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We already know that “get a grip” on depression does not work. And it just turned out that it has as many as twelve varieties. What does this mean for patients? We ask Dr. Sławomir Murawiec, a psychiatrist.
Zuzanna Opolska: Depression multiplied. Scientists in the journal “Brain, Behavior and Immunity” argue that there is no one, there is twelve. This is the first division of this type?
Dr Sławomir Murawiec: Previously, researchers and clinicians distinguished various forms of depressive disorders or differentiated depressive episodes according to their severity. This time, the scientists took it a step further. First, they found that depression was not a single disease, but a heterogeneous syndrome. Secondly, they shifted the emphasis from symptoms to the genesis of the uprising and distinguished its 12 subtypes.
At the moment, the situation is simpler….
Yes, we recognize the depressive syndrome on the basis of a group of symptoms such as: depressed mood, anhedonia, which patients define by saying: I am not happy, I am not interested in anything, decrease in life activity, occurrence of sleep disorders and the presence of anxiety, sometimes irritability appears.
In this way, we have thrown 350 million people in the world into a sack that says depression?
Earlier, during my lectures, I pointed out that diagnosing depression in a way resembles shopping in a hypermarket. We take everything green and put it in the basket: peas, green stuffed animal, lettuce, Christmas tree. We group different items according to a specific common feature. The authors of the study point out that, apart from the common denominator, depressive episodes have different faces. Some patients suffer from insomnia, others experience excessive sleepiness. Some people lose their appetite, others develop excessive hunger. Similarly, not all patients have elevated levels of cortisol or pro-inflammatory cytokines. This differentiation of depressive episodes, according to Markus J. Rantal’s team, depends to a greater extent on the causes and not on the patient’s personality.
There are a dozen reasons – what?
Among the 12 subtypes we have depression caused by: physical illness, long-term stress, loneliness, traumatic experience, conflict and a sense of social exclusion, mourning, rejection by a partner, postpartum mood disorders, season, alcohol or drugs, brain diseases and hunger. Interestingly, the authors of the study, starting from the assumptions of evolutionary psychiatry, argue that depressed mood in many cases is an adaptive behavior.
How is this possible?
We can explain this on the basis of infection-induced depression accompanied by the so-called morbid behavior. “Sickness behavior”. The symptoms we experience are a “trick” developed by our body over thousands of years of evolution. It is also evidence of a link between the immune, endocrine and nervous systems. Each symptom of the “sickness behavior” has a justification: lack of appetite and sleepiness protect us from unnecessary energy expenditure. In turn, reducing the drive and limiting contact with other people is a way to stop the infection from spreading further.
If depressive symptoms are part of human nature and increase fitness, should they be treated?
What was an adaptive response in the Environment of Evolutionary Adaptedness (EEA), that is from 100 to 000 years ago, under new conditions may succumb and fulfill a different function, not necessarily improving adaptation. An example is depression induced by stress. In the old days, stress factors were short-lived and were associated with a serious risk of injury or infection. Individuals that reacted by increasing the readiness of the immune system had a selective advantage over the rest. Today, the stress we are subjected to lasts months or even years, leading to chronic inflammation.
A loan in francs may be worse than a face-to-face clash with a bear?
Just like that. As the authors of this work write, it does not even have to be a loan in Swiss francs, the shift work system is stressful enough, compared to the team of sudden time changes, i.e. jet lag. If we consider other factors leading to chronic inflammation, such as: sedentary lifestyle, poor diet, little light exposure, sleep deficiency and social isolation, we will understand why depression has become a modern disease.
Did we make ourselves beers?
Unfortunately yes. As a species, we have not had time to adapt to today’s world. In all communities where we see a transformation, the incidence of depression is increasing. Chinese born after 1966 are 22 times more vulnerable than their countrymen born before 1937. Another example is the Old Order Amish, who have one foot in modern America and the other in their own culture. There is no rat race in their world, but there is work for the good of the community. There are no laptops and smartphones, but there are family ties. The media doesn’t bombard them with a thousand bad news. Perhaps these are the reasons why the prevalence of depression among Amish is only 1%.
They live far from civilization, but they are not lonely. Social isolation is another cause of depression …
From an evolutionary standpoint, single homo sapiens were doomed to death. Belonging to a group determined the survival ability of an individual. Only by being part of a larger whole did our ancestors have a chance to ensure their safety, access to food and shelter. Previous research by the neurobiologist John Cacioppo has already shown that we are biologically conditioned to form social bonds, and the health consequences of loneliness are dramatic. It can contribute to sleep disorders, increase blood pressure, chronic stress and depression.
Do you find your own patients among the twelve subtypes?
Yes, it definitely matches my clinical experience. One group consists of people in whom a depressive episode was preceded by chronic stress, in others it was a traumatic event or conflict, in others depression was preceded by mourning, and in another group the loss of professional and social position and a sense of exclusion were factors that caused depression. In the latter case, we are talking about patients who lost their jobs, were relegated or retired. Such an event struck their sense of having a specific and important position in society. The drive for social dominance can be seen especially in the case of men. Looking at evolutionarily, the symptoms of depression that appeared in the situation of loss of position fulfilled two functions. On the one hand, they protected an individual against conflict with a person higher in the social hierarchy and against outright failure. On the other hand, they were a message that the loser no longer posed any threat and was subordinate to the dominant one.
The study by Markus J. Rantal’s team sheds new light on recurrences of depression, which do not apply to all patients. If we cure a patient of depression induced by hunger or mourning, the symptoms should not recur …
Indeed, if depression was caused by situational factors that have passed, the risk of relapse is lower. On the other hand, what we have so far called “relapse” may be an episode of depression caused by a completely different cause. So even if we come to terms with the departure of a loved one, we may become depressed in the future as a result of losing a job or prolonged stress.
How can distinguishing twelve subtypes change the diagnosis and treatment of depression?
According to the authors of the study, diagnosing depression should not only include symptom analysis, but also blood tests for inflammatory markers and stress hormones. It is the subtype of depression that would determine the type of pharmacotherapy and the nature of psychotherapy.
But how to do it? We don’t have a cure for a broken heart …
According to the current doctrine, we have one type of depression, and therefore all drugs are equally effective. However, their operating profiles are different. Therefore, we can imagine that drugs that reduce anxiety and make it easier to fall asleep will work for patients whose depression was induced by a traumatic event. In turn, activating drugs can be helpful in patients whose depression has been caused by loneliness or those who will seek motivation to open up to new goals in life.
At the moment it is a trial and error method – we will give the drug and see how the patient reacts.
Not really – we select the drug according to the clinical picture of depression, i.e. we take into account various factors: sleep disorders, anxiety level, activity. But in practice, unfortunately, this often happens, as you have noticed – one of the available antidepressants is simply administered.
This study shows that a new one is coming. Will we soon be treating patients by 12 subtypes?
I think it will be a lot of water before or “if” that happens. The prevailing concept is that we find depression and give it medicine. This is a simpler version of the treatment.
But not entirely effective, some studies compare the effects of pharmacotherapy with placebo …
You should be critical of similar information. We are able to help at least 2/3 of patients. Simply put, a placebo, as scientific research shows, has its own short-term effectiveness. Therefore, when comparing the effectiveness of drugs with a placebo, we compare, in a sense, the two active substances if the duration of the study is relatively short. Studies on the effectiveness of drugs tend to be short-term, i.e. they usually last 6-8 weeks, and pharmacotherapy in real conditions is long. Often times, a drug change is made or two are used at the same time. And what is important for some patients with depression, psychotherapy conducted simultaneously is very important.