for me in terms of the scale of
dangerousness and even sort of moral
culpability i just you know the pushing
of opiates on our population is like a
flagrant moral failing
in my book and
for someone to want to criminalize
something like cbd
in the middle of an opiate epidemic i’m
not naming any names
thank you i mean we’ve been talking
around them but yeah yeah um
you know
to me it’s
i can only assume like socrates that
it’s in informed purely by ignorance and
not malice
yeah
i i’m not sure i’m right on that but
that’s not that’s my charitable i
appreciate yeah and i and i and i you
know
i don’t want to i’m not going to dive
off topic here i know that would be
inappropriate but certainly when i when
i think about dialectics i think about
uh the flaws for hegel um in this
process and where he talked about uh
thesis uh antithesis into synthesis and
the important thing is that there’s a
dialect in this process and it collapses
into something that we’ll call a
synthesis and it’s okay to have opposing
viewpoints
on whether it’s uh behavioral health or
addiction or
things like this so um
[Music]
i just appreciate the concept of a
dialectic and certainly i think our
listeners well too you know
especially if they know about marshall
linehan’s dialectical behavior
dialectics cool yeah um
you know and i don’t think it’s any
mistake that it was in treating
borderline personality disorder one of
the hallmarks is
wanting to be all or nothing black or
white
um you know folks with borderline tend
to just
not see any of the nuance in between and
that ability to bring this other
dialectical perspective of
no
you know reality
it’s like no light is a wave and a
particle and they seem to be completely
contradictory but they’re both true even
if you can’t wrap your mind around how
they’re both true they’re both true
right and we’ll have patience
i had a patient who had been sexually
abused by her father
for a short time thankfully
and she told me about it
and it happened when she was 11.
and in the same session she said
same session within five minutes
she said i hate my father
and i love my father absolutely and they
were both completely true
um
and
you know we wrestle with the paradox
clinically all the time that
there are these truths that are in
tension that are seemingly opposed and
yet they are both real and um
yeah i just think it’s it’s such an
important principle maybe not just for
clinical work but just for life in
general
i think we should probably land this
thing yeah i thought that was a great
landing i loved it thank you
steve elardi of the depression cure
thank you so much for