Dr. Grammer: “…if admitting you’re depressed is going to lead to people believing that you’ve been possessed by the devil, you’re probably not going to tell people you feel that way. Right? So self reporting of this 100 years ago, was a lot less easy than it is today. In addition, I think our ability to to put a name to this and have strict criteria also has evolved over time, if you look way, way back at our attempts to, to identify mental illness, we didn’t even have names for stuff, right? And someone tried to come up with these lists of different emotional conditions. And they had this it was like, hundreds long and it wasn’t useful. It took a while to get to the criteria that we have now. So that when I say major depressive disorder, every other mental health professional or medical professional knows what I’m…

Joe: “talking about the same thing.”

Dr. Grammer: “Exactly.”

[Life to Live by Grace Mesa (Instrumental Version) begins]

Beyond Depressed is a mental health podcast for people who want to know the science behind emerging treatments and if those treatments are right for them or a loved one. New therapies using psilocybin, magnetic stimulation, ketamine and medical marijuana are bringing people much needed relief. Together, we’ll take a deep dive into depression and how therapy, medications and drugs can help you feel better.

Beyond Depressed is hosted by Dr Geoffrey Grammer. Dr. Grammer is a decorated retired Colonel with the United States Army and is currently serving as the Chief Medical Officer for Greenbrook TMS. He has experience in psychiatry, internal medicine, and behavior neurology.

Disclaimer: The following podcast is for information and educational purposes only and should not be considered official medical advice.

[Life to Live by Grace Mesa (Instrumental Version) ends]

Joe Clements 

Hi everyone, I am Joe Clements, a professional Podcast Producer. And I have a friend, Dr. Geoffrey Grammer, who recently told me he was interested in doing a podcast about mental health and the state of mental health, and how much advancement has come in recent years in the treatment, specifically, of depression. And when he asked me to do the podcast, I was excited to say yes. And so Dr. Grammer, as you heard in the intro, was a pioneer in the military in the treatment of PTSD and depression, with a technique called transn… transcranial magnetic stimulation, and sometimes you’ll hear me stumble over these words. There’s a lot of acronyms in this field, I’ve learned. And, after that, became a partner at a company that specializes in that specific treatment. But Dr. Grammer, as a psychiatrist, knows a lot more. And so over the next several podcasts, we’re going to talk about different subject areas. And the first one we’re going to talk about today is I think, often misunderstood, and that’s depression. And so Dr. Grammer say Hello.

Dr. Grammer 

Yeah, welcome, everyone to this podcast. And Joe, thanks for working with me on this podcast. You know, my hope is over the course of these episodes, that we give people out their information, so they can understand the latest and greatest in mental health treatments, and help them make better choices for their health care in a way that is tailored to their unique needs, as opposed to maybe sometimes the one size fits all strategy that I think it’s employed.

Joe Clements 

So that surprised me and talking to you, during the pre-show, was most people assume the treatment options for depression are very limited. It’s medication or talk therapy. And we’re going to learn over the next few episodes, that’s not the case. But the place to start is with what is depression at all? Because it’s one of those words that’s tossed out anytime somebody feels a negative emotion. What do you think is the key question in depression? And in the treatment of depression?

Dr. Grammer 

Yeah, I think it’s one of the reasons why depression gets so complicated is because it’s used in everyday vernacular, like, Oh, I’m so depressed, had a tough day. But it’s also a clinical syndrome. And it gets tied into this idea of what we can and cannot control in the way that we think and feel. So ultimately, the biggest question for listeners out there is, do you feel like you’re in control of your emotions, of your sort of day-to-day mood? And in some cases, that answer maybe no.

Joe Clements 

So let’s go into that, right, because there’s two things in mental health and in depression, specifically, you’ll hear advise, so one is, it’s a medical condition, it’s like a broken leg or stroke, you’re not in control at all. And the other is, if you change your lifestyle habits, eat better exercise, change your thought patterns, you’re in control like that. Which of those is actually true? Or is either actually true?

Dr. Grammer 

Yeah, I mean, I think sort of all of its true. And one of the things that makes us so tough is the way our brain works is it has a kind of synergistic relationship, or actually a back and forth or two-way relationship with the environment. So the way we interface with our environment is controlled by our brain. But our environment also controls how our brain functions. And if you think about it, that can seem kind of intimidating at first, because it falls into Well, where am I in my self determination with this, but every other physiologic mechanism, the body has a similar phenomenon. So if you take someone who’s very athletic, okay, they can reduce their risk of injury on like, say, the athletic field, if they are exercise and stretch and do all those sort of precautionary things. The way that they play sort of in a game, for example, if they’re playing a sport, can dictate the risk of injury. But sometimes stuff just happens, and you get injured and sometimes the injury was sort of preceded by a vulnerability to that particular anatomic defect. And so the brain works the same way. So you’re absolutely right, like, not only are there extremes in the range of severity of depression, but the way that depression can come on, and the way that it influences us is almost sort of infinitely dynamic and full of different possibilities.

Joe Clements 

So the thing that seems unique to me about depression, is that everybody seems to have it or experience it right? Or at least by label. I’m just feeling depressed. I’m just feeling down. What distinguishes, I feel depressed, right? Basically, I feel sad from actual medical condition of depression, where treatment or therapy is necessary. What are the differences there?

Dr. Grammer 

Yeah, mainly has to do with the severity of symptoms, the duration and predominance of symptoms, and then meeting certain criteria. Okay. So being unhappy is normal at times, okay. And the absence of unhappiness can actually be maladaptive it can be inhibiting, right? In order to appreciate joy, some people would say, we have to have periods where we feel the lack of joy. But there’s a mechanism in the brain that sort of is the rheostat, for how we feel, and every other part of the body that can become stuck. And if you get stuck on the I’m unhappy or sad all the time setting, then that begins to have a cascade of events that has real world medical complications, and just to help people understand like, in major depressive disorder, which is a clinical condition.

Joe Clements 

So is everybody who’s clinically depressed is that the definition of major depressive disorder? Or is there is there difference, there’s just like, sad because something bad happened, there’s depressed moderate, and then there’s major depressive disorder or is any sort of actual, there’s a physiological issue major depressive disorder.

Dr. Grammer 

So the old days, we used to think of depression having two variants, intrinsic meaning inwardly focused depression and an extrinsic meaning it was influenced by outside events kind of depression. And they got rid of that because in the end, it didn’t really matter. Once you develop depression, you’re depressed. So major depressive disorder, okay, defines a specific condition that is characterized by what’s called a depressive episode. There are other things that can lead to depressive episodes, like bipolar depression, for example, or some medical conditions, for example, can be associated with a depressive life defines a depressive episode, right? So a depressive episode is when you meet this constellation of symptoms, okay, and people see this online, but just bear with me, I You can’t talk about depression without going through the criteria. So we’ll we’ll kind of get through this, but it is the presence of being unhappy or sad more often than not more days than not, or, and depending a decreased interest in activities or lack of pleasure from activities. And then there’s other symptoms that go with it, but you must have one of those first two, okay, and that has to be around for at least a period of two weeks. Then in addition, you can have issues with ruminative guilt, feeling poorly about yourself, changes in appetite that can either be an increase in appetite or decrease in appetite, changes in the way that you move sort of spontaneously, we all have sort of a basal level of almost Brownian movement. And for some people, they get slowed down to they look like a moving through molasses. And for other people, they can actually get sort of neurotically agitated pace, and wring their hands and so forth,

Joe Clements 

is that caused by this relationship between depression and anxiety, where if you have depression, where you’re also really anxious, you might have more of that movement. And if you have a depression, where you’re not anxious, you’re just not experiencing enjoyment, you have lower levels of movement?

Dr. Grammer 

Well, yeah. Let’s get into that in a little bit about the neurotransmitter hypotheses of depression, because I think that is part of it, for sure. But you can also have sort of a restlessness, even if you’re not anxious. And think about it. Sometimes if someone is in pain, or if they feel like they’re sick to their stomach, they will pace they will kind of rub their hands through their hair is they just feel bad. And there’s nothing you can’t offload that discomfort. It’s not like an elbow that you sprain, you’re like, oh, man, I can massage it. So sometimes that motor activity just is born out of trying to offload the discomfort. He can have changes in energy levels, typically lower energy level issues with sleep, either sleeping too much or too little. Sometimes people get kind of a textbook 2 am awakening that can be extremely disruptive, you can lose the ability to concentrate fully, which can have a huge impact with things like school and work. And then at an extreme, some people can feel so badly that they begin to have thoughts of suicide. And a lot of times they’re what we call ego dystonic. So they don’t even want to think about that. But that becomes another symptom of depression, not necessarily

Joe Clements 

What is ego dystonic?

Dr. Grammer 

Oh, sorry, ego dystonic means they don’t want it. So some people believe it or not, will actually have thoughts of suicide, and an impulse perhaps, towards moving towards suicide, even though they don’t want to do that. I know that that can sound really unusual for someone who hasn’t experienced that before. But suicide and self preservation are part of sort of the way our brain operates and in depression, that idea of sort of sustaining our own existence can become impaired and lead to this idea that maybe I would be better off dead. Maybe my value on the planet is so low, it’s not worth me living. And it’s important for people to realize that’s not an epiphany, right? That’s not someone coming to some great awareness of what their role is in the world. That is a symptom of depression, like all the other things, and it’s important for people to keep that compartmentalize as, this isn’t like an awareness I’ve had. But this is really just part of this phenomenon of depression. So when you have all those things, you have to have five total criteria for that for at least two weeks, and it’s causing you either social, occupational sort of dysfunction, then that would meet criteria for major depressive disorder. A lot of patients get caught up in the word major, and they’re like, Well, I don’t think I’ve major depressive disorder. There is no minor depressive disorder. So don’t worry about the word major. It was meant to medicalize, you know, to give credence to the medicalization of depression, and not be a severity classification, the severity comes on the end. So it’s major depressive disorder, either a single episode or recurring episodes, and then mild or moderate or severe severity. So when you match all those up, you come with your final diagnosis for major depressive disorder.

Joe Clements 

So you have a tragic event happen, friend dies, and you’ll have a lot of those same symptoms, probably not the suicide, but a lot of the other same symptoms, versus major depressive, is it the presence of a triggering event that like makes sense? Well, oh, this is why you are sad as you are coping with a loss, you’re going through a grieving process? Is it the presence of that? Or is it something else that distinguishes the two? How do you know when a an emotional response is like normal and healthy versus a disorder?

Dr. Grammer 

I think, and honestly, sometimes it’s hard, like bereavement, which you kind of brought up if you have a loss of a job or relationship, a family member, you name it, that can lead to symptoms that look very similar to major depressive disorder and the old days, meaning, like 10 years ago, we actually had distinctions for that, where we tried to parse out well, is this bereavement meaning grieving from something? Or is this major depressive disorder, what they found was providers, were not very good at consistently making that distinction. So in some ways, the metaphor I would give now for this is like a house fire, there can be a lot of things that cause a house fire, some of them are external entities that come in, like if someone dumps gasoline on your front porch and lights it on fire, that’s a very major external entity. If you have faulty wiring in your house, a predisposition for this that could spark and start a house fire if it’s full of Tinder, like substances like corded newspapers, that can be a fire. So in the end, what medicine has come up with is, once the fire starts, it’s a it’s kind of less relevant why, and more important in that moment to put out the fire. Now, you can’t ignore this other things. If you have faulty wiring, and you put out the kitchen fire, like, don’t go live in through your day, you might have a living room fire, right, so So you still have to address those other issues. But when the fire is ongoing, when you have that depressive episode, that becomes the point, the immediate point of clinical concern, regardless of etiology,

Joe Clements 

Do we know what distinguishes a person who has resiliency to those triggering events externally? Versus what distinguishes somebody who doesn’t, and that tips them over into major depressive disorder?

Dr. Grammer 

Yeah, I think it’s important for people to realize, well, a couple things. Kind of following up what we were talking about before, I want everyone to understand that depression isn’t just uncomfortable. It’s not just inconvenient. There have been a few studies that show that it has real world physiologic consequences, the life expectancy decrease from having untreated depression is about equivalent to smoking cigarettes. So think about that for a moment. So you know, if you smoke cigarettes, people like hey, man, that’s bad for your health, like no one really doubts that, you know, at least most people don’t doubt it. But for a lot of people that are depressed or like, I’ll just get through it. I’m like, No, this is like, you’re decreasing your life expectancy, you’re increasing risk of heart attacks and strokes and you’re increasing your risk of cancer. And if you have an existing medical disease, like diabetes, or cancer, your all cause mortality is going to be greater than other people with the same medical conditions but that aren’t depressed. So it’s got real world consequence.

Joe Clements 

So this is a shame because right, what that would suggest is that there’s some experience of pleasure or enjoyment, that is required for a health essentially, and that that is like biologically hardwired in. So that leads and we were talking about this before, that there may have been an evolutionary purpose of depression, that hardwired so what why is it that a long healthy life is enjoyment and pleasure is beneficial, but natural selection selects pretty heavily for people who can get depressed.

Dr. Grammer 

Yeah, I mean, there’s a reason we have major depressive disorder, you know, and I think of it like, we need a range of emotions to have a healthy human experience. Alright. Even though I’m not a big fan of the saying, you know, there is no pleasure without some degree of pain, I do think there’s kernels of truth within that our ability to experience joy is somewhat dependent upon our ability to feel sadness, right, so that we have that range. There’s actually it’s interesting, there’s a medical condition, where some people actually lack the ability to perceive pain. And on the surface, someone may say, hey, that’s great man, like I would never like have to hurt, right? Those people live their lives with recurring injuries, because they don’t react, you know, like, I remember, you know, reading a textbook example of a child who would lean against a radiator look out the window, not realizing they were burning themselves, because they couldn’t feel it, right. And I think the human experience was sadness is the same thing. Not only does it help us to enjoy things more, because we have that range, and therefore we seek out those things that are enjoyable. But the things that make us unhappy, we probably want to avoid, right. So if you’re in a relationship, where the person is not helping you address your needs, and your goals and wants, that is unhealthy for you. And you want to feel unhappy about that. And you should want to peel back and either change the relationship or get out of that relationship. So there’s a reason we need to feel sad. Now imagine a thermostat, if you will, where you have to say, Okay, well, you need to be avoiding this or understand this is not good for you, therefore, I’m sad. But then that gets stuck. Well, being sad is more than just an emotional state. Remember, how we feel is absolutely tied to the brain, like you can’t escape that the way we think and feel is based on brain functioning. It’s not some etheral spiritual thing. And so that then leads to a cascade of sort of other biologic processes, because your body is reacting to that, right. And so we can do things like raise cortisol levels, which then increases insulin resistance, which makes it harder for your body to sort of metabolize sugars, which then can cause increased fat deposition. And there’s actually a condition called Pseudo Cushing’s of depression, where people put on a ton of weight, even sort of eating the same amount of calories because of both a predilection for simple sugars and an inability to process those sugars, okay, and that can happen in depression. And that’s sort of what leads to some of the immune dysfunction and cardiovascular disease. There’s other things that can occur to it, like thyroid function, and so forth, that we see in depression. If that happens for a few hours, because you’re unhappy with the situation, your body bounces back, but if that persists over weeks, then that starts having more long term consequences. And getting back to the house fire metaphor, then it’s no longer the events that maybe led to the depression, whether it’s a predisposition or environmental control, but the presence of the condition itself now becomes sort of the primacy of concerns.

Joe Clements 

Do we know what’s going on physiologically with somebody who’s depressed? Do you just articulated the symptoms that define it? Do we know what’s going on physiologically?

Dr. Grammer 

Somewhat, and this is probably where most of the work is ongoing right now, in sort of the research world. You know, the old days we used to think of depression as being due to low volumes of serotonin. And when I went to med school, that was it, they’re like, hey, Prozac works. He’s old try psychedelic figured it out. Yeah, that’s right. It’s depression. But then let’s take Bupropion, which is Wellbutrin. That doesn’t impact serotonin increases norepinephrine and dopamine. It’s a very good antidepressant. So right away, we’re like, Okay, well, maybe it’s not serotonin. So then we came up with this thing. And we can circle back on this, but something called the monoamine hypothesis of depression, which is a fancy way of saying, there are neurotransmitters, that serotonin, norepinephrine and dopamine predominantly, that we think influence our mood and emotion. But that doesn’t fully explain it. So now, a lot of work is going into how our brain works to create this idea of consciousness, and thought, and the metaphor I’ll use is think of your brain like an orchestra. Okay, and you have these different sections, you got the winds, and the brass and percussion and all this stuff. And they all have to play in time, and in tune, and all playing off the same sheet of music, right? So there’s a lot of things that go into it. But the summation of that is greater than the sum of its parts, right? Or the whole of that is greater than the sum of its parts. So if I get this beautiful Mozart piece being played by a band, it sounds so much greater than if I just say, Well, I just want to hear the the flutes. But if I go in and those those if the trumpet section, for example, is out of time, well, suddenly the whole music becomes not as beautiful. It’s so even though you may have one section that’s not functioning right, it influences the entire song. So within our brain, we have very similar sort of instruments and they’re sort of three major networks that people think have in this idea of this default mode network where we have sort of inward facing thoughts, outward facing thoughts and then a system that negotiates those two, and an imbalance either over emphasis on outward focus thoughts where you become sensitive to environmental stimuli or an over focus on inward thoughts where you become sort of a captive to your own ruminative thoughts can be pathologic and lead to this phenomenon of depression. And then ultimately, it leads to areas of the brain like one is the anterior cingulate gyrus, which is a part of the mid front part of the brain. That is really just that thermos that I was talking about before. And it can become, in this case, overactive in depression, which gives us the sensation of unhappiness.

Joe Clements 

So, when someone is depressed, do they tend to be like, do they tend to be likely to seek to improve that condition? Or does the depression tend to skew their viewpoint that the condition cannot be improved?

Dr. Grammer 

And like all things in this, I hate to keep copping out between both both, you know,

Joe Clements 

Does that relate to whether they’re more outward or inward?Focused?

Dr. Grammer 

Not necessarily. I mean, some of it depends on the variety of things, but culturally, is a huge one. 100 years ago, we thought depression was associated with phases of the moon, hence the term lunacy, right? That seems preposterous now. But that was like 120 years ago, 120 years ago, right.

Joe Clements 

But a lot of listeners are into astrology that would probably differ there.

Dr. Grammer 

So there, they actually have done studies looking at rates of psychiatric presentation in emergency rooms on full moon days and non full moon days. And sorry to say, for the astrologers out there, there was no difference. But anyone who’s been on call in an ER will say otherwise. So even before that, it was demonic possession, some people still now feel like depression is because of a lack of faith or sinful behavior

Joe Clements 

So this is interesting because it is described, it does feel like a capture by something from the outside of you. Correct? Like, what causes that perception that like, this isn’t an internally generated phenomena that this is something imposed by an outside force,

Dr. Grammer 

Yeah.

Joe Clements 

against your will?

Dr. Grammer 

Well, let’s go back to that thermostat model, if you will, if you were walking around your house, and it was 60 degrees and your heat set on 70 gonna feel like something’s off, right? Like you got a window open, the heater isn’t working like you know that something is not working the way it should be. And when our brains have that phenomenon occur, it does the same thing like, Hey, listen, I’ve got a great relationship. My job is good, financially secure, my health is good. I just feel unhappy all the time. What gives? Why is this happening to me? And I think along those lines, it’s important that people see that as not as their identity, not as who they are. But actually the anomaly in who they are. I see a lot of people who come in and say, I don’t want to take medications because I don’t want them to change me. No, no, they don’t change you. The Depression changes you. That gets you farther from your true self. The treatments bring you back to your true self. Think of it like taking motrin if you have an injury, right? If you take motrin, you have no injury, all it does is upset your stomach,you get side effects.

Joe Clements 

We have an antidepressant episode that will talk more about that because I do think that is a notable feature is people believe the depression, even though it feels like it’s enforced on you from the outside is somehow like normative. But the medication could become, like bad, maladaptive, make you something that you’re not right.

Dr. Grammer 

And you’re right. We do we do talk about this later on. But you know, just to again, give people a bit of a prelude to what we’re gonna talk about this idea that, yeah, I’m doing some other intervention. I don’t I don’t want this to change me. Well, again, it’s not changing the depression changing you. So I think some people will assume, sort of that almost identification with the depression, particularly sort of young adults in late adolescence, because it occupies a

Joe Clements 

very trendy, there’s a segment of social media where having a mental health issue is a status symbol.

Dr. Grammer 

Yeah.

Joe Clements 

Which is bizarre. Yeah. But that is a thing that you can set a symbol against.

Dr. Grammer 

Yeah. And I think that’sa shame because people don’t do that with like hypertension. And I really would like people to kind of see it more like that. And as much as we want to

Joe Clements 

and I have a theory on why it is.

Dr. Grammer 

 Well, what’s your theory?

Joe Clements 

it excuses you from personal growth. It excuses you from struggle or challenge. If you can’t do X thing which you should do because of your self diagnosed, Y condition then you get to maintain your comfort zone.

Dr. Grammer 

It can be because of that. Let me throw out an alternative hypothesis for some people. If you have lived in a world where the ability to feel loved and cared for is impaired, except when you’re ill, you may develop this kind of unconscious rule in your head that to be loved, you must be ill.

Joe Clements 

Ah interesting. So you could also have this as a social, almost as a social mechanism for getting positive affirmation.

Dr. Grammer 

Yeah, to get sort of that what we would call a primary game where you get that sort of emotional food, if you will, by being in that sicker role. I think for other people, it’s the idea of being special. And again, late adolescence, early adults, where that whole idea of identity is being formed. Some people are like, what makes me different than someone else. And there are some easy things that people do like dye their hair, pierce, a body part that’s less commonly pierced, or something like that, or get a tattoo in a visible place. All those are fine, by the way, just, it can distinguish you from the masses, right? Well, for some people, that idea of having some identified medical condition helps them distinguish themselves from everyday folks. And that can be a factor to get back to the whole idea that again, lots and lots of causes lots and lots of things behind it, they’re often sort of a two way street on what contributes to it. But in the end, when you have the condition, you got the condition.

Joe Clements 

So is depression, more common now than it’s been? Or is it merely recognized for what it is? Because there’s two ways of thinking, one is that modern society and mental health are counter to one another. That this essentially isolated, individualistic life, where the only the things that you need are actually too easy to get, it’s too easy to get water and food. So there’s no pleasure in that the things that give you ultimate status are very hard to get, it’s very hard to become extremely wealthy. And there’s not much middle that you can do to produce value in a modern society, that that triggers depression, or has depression just always been endemic. And it’s just only recognized recently in in Western society, that that’s what it is.

Dr. Grammer 

Yeah, I don’t know that anyone on the planet can tell you because we touched on it briefly before, but there is sort of a cultural aspect to this. And if admitting you’re depressed is going to lead to people believing that you’ve been possessed by the devil, you’re probably not going to tell people you feel that way. Right? So self reporting of this 100 years ago, was a lot less easy than it is today. In addition, I think our ability to to put a name to this and have strict criteria also has evolved over time, if you look way, way back at our attempts to, to identify mental illness, we didn’t even have names for stuff, right? And someone tried to come up with these lists of different emotional conditions. And they had this it was like, hundreds long and it wasn’t useful. It took a while to get to the criteria that we have now. So that when I say major depressive disorder, every other mental health professional or medical professional knows what I’m

Joe Clements 

talking about the same thing.

Dr. Grammer 

Exactly. So we can’t go back and redo those studies. I also think there’s a stoicism that was born out of like, every every generation has challenges right? For us. Now, it’s concerned about the world heating up and flooding all our coastal cities and things like that. Okay. But remember, like in World War II, millions of people died. And it affected the entire world, right?

Joe Clements 

And after World War II, it was a nuclear holocaust. And before that, it was, you know, the barbarian hordes are going to raid your village and kill everybody, like humans have always lived under existential threat. It’s not new to our species that has probably been with us as long as it’s why our earliest stories are essentially like the destruction of the earth stories.

Dr. Grammer 

Well, and I think, you know, getting back to your evolutionary advantage in a time where there is armed conflict, for example, one could come to the conclusion that showing the vulnerability being the sick antelope in the herd increases your vulnerability to succumb to whatever that external threat is. So you find a lot of people that sort of live through world or conflict or, you know, military conflict, come out with a sort of veiled stoicism that keeps them from admitting their own distress. Okay. So when you go back and look at old literature, it is a victim, if you will, of the aberrations and self report and the way that people felt about self reporting. So that may be part of the reason why now people just there’s a term for it, people are more likely to kind of report it because it’s, you know, a slightly different existential threat on the planet. So that’s one factor. However, there’s a very real argument to be made, that in the past, we would go take our bikes and go see our friends in the neighborhood and go play baseball or something. Now you go on social media and someone’s photoshopped the heck out of their profile picture. And you’re comparing yourself to people that aren’t even real. Like it’s not even.

Joe Clements 

Yeah.

Dr. Grammer 

So this whole idea of like image and where I fit within this, and this affects it’s not just teenagers, you see adults are like, all my friends are so happy they’re going on vacations with their significant others. And I Why can’t I do that?

Joe Clements 

Because every mental health professional ,will tell you, they are not that happy.

Dr. Grammer 

Exactly, exactly like social media is not reality. It’s it’s what we, I think wish reality was sometimes. And so I think that constant sort of comparison that we have now on these over idealized senses of where we should be and what we should be doing drags mood. And then sort of timely for when this is recorded in 2021 here, the pandemic has really messed with people. So we think of a basal rate of depression being about 6 to 7% of the general population at any one period of time. But the CDC just put out data showing up to 25% of people are now reporting depressive symptoms, because of the things that we used to do to help buffer against work related stress, home related stress, our own internal demons, if you will, you know, our ability to go exercise at the gym or watch a movie or have dinner, meet with friends, all that’s been impaired because of that. And we’re seeing depressing self reporting skyrocket. So to get back to your original question, I think it’s always been there. I think we’re better at recognizing it now. So some of the inflation and rates is probably related to that. But I do think that at this point in time in 2021, because of social media, because of the pandemic, it has a unique time in history, we may see an increase rate of depression beyond what will happen in hopefully, like three years.

Joe Clements 

So in theory, though, that would have intergenerational effects. Because if you take the number of people and triple it, who are experiencing depressive symptoms, in a pandemic, some number of those people are going to be responsible for their rearing of children in their own children or school or whatever. And is it likely that the people raising children in that scenario who are themselves experienced depression, demonstrate behaviors that make the children they are responsible for more likely to have mental health issues?

Dr. Grammer 

Yeah, so there’s two parts of this, there are definitely some genetic risk factors for developing depression, if you have a primary family member with depression, you yourself are at increased risk of depression, if you have an identical twin. Even if you’re raised in separate households from birth, you both will have a higher rate of depression than if you didn’t share the same genetic code. And we know some of the gene locations that contribute to that, but we don’t know all of them. Okay. So your kids are already going to be at risk if you yourself have depression, just because they’re sharing some of your genetic code. But untreated depression in a parent does increase the risk of mental health issues in their children, independent of the genetics. Because your ability to model healthy behaviors, your ability to bond in interface with your kids, even if you think you’re doing the best job you can, it’s going to be influenced by the depression, right? That then influences their own sense of security and development and sense of connectedness to others. And you’re absolutely right, that can then impact their long term mental health, it gets to this point, and I think people, people mess this up, I’m going to appear wet through the minefield here, so to speak, depression can become a very self absorbed disease. Now, I want to be careful to say not selfish, but self absorbed, okay? It’s not that people are volitionally not caring about others, and only thinking of themselves in sort of a sociopathic way. But depression influences our ability to maintain perspective on our environment. And it narrows that perspective down over time. And we actually see that happen in functional imaging showing decreases in metabolic activity in the frontal lobes where it helps maintain that broader perspective. So again, it’s putting sort of biologic blinders on you. So as people go through this suffering, it is easy to underestimate the spillover and the pain, that it causes those around you as well. So some people will come to me and say, I don’t want to be selfish and get treatment, I need to be home for my kids or my friends or what have you. And I’m like, No, the part you may think that you’re protecting them by not getting treatment, but you’re actually not the way to best protect them is to take care of yourself, even if it doesn’t seem like that is intuitively logical.

Joe Clements 

So one last question on depression something I knew somebody still know him, comes from a family with mental illness was depressed would meet all your symptoms of major depressive disorder, medication failures, everything. Decides loves the outdoors decides to hike through hike. The Appalachian Trail does. On the Appalachian Trail, basically no symptoms at all, not taking medication, no symptoms comes back. The depression comes back almost immediately. In you hear this anecdotally in other cases, so people, you know, when they live a certain place, they feel depressed when they leave that place. This symptoms alleviate, how much of what drives even major depressive disorder is environmental.

Dr. Grammer 

Yeah, it can be all or none. I mean, honestly, and again, we’ll we’ll use some medical metaphors for this. If you have ischemic heart disease, and angina, which is where you get chest pain, we exert yourself, if you’re sitting or walking, may be fine. But the minute you do a light jog, your chest starts to clench up, because your heart’s not getting enough oxygen. There are some people where if you simplify the environment, then that is not stressing the resiliency that gets impaired by the depression, and they can be fine. But if the only way you can be happy and healthy is to be essentially on what, like a  vacation.

Joe Clements 

Yeah

Dr. Grammer 

Like that’s not adaptive. Right? It’s showing that vulnerability. And it’s not again, it’s not your fault. That is just the decreased bandwidth.

Joe Clements 

So let me push.

Dr. Grammer 

Yep.

Joe Clements 

Is that adaptive, in that the simplified environment is probably a return to an environment that more closely matches what humans have evolved to be in. And so what is somewhat maladaptive is like, the way we live our lives in modern society, with social media, media, kind of stacked on top of each other in high rise condos or little neighborhoods where no one sees a tree, things like that.

Dr. Grammer 

Yeah, I mean, you can definitely make the argument that the world is more complex now. And that for some people that can overwhelm the sense of mastery of control. On the other hand, I will go back to you know, in this case, because I’m out of town, recording this, I’m going to go back to the hotel room, I will have a roof over my head, it has environmental control, and I’ve got clean running water that I can drink when I’m thirsty. And if I need food, I go down and you know, at Hotel Duval, or whatever, I can get this awesome sandwich, right. But back when the world was hunting and gathering, right, yeah, there was some simplicity to it in some ways, but on the other hand, you lost some of the predictive stability that allows you to extend to have other interests, you’re constantly if you have to stay up all night sleeping, it was actually I was reading the other day about how couples that sleep together part of the evolutional idea about this was they would sleep back to back to maintain sort of 360 scanning of their environment as they fall asleep. And dogs, initially wolves if they had them nearby, and would bark or how was another kind of warning mechanism for that. Llike man, that would kind of stink if the only reason you had to sleep with your significant other was to maintain like environmental guard over potential external threats. So I think, again, two way street, and it’s sort of all and none and everywhere in between in this where, yeah, the world can be more complex in some ways now, but on the other hand, is more predictable and safe. The world was more simple, you know, 1000s of years ago, but if you got a splinter, you could get an infection and die.

Joe Clements 

But what if humans actually don’t do well in predictable safe environments? Because, you know, yeah, take your dog, like, if you board your dog in a kennel, where it’s just in the kennel for a week. It’s predictable and safe. The dog is probably not happy in that environment. So what if predictable, and safe is actually one of those things that is too like in excess becomes too much it becomes an impairment for us.

Dr. Grammer 

Absolutely. So everyone has their own sort of buttons, if you will, and they can be very unique. There are some people who are perfectly content with the routine of their day to day life. And for them that they prefer that there are some people that don’t even like leaving their house because it makes them anxious, right, and they’re perfectly content being by themselves. Some people don’t like having other people in their life, there’s a personality subtype called schizoid, not related to schizophrenia. So I don’t want to confuse readers or listeners with that, but schizoid where not only do people not have a whole lot of interest in multiple social relationships, but they can actually become overwhelming and cause that person distress in their other people are just the opposite. Like they don’t have those touchstones of like meeting with other people, they just melt, right? So I think the theme with that though, is no matter what your environment honoring and gathering, or you know, working nine to five, my old job when I was doing price labeling at what he called Big Box store, where I’d sit there for eight hours with those price guns 30 years ago, and just 39 cents for like 10,000 times, right? You got to define purpose. Everyone needs to have some sort of purpose. And for some people, their purpose is I’m occupying this space and time right here and right now and I’m good with that. And other people are my purpose is right over the horizon and the journey is getting there and sort of everywhere in between. But if people don’t have that purpose, I think that it becomes a big vulnerability and in modern society, I do think it can sort of kidnap people away from pursuing their hopes and dreams and so forth, and get them to accept complacency. And then that then can breed that sense of dissatisfaction. If you don’t like working that much, and you’re working 100 hours a week, it is going to be hard to find places of serenity and happiness in that environment.

Joe Clements 

So wrapping up on depression, multiple causes, there is a criteria that must be met to have major depressive disorder. Probably most of the things people labeled as depression are not actual major depressive disorder, they are responses to negative stimuli, which people with a healthy level of resilience will work through. But Major depressive disorder is something that requires treatment, it doesn’t go away on its own. And I think I’ve heard you say before, that if you have a relapse of major depressive disorder, it makes you more likely to have the next episode.

Dr. Grammer 

Yeah,

Joe Clements 

each episode increases the chances of a future one.

Dr. Grammer 

Yeah, I think one thing that I don’t want people to misunderstand, okay. And that is, people will use the word depression in everyday language to describe unhappiness. And that is different than when in mental health, we use the diagnosis of major depressive disorder. Okay. And most people with major depressive disorder, struggle with an awareness that they have that I will never forget, I saw a patient several years ago. And she was profoundly depressed. There was a speech latency. So you’d ask a question, and it would take her about 10 seconds to kind of sum up the energy to even say the words, she was suicidal and couldn’t focus and had no energy was sleeping like 20 hours a day, I mean, bedridden depression, and I got done with the interview. And I said, Well, here’s what we’re going to do, and to try to get you feeling better. And she said, Do you really think I’m depressed? And I remember just being taken aback at the time, like, yeah, like you could like on the outside, you could not be more depressed, right? But in her world, there was this ambivalence of is it really that bad? So I would encourage folks, it is far better to go see your primary care or behavioral health specialists and have them say, you know, I think you’re having an adjustment reaction to a difficult circumstance, I think you’re having, you know, normal grief and loss because you lost your pet, okay, then to not go at all and miss a medical diagnosis that will decrease your life expectancy, impact those around, you decrease your functioning, and really keep you from being the person that you’re meant to be by overshadowing it with this constant veil of unhappiness.

Joe Clements 

So, I think that’s a good place to leave this episode on depression, I think we covered a lot. So next couple of episodes are going to be talk therapy. I think it’ll surprise most people how often talk therapy doesn’t work. And then also anti depressants, how often those don’t work. And that’ll be the third episode. Here is the anti depressive episode. So any thing else before we wrap up here?

Dr. Grammer 

Yeah, I want to encourage our listeners to really make sure you listen into those other episodes, because we’re going to get into some specifics on the way people treat depression now and then even further down the road. We’re going to talk more about kind of new emerging treatments for depression, like ketamine or spravato, or magic mushrooms and things like that. And I think people will be very surprised to find that the treatment options out there for folks are much broader, much greater and much more varied than maybe they had been previously led to believe.

Joe Clements 

Excellent. All right. Well, looking forward to the next few episodes.

Dr. Grammer 

Joe, always a pleasure. I will see you next time. Thank you. Bye.

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