Thursday, February 24, 2011

The Road Map For Loonie Liberation

First they ignore you.
Then they laugh at you.
Then they fight you.
Then you win.

This is a preview of next week.  Me -- taking a mental health break.

photo of Mahatma Gandhi in public domain

Friday, February 18, 2011

It's Not Stigma -- It's Prejudice and Internalized Oppression

Stigma sticks to the persons stigmatized.  And sure enough, we are stuck.  Every time we repeat the word, we reinforce it.

Here is an idea.  It's not stigma.  It is prejudice and internalized oppression.

We gotta do something new, people.  We're dying out here.

Treatment For Mental Illness -- The Streets Or Jail

Ever since John Kennedy promised us more humane, community-based treatment for mental illness, we have been living on the streets.  Somebody with serious mental illness is four times more likely to be homeless than somebody without.

Or in jail.  On any given day, there are roughly 283,000 persons with severe mental illnesses incarcerated in federal and state jails and prisons.  In contrast, there are approximately 70,000 persons with severe mental illnesses in public psychiatric hospitals, and 30 percent of them are forensic patients.  Los Angeles and Cook County jails are the largest inpatient mental health facilities in the country.

No Respect=No Money=No Help

Does anybody out there live in a state where funding for mental health services is not being slashed?  Wasn't being slashed even before the last elections?

Now that we are talking money, how is this for a reality check on what we are worth -- from John McManamy's blog Knowledge Is Necessity:

In 2009, the NIH allocated $3.19 billion for HIV/AIDS research.  By contrast, research for depression (including bipolar) was a mere $402 million.

Million, not billion.  These are ratios that have held fairly steady over the years.  Approximately 1.5 million individuals in the US are affected by HIV or AIDS.  About 19 million in the US in any given year deal with depression or bipolar.  That translates to the NIH spending $2,013 per patient for HIV/AIDS research vs a paltry $21 per patient for depression and bipolar.  Putting it another way, for every dollar the NIH invests in an HIV/AIDS patient, depression and bipolar patients get one penny. [emphasis added]

Kinda puts things in perspective.

Funding By Death

But AIDS is fatal.  What about spending per death?

The number of deaths of persons with an AIDS diagnosis has stabilized in recent years at around 17-18,000 per year.  (Deaths of persons with an AIDS diagnosis may be due to any cause).  Since the beginning of the epidemic, an estimated 597,499 people with AIDS have died in the U.S.  Again, that does not mean they died of AIDS.  The figure includes heart attacks, cancer, accidents, suicide, etc.

In contrast, the Center for Disease Control reports that 34,598 people died by suicide in 2007.  We are pushing 900,000 deaths by suicide in the same period as the 600,000 people with AIDS who died for whatever reason.

But people with AIDS are now living longer.  Today, for every death of a person who has AIDS, two people die by suicide.  Far from stabilizing, the suicide rate has been rising since 1995.  [Side note: so much for that claim that increased antidepressant use caused the rate to go down.  There are more of us on them now than ever, and more of us dying anyhow.]

Depression is not the cause of suicide in all cases.  Research indicates that 90% of those who die by suicide have a mental illness.  That 70% have a mood disorder is a low ball estimate.  But that would yield 24,218 deaths by suicide among persons with mood disorders.

So the NIH spends $for 187,647/year for every death of a person with AIDS and $16,599/year for every death of a person with a mood disorder.

Oh, it's not so bad after all.  If we look at death rates, the disparity is down to $11 for somebody who has AIDS and dies by any cause to $1 for somebody who dies from depression.

Feelin' all warm and gooey inside now. 

No Political Price To Pay

Here is the politics at work.

The Ryan White Act was enacted in 1990 and named after a twelve-year-old who was kicked out of school because he had HIV/AIDS.  The act provides funding of last resort for poor people with HIV/AIDS and technical assistance to state and local organizations dealing with HIV/AIDS.  This is on top of the NIH research funding.

The money is not much, just over $2,000,000.  But it has held its own in the last decade, with modest increases every year until 2010.  Up for expiration in 2009, it was renewed by unanimous vote in the Senate and 408 aye/9 nay/15 abstaining in the House.

Now I am totally in favor of the Ryan White Act and the amount is stingy.  But I ask you to consider, do people with mental illness have anything like the Ryan White Act?  And can you imagine a legislator who thinks there will be any political price to pay for the cuts he/she is voting right now to services for people with mental illness, or for teaching laws enforcement how to handle mental health emergencies?

We could run the numbers for other diseases.  Breast cancer would reveal similar results.  Please, please understand me.  We are not on different sides here.  The AIDS example is especially valuable because we can draw lessons from what AIDS activists have accomplished. 

Stigma Busting Is A Bust

The problem is that people don't think of mental illness as real illness, right?  The solution is more education about the biological basis for mental illness, right?

No, not so much.  Researchers at Indiana University and Columbia University examined changes in understanding and attitudes in the US between 1996 and 2006.  Education has indeed increased understanding that mental illness is a biological condition.  54% of people knew that about depression in 1996, 67% in 2006.  Let's give the pharmaceutical companies some credit for their share, probably the lion's share of that change.

On the other hand, do they want to work with, socialize with, marry or live next door to us?  Nope.  Those numbers did not budge in the same time frame.  More telling for the task of designing stigma-busting strategies, there is no difference in attitudes between those who know that mental illness is biological, and those who do not.

In fact, those who understand the neurobiological basis for depression are more likely than those who do not to think that we pose a danger to them.

I'll kill 'em.  I swear, I'll kill 'em.  Just as soon as I can get out of bed.

What we are doing against stigma -- it's not working, folks.

How come?

Evidence-Based Stigma Busting

A study from the University of Kent in Cambridge, UK uncovered one flaw in typical stigma-busting efforts.  To bottom line it, how the listener responds depends on who the speaker is.

When allies (such as doctors or family members) make positive statements about people with mental illness, they are less credible than when people who have a mental illness speak for ourselves.  They is a word that doesn't cut it in stigma-busting, regardless of intention or attempt at sensitivity.  The authors cite previous research regarding other stigmatized groups showing that positive statements about them can be perceived as patronizing. 

This Is Good News

1. We were never worth much and now are worth less.

No, I mean it.  This is good news.  As my therapist used to say, The facts are friendly.  These are the facts, and they will be our ammunition.

2. We can do better.  In fact, the bar is set pretty low.

3. We have others, even among us, who have fought prior battles and can point the way.

Next week we take advocacy to the next level.


photo from La Brea Tar Pits by 3scandal0 and in the public domain
photo of homeless vet by Matthew Woitunski and used under the Creative Commons Attribution 3.0 Unported license
image of red ribbon in public domain
photo of coffins of members of the 101st. Airborne in the public domain
photo of chocolate molten cake by rore and used under the Creative CommonsAttribution-Share Alike 2.0 Generic license
photo of Ryan White taken by Wildhartlivie and used under the GNU Free Documentation License
flair by facebook
photo of Thomas Insel, director of NIMH in public domain

Friday, February 11, 2011

Health Policy of Sleep

Pharma/Research/Medicine Industrial Complex

A psychiatrist friend directed me to, a  source for all things seedy in medical research, medical education, and the sale of pharmaceuticals.  I don't need to repeat what you already know about ghost writing research articles, how pharma gets around restrictions on bribes by paying doctors to "teach," the sample scam, etc.  I am not spending time this week on what I didn't know until now about the editorial/advertising relationship in medical journals, or that the drug companies are the major subscribers to these journals and give them to doctors, and are the major purchaser of reprints (at inflated prices) to be distributed by drug reps to doctors.  But it is more of the same.  Just thought I'd mention it.

We go round and round about this.  Still, every research article ends with a cry for more funding, which will come from just one source.  Every doctor gets everything he/she knows about medications ultimately from just one source.  Every friend and family member who wants to help repeats the message taught by one source -- Keep trying.  Translation: keep buying drugs.

Addicted To Big Pharma

Bottom line, every part of the mental health industry is an addict.  Everybody in the system is a pusher.  Most patients are not even lab rats, because that would suggest somebody is learning from results.  No, we are simply little mice caught in a big machine.  This trifecta of pharma/research/clinical practice is crushing us with barely effective or ineffective and often toxic treatments.

Okay, how much time and ink are we going to spend wailing and railing?

One way to get out of vicious vortex thinking is to bring in another perspective.

Enter The Gorilla

So I open my mailbox.  There is the winter issue of Blue, Wellmark Blue Cross Blue Shield's customer journal.  First article inside, page 4, Are Antidepressants The Answer?

Blue usually supplies information for healthier lifestyles, extolling exercise, weight loss, sleep, stress reduction strategies, all that stuff you know very well.  But here was something new.

Because medications help us address so many health conditions, it is easy to assume that popping a pill will fight depression.  In some cases, it does.  However, the side effects of antidepressants, such as weight gain, loss of sexual desire, insomnia and increased suicide risk, can add to an individual's struggles.

This article will not be published in JAMA's next edition.

If any research scientist said such a thing, he/she would be compared to a blogger.

The content has, in fact, found its way into many a blog.  The news is that an 800 pound gorilla has entered the room.

At this point, we may practice the reflex we learned in our doctor's office -- that 800 pound gorilla has one aim, to deny coverage.

Follow The Money

Or we could do something new.  No illusions here.  The insurance companies' interests and patients' interests do not coincide.  But neither do those of the pharmaceutical companies and us.  So let's just follow the money.

Wellmark of Iowa reports that The number of Americans taking antidepressants has doubled in a decade, from 13.3 million in 1996 to 27 million in 2005... the number of Wellmark members using antidepressants increases by an average of six to eight percent each month.

Lilly and Pfizer might cite the same statistic in a shareholder's report.  It's great news for them.

Wellmark is not so sure it's great news for you and me.  Insurance companies have been paying the bulk of the astronomical cost of these medications.  In turn, these costs are passed on to you, the consumer, in the form of higher premiums.

Premiums.  Follow the money.  Premiums.

Blue Cross Blue Shield Already Got Theirs

The insurance companies get paid upfront.  Their interest is to control costs.  They have no interest in increasing numbers of people with mental illness, no interest in creating new diseases to be treated with the latest medication (nor the old one that needs a new market), no interest in getting you to keep trying.  Regarding those of us who have a mental illness, they want to control costs.  They would just as soon we got better.

The pharmaceutical companies don't get paid unless we are sick.

Again, no illusions.  The insurance companies' interest is not our health.  They just don't want us to use services that cost them money.  So they keep sending out magazines that tell us how to eat right, exercise, reduce stress and get a good night's sleep.  If we did that stuff, we wouldn't be so sick.  We wouldn't go to the doctor.  They wouldn't pay out so much to the pharmaceutical companies.

Not the same as our interest, but we can find some common ground.

Healthy Habits -- Good Luck With That Message

The problem for Wellmark, et al is that they have sent us the same material for years.  Yet we are more overweight, less active, more stressed and sleep less than ever.  Their message is not getting through.

So now they have a new approach -- tell us that if we take antidepressants, we will lose our sex lives and might become suicidal.

Frankly, that won't work either.  We are still the mice caught in the rock crushing trifecta of pharma/research/clinical practice.  We could be grown-ups, of course.  But people who do not have a mental illness are not grown-up about health practices.  So get real.

It's The Economy, Stupid

The mice cannot do the heavy lifting here.  King Kong, on the other hand, can be a game changer.  It sure got its way in health care reform.  It needs to step into the fray against the coercive sales pitch we face whenever we try to get help.

The structure of the economy has changed our sleep patterns.  Here is their opportunity.  The insurance industry can address its bottom line by influencing customers' sleep patterns through the economy -- much more effective than these quarterly magazines that customers get in the mail.

This is what I mean:

Poor Sleep Hygiene Surcharge

As Prozac Monologues reported last week, sleep (the lack thereof) and suicidality are intimately connected.  Suicidality is often the the symptom that trips the trigger and gets people to the doc to deal with their depression (which is a good thing, getting yourself to the doc if you start thinking about knives.)  What if health insurance companies charged a poor sleep hygiene surcharge to companies that regularly require workers to put in more than fifty hours a week, or stay connected in "off hours," or change shifts, disrupting workers' circadian rhythms?

Hospitals could be at the top of the hit list, especially those with residency programs.  Did you know that surgery residents in the US often put in 100 hour work weeks?  That lack of sleep and suicidality are clearly linked in a variety of studies?  That doctors, especially young ones have one of the highest suicide rates among professions?  Can you connect the dots?

The poor sleep hygiene practices built into residency programs have ripple down effects.  Just as doctors who smoke don't do good patient education on the health risks of smoking, doctors who don't sleep are not going to do good sleep hygiene education.

These studies have not changed medical education practices or hospital administration.  But I'll bet a poor sleep hygiene surcharge would get action. 

School Is Bad For Teenagers' Health

There are 3,756,000 elementary through high school teachers in the US, a huge cohort of health insurance purchasers.  Education as an industry works close to the bone financially.  And health insurance premiums are a major portion of education budgets.  The insurance industry, which really names its own price, is uniquely placed to pressure schools and school systems to apply research findings about sleep to their schedules.

If high schools shifted their hours, starting one hour later, they could improve their students' sleep, decrease student suicidality, and roll back this exponential growth in numbers diagnosed with depression and treated with antidepressants.  This move would be akin to anti-smoking efforts directed at teenagers, preventing them from developing illnesses that will be with them, and costing health insurance companies for their lifetime.

This skirmish, by the way, could be a warm-up for the battle with Coke, Pepsi and Frito Lay over vending machines in schools.  Michelle Obama will not win this battle on her own.  Improved eating habits would push back against the epidemic of obesity, again yielding life-long savings for health insurance companies, and decreasing depression at the same time.  See Sleep -- The Real Antidepressant on the way that obesity works its way through the DSM criteria for depression.

Incentives For Better Sleep Hygiene

The big money is with the stick approach.  But here is a carrot.

Offer college students a rebate on their student health fees if they live in a dormitory, fraternity or sorority house with a noise curfew.  Oo oo, here is one better:  Offer ITunes credits and a **$$CHANCE TO WIN$$** an IPod and, for one lucky student in the Big Ten or whatever, **$$SPRING BREAK SOMEWHERE WARM$$**

I am not going to do their work for them.  The insurance companies can pay for more ideas.  The essential point: Health insurance companies can become game-changers in the overuse of noneffective antidepressants by throwing their weight around where it could really make a difference -- society's structures that discourage healthy habits.

One More Time -- The High Cost Of Insomnia

Here is one more research study providing economic incentive for health insurance companies to do something effective about sleep issues.  A study at the Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA found:

Current insomnia was associated with significantly greater functional impairment.., more days of disability due to health problems, and greater general medical service utilization.  While insomnia was associated with depressive disorder and chronic medical illness, adjustment for these factors only partially accounted for the association of insomnia with disability and with health care utilization.  Of the patients with current insomnia, 28% received any psychotropic drug, 14% received benzodiazepines and 19% received antidepressants.

Utilization is King Kong's word.  Income - costs = profits.  For insurance companies that translates to  premiums - utilization = profits.  Decrease utilization by decreasing insomnia, they increase profits.  And note -- better sleep results in lower utilization, even for those who do not have a mental illness.  Follow the money. 

Sleep Hygiene -- Do It Yourself Version

Meanwhile, I'm not holding my breath.  I want to sleep tonight.  Now that I kept trying antidepressants all the way to disabled, my job no longer requires long and irregular hours with fast food to keep me awake while I drive the interstate after antidepressant-induced insomnia.  My job is to manage my symptoms.

Maybe you are already with me.  Maybe you would just as soon not join me.  You think getting mental health care reimbursement is difficult?  Try SSDI.  It takes a team of lawyers and a very long time to get those benefits you have been paying for all your working life.  And once you get them, disability still sucks.

There's a lot working against you.  But it is worth your while to find a way out of that mouse crushing machine.

The University of Maryland Medical Center has a long list of things you can do to address your sleep difficulties.  They start with circadian rhythms (keeping a regular schedule), work through diet, take a short cut through medications, and keep going -- Chinese medicine, homeopathy, foot massage with lavender oil...  There's something there for everybody.

That circadian rhythms thing will find its way into another post soon.

For now, good luck and sweet dreams.

Godzilla poster from Toho Company Ltd 1954 is in the public domain
King Kong poster in public domain
photo of rock crusher gears by Les Chatfield and used under the Creative Commons Attribution 2.0 Generic license
photo of Big Mac by kici and in the public domain
Caduceus drawing by Rama and in public domain
flair from facebook
photo of vending machine by Nenyedi and released to the public domain
The Dream by A Cortina (1841-1890) 

Thursday, February 3, 2011

Sleep -- The Real Antidepressant

Your sink has backed up three times in as many weeks.  This time the plunger won't work, and it's beginning to stink.

The hardware salesman says you need a new garbage disposal -- $169.00.

Your plumber takes the pipes apart and clears the plug.  Depending on the plumber, she might show you how to do it yourself next time.  (My plumber is a woman.) -- $60.00 in my neighborhood.

Your brother says, stop putting banana peels in the garbage disposal.  (My brother owns rental property, and tells me what the plumbers almost always find in the plug.) -- $0.00.

The hardware salesman says a better garbage disposal could handle banana peels, and whatever else might also be causing that plug -- $249.00.

All of them are trying to help.  Each of them is working with the tools at his/her disposal.

Okay, now let's look at your depression.

Remember last week's list?

DSM On Depression -- The Chinese Menu

Column A:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
Column B:
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Last week's example was a miserable anorexic looking young woman who went to the doctor complaining that she isn't having fun, is tired all the time, doesn't sleep well, has no appetite and feels pretty worthless about her inability to exercise control over anything in her life.  Sometimes she feels like just ending it all.

I could just as well have used a middle-aged man who is having sexual difficulties, has quit the bowling league and sits around all day, is tired all the time, doesn't sleep well, feels like a failure at work, and is here under protest because his wife insisted -- she is fed up with his rages.  Finding the gun was the last straw. 

Who Is Treating Your Depression?

Both the skinny miserable looking young woman and the overweight angry man get the same diagnosis, major depressive disorder and the same medication, Zoloft if they have good drug coverage, fluoxetine if not.

Some would say they do not have the same illness, and should be treated differently.  Read John McManamy's work on this.  That is not my issue today.  Mine is that there are a variety of treatments that could indeed work for either of them.

Both went to the same hardware salesman.  Or in this case, a psychiatrist, who truly wants to help and has one solution, a prescription pad.

If they had gone to a plumber, AKA therapist, the therapist, who truly wants to help, would have opened up the pipes.  A cognitive behavioral therapist would have taught them how to clear their own pipes next time.

If they had gone to their mother, who truly wants to help, she would have said How many times have I told you?  Stop watching Fox News at night and go to bed!

Each caregiver truly wants to help, and uses the tools that he/she has to hand.  Depending on which helper is, each sufferer would pay accordingly.  There is a possibility that Mom may have the longest time to relapse rate.  Certainly her advice carries low to no risk of harm.  And is cheap.  Which makes it worth a try.  Even if it comes from your mother. 

The Problem With Antidepressants As A Cure For Depression

The psychiatrist is focused on symptom #1 -- the depression symptom of the mental disorder known as major depressive disorder.  The psychiatrist believes that if you take a medication which has been shown to have a significant advantage over placebo in relieving this one core symptom of depression, the other symptoms will go away.

Maybe.  Except antidepressants can cause some of these other symptoms.  First generation antidepressants (tricylics) cause fatigue.  Second generation (SSRIs, SNRIs) cause insomnia, which causes fatigue.  The latest fashion in psychopharmicology is augmentation, adding an anticonvulsant or antipsychotic to the chemical mix, either of which is a sledgehammer of fatigue.

Other symptoms of depression that are potential side effects of antidepressants include weight gain, agitation, poor concentration and suicidality.

Notice, we now have six out of nine items on the list.  If you complain about any of them, the psychiatrist will increase your dose.  Because they will go away when your depression goes away.  You won't complain about the liver damage, because you don't know about the liver damage.  And your doctor won't check.

The Chicken And Egg Of Depression

Think about your brain as a planet and your depression as an ecological issue to be addressed.  That menu of symptoms offers a whole variety of entries into that ecological system.

The trick is to find the entry that will work its way through the rest of the list -- a nontoxic intervention.

Here is another image that captures the goal, the Brunnian link.  The cool thing about the Brunnian link is that all of these colored strings are intertwined.  You can't pull any one of them out of the whole.  However, if you cut any one of them, all the rest will be released.

Will this really work for depression?  I don't know.  But let's start with the possibilities of one string -- sleep.

Insomnia And Fatigue

Insomnia leads to fatigue.  Well, duh.  We don't need research for that one.  I mention it because it is an easy start.  Then once the fatigue is addressed, others will follow.

Insomnia and Weight

Here is a study that may surprise you.  Insomnia contributes to weight gain.  This conclusion comes from that huge sixteen year study of 68,183 nurses.  Women who ate the same calories but slept less gained more weight than the women who slept more.  The amount of exercise didn't matter.

There is speculation as to other causes.  Perhaps less sleep leads to a slower metabolism.  Perhaps tired women sit more than stand.  Perhaps they fidget less.  Skinny people who fidget burn an extra 350 extra calories a day.  So people who are overweight burn less calories and gain more weight.  Regardless of the underlying mechanism, this weight gain is one of the strings in the link, binding together the other symptoms.

Overweight is one of the risk factors for sleep apnea.  This is a serious medical condition with a variety of causes, one of which is excess neck fat that constricts the airways.  When you stop breathing while asleep, you wake up -- ever so briefly.  You take a breath and fall back to sleep, over and over and over all night.

This stop breathing/wake up/breathe/fall asleep cycle is so short you don't even remember it the next day.  But you wake up exhausted.  Overall, your blood oxygen level plummets, leaving you fatigued, leaving you less likely to exercise or fidget, more likely to sit rather than stand, more likely to engage in other energy saving behaviors such as elevator instead of stairs, and thus more likely to gain more weight, leading to more fatigue...

See what I mean about a system?  #3 weight gain, #4 insomnia and #6 fatigue are intricately intertwined.

Fatigue, Overweight And Exercise

Here is another version of depression's Brunnian link:

People who are overweight feel self-conscious in the gym.  They also are too tired to exercise.  I'm not looking that one up, just going by what I hear.  Am I wrong?

Ironically, if they did exercise, they would feel more energized and less fatigued.   20% more energized, 65% less fatigued with a moderate intensity activity for 20 minutes, three times a week, according to Tim Puetz at the University of Georgia, beating the health claims of a Snickers Bar all to heck.

If you need a mid-afternoon boost to keep going at work because you didn't sleep well last night, so you didn't have the energy for your morning walk, so you reach for the Snickers Bar instead, then you gain weight.

Fatigue causes the brain to crave carbs.  The brain uses lots of energy, and carbs deliver it fast.  But the carbs in that Snickers bar are the kind that zip you up and then let you crash.  Now your brain is offline entirely.

Can anyone spell vicious circle?

I love that Betty White commercial.  But a handful of peanuts would be a better choice.

We are not finished with that symptom list yet.

Exercise And Brain Function

Lots of common sense about this one: less fatigue leads to more exercise leads to more oxygen in the brain leads to clearer thinking.

Turn it over, and it is also true.  Start with more fatigue, you get to poorer brain function.  This has been researched in various of work settings, including driving and, of all things, medicine.  You'd think that doctors would get it.  Surgical residents can work over 100 hours a week.  The result -- mistakes.  But maybe they don't get the connection, because doctors don't talk about their mistakes, lest it reinforce their excessive or inappropriate guilt.

From the positive way round, Dr. Catherine Davis, clinical health psychologist at the Medical College of Georgia studied 200 overweight, inactive grade schoolers.  After an intervention of daily vigorous activity for three months, their executive function (decision making) improved.  It showed up in their fMRIs.

#4 insomnia, #6 fatigue, # 7 inappropriate guilt, #8 poor concentration and indecisiveness.

Exercise And Depression

Having gotten a decent night's sleep, you get out and go for that jog.  Three decades of studies conclude that exercise will relieve your depressive mood.  In 1999, exercise went head to head with Zoloft.  Zoloft leaped out to an early lead.  At the sixteen week mark, they were tied.  But at six months, exercisers stayed healthier longer.  The pharmaceutical companies want to win the sprint.  I imagine you want to live the marathon.

How does exercise relieve depression?  A couple ideas.  Exercise increases the release of endorphins, a neurotransmitter that reduces perception of pain and is the source of the runner's high.  The other idea -- exercise stimulates norepinephrine -- one of the neurotransmitters that Zoloft is supposed to jazz up.

Except that, unlike Zoloft, exercise enhances self-esteem and doesn't deep six your sex life.

#4 insomnia, #6 fatigue, #2 anhedonia/lack of pleasure and #7 feelings of worthlessness.

Insomnia And Suicidality

Insomnia causes suicidality regardless of depressed mood.  That was the topic of The Insomnia Cure, a couple posts ago.

#4 insomnia and the biggie, #9 suicidality.

In the doctor's office, relief of depression is the carrot, threat of suicidality is the big stick -- the one-two combo sales pitch.

Sleep -- The Real Antidepressant

So here we go.  If we start with the sleep issue, we address:

Column A:
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
Column B:
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

I didn't find anything about sleep and
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
But pick away at only a couple symptoms and you no longer qualify for the diagnosis, releasing you from the carrot (relief of depressive mood) and big stick (potential for suicide) sales pitch for the latest antidepressant.

Next Week -- Implications For Public Policy

By public policy I mean the behaviors of financial stakeholders.  Change the way the money flows, and you really change the ecology.

photo of miss-do-it-yourself by Nina Malyna from 
photo "Angry Father" by Akapl616.  Permission is granted to copy
under the terms of the GNU Free Documentation License
flair from facebook
clip art of planet with circles from microsoft
photo of walking the dog by federico stevanin
photo of Snickers Bar by Scott Ehardt who released it to the public domain
photo of Dutch queen Juliana riding a bike, July 11, 1967 is in the public domain
image of Brunnian link in public domain 
NASA screenshot of Amazon  River in public domain