DEPRESSION ANS SUICIDE, or Why Prozac failed… (another great lecture by Dr. Hagen at WSU Vancouver)
Illness concept (wakefield)
Dysfunction in organism
That causes harm to individual
Depression is assumed to be a dysfunction, a mood disorder, it is often related to serotonin what we often hear, it is a chemical imbalance. The implication is the proper level of serotonin (molecule neurotransmitter that is secreted by neurons to create connection), or serotonin deficiency. Final point is the depression is not a dysfunction.
Why we assume it is serotonin and not dopamine. Monoamine hypothesis. There are chemicals that manipulate monoamines. Various compounds that manipulate the levels of monoamines. In Dr. Hagen’s alternative view we seek the answer that it maybe is a trigger to change rather than a disease.
The global burden of disease is increasingly caused by “mental illness.” Resources for public health were limited, back in the time they wanted to cure as many people as possible to make a good bang for the buck. They looked at mortality but there are all kinds of diseases that also kill you. They need to look at the disease that slowly kill you. The depression came up on the top along with Alzheimer’s and other disease of such sort.
For most human history it was infectious disease that contributed to the global burden. Infectious decease work extremely well. Vaccine is an actual disease, a pathogen that does not make you sick or makes you mildly sick, it is derived from usually the original pathogen. It is bread in other animal cells, adapting those diseases and teaching your immune system to protect itself. Second big thing was sanitation – basically get rid of human waste away from humans. The third big major invention were antibiotics. Toxins specific to a certain bacteria. Penicillin – fungus produced a defensive chemicals. Fundamental scientific inside of diseases are living organisms that essentially harm you so you treat them with antibiotics, avoid them or treat them with vaccines. We have the right concept here, we know what we have to do. We have to find the pathogen, identify it and kill it.
In contrast, when it comes to mental disease, we don’t know what is going on. Paxil, Zoloft, Prozac they work but they don’t work very well. With antibiotic – you take it and the decease is gone, vaccine – gone, sanitation – gone. But these are not fully healing the body.
Antidepressants and talk therapy are not much better than the placebo. Any antidepressant will deliver over 50% improvement in symptoms for 50% of patients.
- Talk therapy in over 50% improvement in symptoms for 50 % of patients.
- Placebo over 30% improvement in symptoms for 50% of patients.
Might be no clinically significant effect when unpublished studies were included.
The drug companies had to release the unpublished studies, when those were pulled into the pool of information about depression they showed that antidepressants were not really a solution. Antidepressants work for strong severely depressed people who are completely dysfunctional. In these case antidepressants work. However, there is a small placebo effect on the mild spectrum of depression disease. These drugs are not that good.
The first generation of antidepressants, that involves drugs, half a century of research on depression – no improvement in treatment. About 50-60 yrs ago. Since then billions have been spent. It is a National institute for Health. Has it lead to the better treatments? Not really! The newest antidepressants are compared to the original antidepressants. There is no evidence of improvement. The improvement is in fewer side effects – meaning that they are safer but not more effective.
How bad is the depression? Global burden of disease (DALYs), the top 10 high income countries show that the problems can’t be solved even with wealth and money. Ischemic heart disease are top cerebro-vascular disease are second, unipolar depressive disorders are third. Alzheimer’s dementias are after that. Trachea, bronchitis, and lung cancers are fifth down. Old age and depression are two problems that have yet to be solved.
In purlieu in middle income developing countries the infectious diseases are at the top. Yet depression is a definite contributor within the global disease burden. We do not have a solid conceptual resolution.
Depression is a major risk factor for suicide. Worldwide, suicide causes about the same number of deaths as all wars and homicides combined globally. The suicide rate varies by a factor of 20 cross-populations. Higher is about 50 people per 100K per year lowest is about 2.
The harm comes from:
- Sad depressed mood,
- Loss of interest in virtually all activities.
We are looking at suicide as the most extreme cost of depression. #2 bullet is similar to killing yourself – a temporary suicide so to speak. There is a number of societies that view a suicide as a sin, tabu, etc. Other societies there is either no stigma attached to it or a requirement, to kill yourself as you suffer from defeat if you are a warrior for example.
Standard story – depression not a chemical imbalance – abnormally low levels of serotonin in the brain. Biochemical plausibility – standard model has problems. It is no longer true. There was a law suit against drug companies advertising that their product corrects the balance of chemicals in the brain.
- Antidepressants immediately increased neurotransmitter concentrations, but depressive symptoms take at least 2-4 weeks to lift. There is a big disconnect in the time scale between increase in serotonin and depression symptoms. If depression caused by serotonin deficiency.
- Depletion of 5-th does not cause depression in non-depressed subjects. All the psychoactive drugs work by interacting with receptors, interfering with neurotransmission by blocking or activating.
- Depletion of 5-th does not exacerbate symptoms in depressed subjects.
- (Altering the growth of receptors – changing neurostructure – which takes time)
- Some drugs are antidepressant drugs (e.g. tianepltine) actually decrease availability of 5-HT!!!
- Some drugs that do increase serotonin or noradrenergic transmission are not effective antidepressants.
In sum – some drugs inspired by the monomaine hypothesis can alleviate depression, but no one knows how or why (newer variants emphasize, e.g. neurogenisis).
Depression and suicidality are NOT caused by simple chemical imbalances! It does not mean the depression is a dysfunction. We simply don’t know how it works!
CHANGE YOURSELF TO SOLVE A MAJOR PROBLEM CHANGE OTHERS
We need a new paradigm. It is time to step back and ask ourselves is it true that depression is a disease or illness. Loss of interest, increased risk of suicide, how can it not be a dysfunction? One possibility is a mismatch hypothesis. These are costs, therefore we need to find a benefit. Is there any compensating benefit to depression? The main argument is “how do you know if we don’t look?”
Can we look at the depression as a sort of pain. Psychic pain and physical pain are same. To solve a major life problem change yourself or change others.
Death of the loved one is one of the biggest predictions for depression. Others are divorce, relationship problems, marital problems. Number three is a physical assault. There are many predictors and also depression itself. They are all having a negative impact on your fitness:
- Marital problems, you lose a partner – you can’t produce children.
- Loss of jobs and social status – access to resources – money, salary, social, monetary, etc.
- Death of the loved one – the loss of close kin, there is a lot of mutual assistance, almost in every society your fitness depends on the fitness of others.
All of these have assumed to cause the depression.
If you think about the relationship problem – the causality of depression. It is difficult to conclusively proof causality – predictors of depression. These strong social correlates of depression it is hard to predict that if you are physically assaulted, if your parents to die, they are not the causing of the social problem. Social problems come first and the depression comes second – does that proof causality – no, but it could… When asked it is often that we infact say that these social problems cause depression.
Form here we are going to assume that the life problems cause depression.
Death of the loved one is a long standing evolutionary problem. Any kind of social species relationship problems may cause the depression.
In a case of the relationship problem, if you lose a loved one, you lose social benefits, the potential solution to forge a new relationship. Marital problem, lose a spouse – get a new one. Physical assault – you sick protection. Status – you lose a job, you get yourself to find a new one. Depression and suicide help to change yourself and help you change others.
DSM – IV major depressive episode – what defines disease – mostly studies in North America, Europe, ICD has a little more global perspective.
- Sad or depressed affect
- Marked loss of interest in virtually all activities
- Significant weight loss or gain
- Hypersomnia or insomnia
- Psychomotor retardation or agitation
- Fatigue or loss of energy
- Feelings of worthlessness of guilt
- Diminished ability to think or concentrate
- Recurrent thoughts of death.
When we look at 1,2 or 9, it relates to the formula change yourself or change others. Depression is a form of psychic pain – it is close to a physical pain. You break your ankle; you begin to avoid hurting it. Think about what you did and learn from mistakes. It turns out that people who are depressed – they ruminate – dwell, or think.
In the illness model, the rumination is interpreted as dysfunction and they want you to stop from that. That is clinically. However, in alternative approach, there is a radically different interpretation – because rumination is a good thing, you have to go through that process to think it through and make sure to clear your path. In Dr. Hagen’s story – rumination has a tremendous utility. Drug treatment is chemically interfering with things that you are doing to heal yourself. You have to ask are we interfering with cognitive process here?
Psychic pain tries to keep you from making it worst. Physical pain is not fun, when you break a bone, it is not fun. Depression is painful, there is a lot of rumination going on but it is beneficial in a long term and we need to make sure not to repeat the experience. From the evolutionary perspective – you have to bounce back, in order to reproduce, so as long as you do… you are in good future.
Number 2 and number 9 – hypothesis: Suicidality – Idea here is conflicts of interest – your wife left you – it was not in her good interests, your boss fired you, there is a conflict of interests. When something happens – you send signals that you need help – you cry, you look sad, but people will help you if you have good true close people who are willing to give you help. When you need to change from others, when you have lots of conflict, those are the people that get depressed. They have severe conflicts with their close-ones. Depression and suicidal threats are a away to force people to change and overcome those conflicts.
The basic idea: if others won’t change…
- The strong will physically (or politically) threaten others
- The weak will threaten to hurt themselves instead.
Wife will more likely to hurt herself if a husband is cheating or abusive. Husband will end up with the kids. This is a serious threat to the husband. Parent – child relationship – there is a conflict between the parents and the offspring. In close interdependent relationships when people need each other, if one person threatens to kill or hurt self, others will be threatened and try to do something to change that.
The weak are still extremely valuable as offspring siblings, mates, and/or parents.
If you kill yourself you fail in Dr. Hagen’s model. General idea is threats to be credible. So as long as people intervene you have a less chance in dying. When suicide happens, that is a failure.
In conflicts suicidality is a strategy of the weak to threaten or hurt the strong.
Over and over the record – people are using a threat of self-harm as means of getting back at others. Malinowski – suicide is performed as an act of justice, not upon oneself, but upon some person of near kindred who has caused offense. Do threats and attempts yield benefits?
17 f 81 threat/attempts cases mention a benefit
35 of 81 threat attempts
Used by the week to hurt the strong and failed suicide attempts often elicit valuable benefits. Suicide is extreme of depression. So, Change yourself or Change others!