“Exercise is the first step for all my patients,” Richard A. Friedman of Payne-Whitney says. “It boosts everyone.” I hate exercise, but as soon as I can drag myself out of bed, I do some calisthenics; or if I can manage it, I go to a gym. When I was emerging from depression, it didn’t really matter what I did; StairMasters and treadmills were the easiest. It felt as though the exercise helped to clear the depression out of my blood, as though it helped me to get cleaner. “It’s a very clear matter,” says James Watson, president of Cold Spring Harbor Laboratory and one of the discoverers of DNA. “Exercise produces endorphins. Endorphins are endogenous morphine, and they make you feel great if you’re feeling normal. They make you feel better if you’re feeling awful. You have to get those endorphins up and running—after all, they’re upstream of the neurotransmitters too, and so exercise is going to work to raise your neurotransmitter levels.” Further, depression makes your body heavy and sluggish; and being heavy and sluggish exacerbates depression. If you keep making your body function, as much as you can, your mind will follow suit. A really serious workout is just about the most disgusting idea I can imagine when I’m depressed, and it’s no fun doing it, but afterward I always feel a thousand times better. Exercise allays anxiety too: nervous energy gets used up by sit-ups, and this helps to contain irrational fear.
You are what you eat; you feel what you are. You cannot cause a depression to remit simply by choosing the right foods; but you can certainly bring on a depression by failing to eat the right foods, and you can to some extent protect against recurrence through careful monitoring of diet. Sugar and carbohydrates appear to raise the absorption of tryptophan in the brain, which in turn raises serotonin levels. Vitamin B6, which is found in whole grains and shellfish, is important to serotonin synthesis; low levels of B6 may precipitate a depression. Low cholesterol has been linked to depressive symptoms. The studies aren’t in, but a good diet of lobster and chocolate mousse may do much toward improving one’s state of mind. “The twentieth century’s emphasis on a physically healthy diet,” says Watson, “has probably given us a psychologically unhealthy one.” Dopamine synthesis also relies on B vitamins, especially B12 (found in fish and dairy products) and folic acid (found in calf’s liver and broccoli), and also on magnesium (found in cod, mackerel, and wheat germ). Depressed people often have low levels of zinc (which occurs in oysters, endive, asparagus, turkey, and radishes), vitamin B3 (found in eggs, brewer’s yeast, and poultry), and chromium; and these three have been used to treat depression. Low levels of zinc have been especially strongly associated with postpartum depression, since all reserves of zinc pass from the expectant mother to the baby at the very end of pregnancy. Increasing intake of zinc can elevate mood. One theory in circulation is that people in the Mediterranean have less depression because of the amount of fish oil—rich in B vitamins—they consume, which raises their level of omega-3 fatty acids. The evidence for beneficial mood effect from omega-3 fatty acids is the strongest of all.
While these foodstuffs may be effective in preventing depression, other foodstuffs may cause depression. “Many Europeans have wheat allergies, and many Americans have corn allergies,” Vicki Edgson, author of The Food Doctor, explains. Food allergies can also trigger depression. “These common substances become brain toxins which precipitate all kinds of mental distress.” Many people develop depressive symptoms as part of a syndrome of adrenal exhaustion, a consequence of excessive indulgence in sugars and carbohydrates. “If you’ve got a constantly fluctuating blood sugar level, with highs and lows throughout the day, quick fixes from sweets and junk food, this will cause sleep problems. It will limit not only the ability to cope throughout the day, but also patience and tolerance with other people. People with this syndrome are tired all the time; they lose their sex drive; they ache all over. The stress on their systems is ruinous.” Some people develop celiac disease, which causes a general failure to thrive. “People who are depressed fool themselves into thinking that coffee is the one thing that provides energy,” Edgson says, “but in fact it leaches energy and stimulates anxiety responses.” Alcohol also, of course, takes a substantial toll on the body. “Sometimes,” Edgson says, “the depression is your body’s way of telling you to stop abusing it; it’s evidence of how things are falling apart.”
Robert Post at the NIMH has been working on repeated transcranial magnetic stimulation (rTMS), which uses magnetism to create metabolic stimulation much like that caused in ECT, but at lower levels. Modern technology allows magnetism to be focused and concentrated to provide intense stimulus to specific areas of the brain. While electric current has to be turned up quite high to get through the skull and scalp to the brain, magnetic fluxes travel through easily. So ECT causes a brain seizure, and rTMS doesn’t. Post proposes that with the advance of neuro-imaging, it may ultimately be possible to pinpoint the areas of the brain that are depressed and to aim magnetic stimulations at those areas, customizing treatment to correspond to the specific form of illness. Also, rTMS offers the possibility of enormous specificity; the magnetic stimulation can be focused with precision. “Sometime,” says Post, “we may use technology to put a hood, like an old-fashioned hairdryer, over your head. It would scan your brain and pick up the areas of depressed metabolism, and it would then focus stimulation on those areas. Half an hour later, you would leave with your brain rebalanced.”
Norman Rosenthal discovered seasonal affective disorder (SAD) when he moved from South Africa to the United States and began getting rounds of the winter blues. Many people have seasonal changes of mood and develop recurrent winter depression; the changes of season—what one patient called “the crossfire between summer and winter”—are a difficult time for everyone. SAD is different from just not liking cold days. Rosenthal argues that human beings were made to respond to seasonal variation, which artificial light and the artificial constraints of modern life do not allow. When the days get shorter, many people go into withdrawal, and “asking them to perform in the face of their own biological shutdown is a formula for depression. How would a hibernating bear feel if you wanted it to enter the circus and stand up on its hind legs and dance all winter long?” Experiments have shown that SAD is affected by light, which influences the secretion of melatonin and so affects neurotransmitter systems. Light stimulates the hypothalamus, where many of the systems—sleeping, eating, temperature, sex drive—that depression deregulates are based. Light also influences serotonin synthesis in the retina. A sunny day offers about three hundred times as much light as the average household interior. The therapy generally prescribed for SAD sufferers is the use of a light box, which casts terrifyingly bright light at you. I find that light boxes make me a bit dizzy, and I feel as though they challenge my eyes, but I know people who love them. Some actually wear light visors, or head-mounted light boxes. A bright box, which is very much brighter than regular indoor lighting, has been shown to raise brain serotonin levels. “You see the SAD people beginning to go in the autumn,” says Rosenthal. “It’s like watching the leaves fall off the trees. And then we started treating them with intense light exposure, and it’s like seeing the tulips come up.”
Eye movement desensitization and reprocessing (EMDR) therapy originated in 1987 for the treatment of post–traumatic stress disorder. The technique is a bit kitschy. The therapist moves his hand at various rates across a field from your right-side peripheral vision to your left-side peripheral vision, so stimulating one eye and then the other. In a variant on the technique, you wear headphones that alternate sounds to stimulate one ear and then the other; or in a third possibility, you hold little vibrators, one in each hand, and they pulse alternatingly. While this is going on, you go through a psychodynamic process of remembering your trauma and reliving it, and at the end of the session you are free of it. While many therapies—psychoanalysis, for example—comprise beautiful theories and limited results, EMDR has silly theories and excellent results. Practitioners of the therapy speculate that it works b
y stimulating left and right brain in rapid alternation, so helping to transfer memories from one brain storage center to another. This seems unlikely. Something, however, about EMDR’s oscillating stimulation does have a dramatic effect.
EMDR is increasingly being used for depression. Since the technique uses trauma memories, it is more often prescribed as a treatment for trauma-based depression than for more generalized depression. I tried all kinds of techniques in the course of researching this book, including EMDR. I was convinced that it was a cute but insignificant system and was very much surprised by the results. I had been told that the technique “speeds up processing,” but that did not prepare me for the intensity of the experience. I put on the headphones and tried to think about my memories. I was flooded with incredibly powerful images from childhood, things I hadn’t known were even in my brain. I could form associations in no time at all: my mind became speedier than it’s ever been. It was an electrifying experience, and the EMDR therapist with whom I was working proficiently led me to all kinds of forgotten childhood difficulties. I am not sure that EMDR has much immediate effect on a depression that is not triggered by a single trauma, but it was so stimulating and so interesting that I kept it up for a twenty-session course.
David Grand, a trained psychoanalytic therapist who now uses EMDR with all his patients, says, “EMDR can help a person to do in six to twelve months what couldn’t be done in five years of ordinary treatment. I’m not comparing in the abstract: I’m comparing my work with EMDR to my work without it. The activation bypasses the ego and activates deeply, quickly, and directly. EMDR is not an approach, like the cognitive or the psychoanalytic; it’s a tool. You can’t just be a generic EMDR therapist. You have to be a good therapist first and then figure out how to integrate EMDR. The oddity of it is a turnoff, but I have been doing it for eight years, and I could not go back to doing therapy without EMDR knowing what I know now. It would be such a regression, such a return to the primitive.” I always came out of my EMDR therapist’s office reeling (in a good way); and the things I learned have stayed with me and enriched my conscious mind. It’s a powerful process. I recommend it.
In October 1999, I traveled to Sedona, Arizona, to have four days of New Age massage at a time when I was experiencing great stress. I am in general rather cynical about New Age treatments, and I greeted the “analyst” who would perform my first treatment with some suspicion as she laid out her crystals at the end of the room and told me about her dreams. I am not persuaded that deep inward tranquillity is an automatic result of being sprayed in sequence with oils from sacred Chaco Canyon and Tibet, and I don’t know that the strand of rose quartz beads she draped like a rosary over my eyes was really connecting with my chakras; nor do I believe that the interpretive Sanskrit chants with which the room was filled were inscribing antidepressant virtues into my meridians. All that being said, four days of gentle handling by beautiful women in an opulent resort did a great deal for me, and I left high on peace. My final treatment—cranial-sacral massage—seemed to have particularly beneficial effects: a certain serenity descended on me and lasted for several days.
I believe that extensive massage, which reawakens the body that depression has cut off from the mind, can be a useful part of therapy. I don’t think my Sedona experience could have done a thing for someone in the depths of major depression, but as a tune-up technique it was pretty terrific. The theorist Roger Callahan claims to mix applied kinesiology and traditional Chinese medicine. Callahan posits that we change on a cellular basis first, then a chemical, then neurophysiological, then cognitive. We have, he says, been working backward in treating the cognitive first and the neurophysiological second; he begins with the mystic realities of muscle responses. He has many followers. Though their practices seem hokey to me, the idea of starting from the physical seems rather intelligent. Depression is a bodily affliction, and the physical helps.
During the Second World War, many British soldiers had to spend extended periods adrift in the Atlantic after their ships had suffered disabling attacks. The soldiers who had the best rate of survival were not the most young and able but the most experienced, who often had a toughness of spirit that transcended the limits of their bodies. The educator Kurt Hahn observed that such toughness had to be learned, and he founded Outward Bound, which is now a large confederation of associations scattered around the globe. Through structured encounters with the wild, Outward Bound attempts to keep to Hahn’s objectives: “I regard it as the foremost task of education to ensure survival of these qualities: an enterprising curiosity; an undefeatable spirit; tenacity in pursuit; readiness for sensible self-denial; and, above all, compassion.”
In the summer of 2000, I went on an expedition with Outward Bound’s Hurricane Island School. I could never have done Outward Bound from the seat of a depression, but doing it when I was not depressed seemed to strengthen the things in me that resist depression. The course was rigorous and sometimes quite punishing but also pleasurable, and it did make me feel that my life was tied to the organic processes of the larger world. That was a secure feeling: assuming one’s place in the sweep of eternity is enormously comforting. We went sea kayaking, and our days were filled with muscular exertion. On a typical day, we might rise at about four in the morning, then run a mile, then go to a platform some twenty-eight feet above the sea and jump off it into the frigid Maine water. Then we’d strike camp and pack our supplies in our kayaks, then carry the kayaks—two-person boats some twenty-two feet long—down to the sea. We’d paddle perhaps five miles against the tide (going just over a mile an hour) until we reached a place where we could stop for breakfast, and we’d stretch and cook and eat there. Then we’d climb back in the boats and do another five miles of paddling, then arrive at our location for the night. We’d have lunch and then practice assisted rescues, turning our boats over and releasing ourselves underwater from the webbing that held us in, righting the kayaks in the sea, and reentering them. Then we’d be taken individually to separate spots for the night, which we would pass with a sleeping bag, a bottle of water, a plastic tarp, and a piece of string. Fortunately, the sun was shining during my trip; we would have stuck to the same agenda had there been sleet coming down on us. Our instructors were remarkable, people of the earth who seemed to be absolute survivors and strong and even sometimes wise. Through our close encounters with wilderness, and through their careful interventions, we gained some fragment of their intense competence.
At times I wished I had never come and felt that the final mark of my lunacy was that I had consented to let my life be stripped of its luxuries like this. But I also felt myself back in touch with something profound. It smacks of triumph to inhabit the unimproved world of nature, even if you do so in a fiberglass kayak. The rhythm of paddling helps, and so does the light, and the waves seem to pace the blood as it goes to the heart, and sadness ebbs. Outward Bound reminded me in many ways of psychoanalysis: it was a process of self-revelation that pushed out one’s sense of limits. In this, it met the intention of its founder. “Without self-discovery,” Hahn wrote, extending an idea of Nietzsche’s, “a person may still have self-confidence, but it is a self-confidence built on ignorance and it melts in the face of heavy burdens. Self-discovery is the end product of a great challenge mastered, when the mind commands the body to do the seemingly impossible, when strength and courage are summoned to extraordinary limits for the sake of something outside the self—a principle, an onerous task, another human life.” That is to say, one has to do things between bouts of depression that will build up the resilience so that you can survive despair when it comes knocking again—much as we do daily exercise to keep our bodies in shape. I would not suggest doing Outward Bound instead of therapy, but as a supplement to therapy, it can be powerful; and it is, in its entirety, gratifyingly beautiful. Depression cuts you off from your roots. Though it can feel leaden, depression is also a helium situation because nothing holds you to the earth. Outward Bound was my way into the
rootedness of nature, and to have done what I did made me feel, finally, both proud and safe.
Hypnosis, like EMDR, is a tool that can be used in treatment rather than as a treatment itself. It is possible through hypnosis to take a patient back to his early experiences and help him to relive them in a way that brings about some resolution. In his book on the use of hypnosis in depression, Michael Yapko writes that hypnosis works best when the personal understanding of an experience seems to be the source of depression and can be changed to an alternative understanding that feels better. Hypnosis is also used to conjure in the patient’s mind an image of a potential bright future, the anticipation of which may lift him out of current misery and so enable that bright future itself. At the least, a successful hypnosis is useful in breaking negative patterns of thought and behavior.
One of the primary symptoms of depression is a disruption in sleep patterns; really depressed people may have no deep sleep at all and may be spending lots of time in bed without ever getting rested. Does one sleep oddly only because of depression, or does one sink into depression in part because of sleeping oddly? “Grief, which leads to depression, disrupts your sleep one way; falling in love, which can lead to mania, disrupts your sleep another way,” Thomas Wehr, at the NIMH, points out. Even people who do not suffer from depression have had the experience of waking up too early with a sensation of ominous dread; in fact, that fearful despairing state, which usually passes quickly, may be the closest that healthy people come to the experience of depression. Almost all people who suffer from depression feel worse in the morning and better as the day goes on. So Thomas Wehr has done a series of experiments that show that you can alleviate some symptoms of depression with controlled sleep deprivation. It’s not a practical system for the long term, but it can be useful in people who are waiting for the effects of antidepressants to kick in. “By not letting someone go to sleep, you extend the day’s improvement. Even though depressed people seek the oblivion of sleep, it is in sleep that the depression is maintained and intensified. What kind of horrible succubus visits during the night and brings about that transformation?” Wehr asks.
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