Tech + Health

08.20.14

We're Talking About Depression All Wrong

Robin Williams’ death has sparked an international conversation about mental illness, and it shows we still have a lot to learn.

The suicide of beloved comedian Robin Williams has launched a collective dialogue about mental illness. Many have poignantly noted the ways depression and other mental illnesses can ravage the individual psyche, and the ways people can seek help if needed. Others have noted the sad truth that Williams probably had access to the best care, and it still wasn’t enough.

But as a psychiatrist who has grappled with it both professionally and personally, depression can be a multilayered beast, interlaced with one’s personality, vulnerabilities, and upbringing, all intermingling with the dark shades of misfiring brain chemistry. This complexity leads to ongoing confusion and debate over how much mental illness relies on personal resolve versus personal biology.

Too often, people are quick to stigmatize depression and other mental illnesses as forms of moral weakness or lack of willpower, especially in individualistic America. It’s even worse when Hollywood celebrities join the gambit with overly one-sided or misinformed opinions, like actor Tom Cruise critiquing Brooke Shields’ use of medication for postpartum depression, or Kiss frontman Gene Simmons recently telling a depressed teen, “Fuck you, then kill yourself.”

People are quick to judge therapy or medication as a crutch in this oh-so-simple game of mind over matter: such treatments are either an easy tool for wimpy people who can’t solve their own problems, or an evil toxic mind control method created by various conspiracies.

But with Williams’ death, something has shifted. People are starting to recognize that depression must relate to biology, because who would give up such an outwardly gifted life? Williams was always busy making the rest of us happy, and we absolutely adored him for it. For such a source of outward joy to crumble so violently, what the hell happened?

... Our complement of tools remains relatively limited—and admittedly crude—compared to the brain’s immense complexity.

Depression’s biology skews your vision and distorts reality. It sprays a fog that makes the afflicted person feel that nothing is ever good enough, that people hate you or you hate them, and that you will never feel secure in your world, no matter what. Sometimes it is accompanied by anxiety, its evil sibling, which is triggered by the same misfiring neurochemicals. Anxiety brings crippling panic, feelings of danger, racing thoughts of doom, and obsessions about misery, plaguing you in the dark of night or jerking you awake at the crack of dawn. You feel a horrible, self-punishing sense of isolation and loneliness. And yet, you can appear outwardly perfect, seeming to have it all together. You frenetically play-act while you feel your soul is dying.

To varying degrees, the foundations of your background can help or harm you. If you have supportive parents, financial stability, good friends, or a job you love, you might do better despite some negative biology. Others have resilience, overcoming negative socioeconomic or situational circumstances and ending up with a positive outlook, if they are not saddled with certain types of genetic vulnerabilities.

Confounding matters is the influence of external stressors and trauma on a person’s neurobiology, particularly in childhood. Several studies have shown that abuse and trauma can affect one’s hypothalamic-pituitary-adrenal (HPA) axis, which triggers one’s fight or flight response. The HPA axis is a circuit between your brain, your hormone glands, and the rest of your body. The different parts are constantly signaling each other.

For example, you see and hear someone yelling at you. Your brain recognizes it and signals the parts of the brain—the hypothalamus and pituitary—that release hormones to signal your adrenal glands, which in turn release chemicals that raise your heart rate and blood pressure. You go into hyperalert mode until the threat passes, and other hormones shut down your signaling loop. However, prolonged stress exposure over time can actually modify your HPA axis’ thresholds so that your system does not turn off easily, or is hyperreactive to minor, even nonexistent threats. Your brain chemistry changes to one that is more easily prone to anxiety and depression, since the same chemicals and signals are involved in this fear response.

Your brain is even more sensitive during childhood, which renders this population especially vulnerable to future mental illness. Early intervention, in these cases, may lead to better long-term outcomes. But even in adulthood, the HPA axis can be malleable. Both medications and therapy—and often, the combination of the two—have been shown to help restore its balance, which I have witnessed in research and clinical practice. As someone who worked hard at therapy for many years and resisted medication, when I finally tried the right one, I realized that I had a medical condition all along that wasn’t being adequately treated. I wasn’t weirdly happy or numbed out. I was just myself again—the person I was meant to be, without the fog.

Perhaps the Robin Williams tragedy will be a clarion call for Americans and others around the world, to recognize that mental illness is real, is nobody’s “fault,” and that there is no shame in getting help.

Another factor is epigenetics, a burgeoning field where scientists are realizing that parts of the genome can actually change its code in response to outside stressors or influences. So some people who might have a genetic tendency toward depression, anxiety, or schizophrenia may not develop it if they grow up in a safe, nurturing environment. But if they are exposed to even minor trauma, parts of their genome involved in the HPA axis or other neurochemical circuits in the brain might get activated for the worse. It’s like a railroad switch that gets flipped, leading to a new track from that point on.

However, there are some genes that switch on from the beginning with a severe and intractable course, and no amount of love and support can save them. Virginia State Senator Creigh Deeds’ late son was a classic example of someone who, despite being from a solid and well-off family, developed a serious mental illness. He became acutely delusional and committed suicide after attacking his father. Robin Williams also likely battled his condition valiantly for many years, but may have taken a turn for the worse after the additional biological stressors of open-heart surgery and Parkinson’s disease, both of which are known to exacerbate and/or cause depression. These treatment-resistant cases indicate the ongoing need for more cutting-edge medical and genetic research into what causes devastating conditions like schizophrenia, severe bipolar, and psychotic depression, as well as how to develop better treatments.

The brain is the most complex organ in our body. It runs as a polyphonic symphony compared to the simple percussion section of the heart or the synchronized cellos of the liver. We have only barely scratched the surface of how it functions, although we are making amazing advances in the last few decades thanks to new strides in DNA and genetic research and neuroimaging. Medications and psychotherapy and other treatments like electroconvulsive therapy (ECT) are important and can be helpful, but our complement of tools remains relatively limited—and admittedly crude—compared to the brain’s immense complexity, and to the complicating factors of life itself: how people interact with their world, talk to people, the aspirations and goals they encounter in their socioeconomic circle, their heartbreaks, their tragedies, their flaws. The brain and the universe are in constant flux, playing with and against each other, with the mind struggling to make sense of how to survive out there, and the world pushing back against the brain’s physical limitations.

For the unfortunately common perception that depression and anxiety are just a matter of “snapping out of it” and “pushing ahead” or “just being happy and grateful,” we need to step back and recognize the immensity of what we are dealing with. The brain is miraculous, whether you come to that recognition via faith or evolutionary science, and not a simple toy box or video game. Even without understanding advanced neurobiology, you can recognize that the brain is, really, everything. We see what happens with even small strokes or traumatic brain injuries—how your ability to talk, think, speak, and move all quickly get affected, and how limited our ability to treat even small abuses to our brain is. Our behavior and our moods are no different; they are also part of the central package.

Perhaps the Robin Williams tragedy will be a clarion call for Americans and others around the world to recognize that mental illness is real, is nobody’s “fault,” and that there is no shame in getting help. Mental illness is physical and medical, but it is also even more intricate than that; mental illness ties into our very existence, our interaction with everyone and everything. The prognosis of each person runs on a spectrum relative to their genetic loading and their environment. At least on a limited but important part of that spectrum, we as mental health professionals can intervene and help some people hang on, improve, come back against biology, and soothe against environment. For those that we can save, the rest of us must stand watch and bring them to light instead of losing them to falsehoods and misplaced moral codes about independence.

After all, is it stronger and more effective to till a large field alone, or with a team of fellow human beings alongside you?