A case for mixed depression with Bourdain

Mixed depression according to some researchers is rather common but for some reason people don't think of it when someone like Bourdain commits suicide. Perhaps the depression goes unrecognized since the person's behavior isn't consistent with depression and the hypomanic symptoms are not meeting some arbitrary threshold. According to Targum:

“Mixed” depression is a clinical presentation in which a patient meets the full criteria for MDD and, at the same time, has a mixture of other features that are consistent with hypomania or mania. However, when only two or three of these manic symptoms are present, the duration fails to meet current criteria for hypomania (4 days) or mania (7 days), and therefore the diagnosis does reach the full criteria for a hypomanic or manic episode.²  

One hypomanic symptom would be Bourdain's restlessness and consistent traveling in search of the perfect meal in Parts Unknown. This is at odds with depression but his affect while doing so often seemed depressed to me. His commentary for the most part rather acerbic/cynical but punctuated with periods of levity.

A second sign of hypomanic symptoms was his suicide. It is fairly well known that suicide increases with mixed states. A mixed state is often a high energy state combined with a depressed mood. What constitutes high energy though is somewhat debatable. Most see it as an increase in physical activity which is productive but I contend from personal experience that one can have an extremely restless mind and be quite fatigued at the same time. In addition to the high energy there is often insomnia which might be attributed to stress or depression and not a symptom of hypomania.

A third sign of bipolar disorder was that Bourdain also seemed irritable which is another symptom of hypomania but most would probably see it as consistent with agitated depression. Depressed people can be irritable but it is usually not combined with excess goal orientated energy.

A fourth indication of bipolar was he was an ex addict. Addiction is more common among people with bipolar and could be due to a need to medicate or control an agitated and unhappy mind. What is unknown is had he relapsed or was he taking any antidepressants which might have precipitated the suicide. Antidepressants are known to aggravate bipolar depression and it is not a stretch to think they might have been involved.

A fifth sign was that he was married twice and in a relationship with a third woman. Multiple marriages are more consistent with bipolar tendencies. Irritability, grandiosity and restlessness is obviously going to cause more conflict.

And finally, his success as author, journalist and chef supports someone with a tendency towards hypomania. On average individuals with bipolar tend to be more productive and creative people which he certainly was. He wrote numerous books and was a famous TV personality.

Symptoms can fluctuate to quite a degree in bipolar disorder/unipolar depression and if that happens within a day this is often just attributed to what is know as diurnal variation. Personally, I experienced a very pronounced variation when younger. Somewhat of a mixed state early in morning, around 3am- 6am and then an improvement as the day went on. At night I often felt much better and was considerably more productive. This was considered as still consistent with Dysthymia according to my doctor.

What really seems to confound a diagnosis of "mixed depression" or bipolar disorder is how one evaluates what is "high energy". Is it always productive or can it be nonproductive as in anxiety? Dr. Phelps is one doctor who challenges how excessive energy is evaluated. How can one measure a racing mind which can occur in mania or depression with mixed features. It sounds like it often depends on self report and a rather subjective evaluation of a patient's symptoms.

Is there a correlation between Dysthymia, personality and the MBTI?

I have been diagnosed with Dysthymia (Persistent Depressive Disorder) in the past and I was reluctant to accept the diagnosis. Even though I have spent most of my life dealing with depressive like symptoms, for some reason I refused to identify with the label completely. In the past, when a teenager and young adult, I experienced mostly depression and occasionally normal/ hypomanic periods. As I have stated in my about section, I experienced severe depression in the morning and normal/hypomania in the evening with quite a regularity. Many clinicians would describe this as diurnal variation in the context of a mood episode but I am not so sure. 

In my mind over identifying with the depressive symptoms didn’t make sense since along with a depressed temperament I experienced many physical symptoms that suggested something other than temperamental problems. I have rarely read about people with Dysthymia mentioning much in the way of physical problems(insomnia/over sleeping,lack of appetite, fatigue). There seemed to be much more of a focus on how they felt emotionally and most of them identified strongly with being depressed for as long as they could remember. I however identified to quite a degree with the brief euthymic/hypomanic periods when I was quite productive and when I had no physical problems.

The other day though, I came across a Youtube video on the topic of INFP and the MBTI. In the video the person described a personality type that describes me when depressed and consequently I could identify with it to quite a degree. This made me ponder the difference between personality and Dysthymia. This topic has been debated for quite some time. In the past a Depressive personality type was accepted but once Prozac was introduced and successfully treated Dysthymia that changed. The DSM doesn’t have a label of Depressive Personality Disorder anymore but Persistent Depressive Disorder(Dysthymia) still remains. Despite the change the debate about a depressive personality hasn’t been resolved entirely. Many psychologist still view depression as more of a character flaw while psychiatrists are more open to the idea that there is something biological. The following excerpt supports my contention that my form of depression is more biological in nature and doesn’t overlap with Depressive Personality Disorder.

Many researchers believe that depressive personality disorder is so highly comorbid with other depressive disorders, manic-depressive episodes and dysthymic disorder, that it is redundant to include it as a distinct diagnosis. Recent studies however, have found that dysthymic disorder and depressive personality disorder are not as comorbid as previously thought. It was found that almost two thirds of the test subjects with depressive personality disorder did not have dysthymic disorder, and 83% did not have early-onset dysthymia.(Wikipedia)

I still tend to favor the idea of a biological explanation but have not entirely excluded the idea that a depressive personality might exist. This has been supported to a minor degree by an individual studying the MBTI and mood disorders named Janowski. He found depressed people tended to prefer introversion, feeling, and perceiving. Another small survey on McMan’s Depression and Bipolar Web found that most people with bipolar disorder identified with INFX as a MBTI type.

Unipolar Depressed patients were significantly more often Introverted, Sensing, Feeling, and Perceiving single-factor types respectively, and Introverted-Sensing-Feeling-Perceiving, and Introverted-Intuitive-Feeling-Perceiving four-factor types. The male Introverted-Sensing-Feeling-Perceiving four-factor type was the most dramatically over-represented.(Janowsky DS, 2002)

My conclusion from this small amount of information is that there might be an association between MBTI type and Depressive Personality Disorder but not so much with Dysthymia which has more of a physical basis. Hopefully more research will illuminate the debate regarding personality and clinical depression.

The relationship between diet, inflammation and depression

A new study by the Centre for Addiction and Mental Health (CAMH) found that the measure of brain inflammation in people who were experiencing clinical depression was increased by 30 per cent. The findings, published in JAMA Psychiatry, have important implications for developing new treatments for depression.

A growing body of evidence suggests the role of inflammation in generating the symptoms of a major depressive episode such as low mood, loss of appetite, and inability to sleep. But what was previously unclear was whether inflammation played a role in clinical depression independent of any other physical illness.

More research has come out which supports the link between inflammation and depression. While this link hasn't been confirmed my experience has piqued my interest in the topic. For about fifteen years I have been experimenting with Ayurveda which is a form of medicine which originated in India a thousand years ago. In Ayurveda the world is divided up into three different categories(doshas in human body), Vata, Pitta and Kapha. Vata is associated with air, Pitta with fire/water and Kapha with water/earth. In the human body the various categories govern certain functions and areas. Pitta governs metabolism, heat regulation and the immune system. It is located in the eyes and small intestine. Various tastes/qualities are said to balance the doshas. Pitta is said to be balanced by sweet, bitter, astringent and coolness.

For many years I have experimented with Ayurveda and discovered that balancing Pitta was very helpful, even more than balancing Vata which is associated in Ayurveda with the nervous system. Balancing Pitta is helpful especially in regards to anxiety, irritability and depression. Perhaps Pitta's association with inflammation in Ayurveda might explain this. In addition, Ayurveda recommends a vegetarian diet for a Pitta type of imbalance, a vegetarian diet has been shown in western medicine to help with inflammation.

Balancing Kapha, which is said to be localized in the stomach, has been helpful in regard to lack of motivation and energy. Balancing a dosha can aggravate another. Whenever I balance Kapha I notice Pitta becoming imbalanced. Balancing or pacifying Kapha can increase irritability which is a Pitta imbalance. In Ayurveda there are different methods of balancing more than on dosha. One way is to balance Vata which is believed to govern the other doshas. The second method is to balance the two using the qualities that balance the two doshas. In the case of Pitta and Kapha they are both balanced by bitter and astringent tastes. While this balancing act can be consciously performed I think it is also subconsciously performed when we have desert after a meal that has had too much salty and sour taste to it.

Somewhat interestingly healthy food tends to be higher in bitter and astringent qualities while junk food is higher in salty, sour and sweet tastes. According to Ayurveda salty, sour and sweet all balance Vata which is associated with the nervous system and stress. Perhaps this preference is one reason why western cultures seem to have more problems with inflammation and depression.

Fish intake might improve antidepressant response

Approximately half of the people suffering with depression don't respond to SSRIs. Recently a group of Dutch researchers discovered that adding fish oil to antidepressants increases the response rate.

According to a lead researcher they saw that depressed patients had an altered metabolism of fatty acids, and this altered metabolism was affected by stress hormones. In the experiment the researchers planned on examining the relationship between depression and fatty acids, and hormones such as cortisol.

They took 70 patients with depression and compared them to 51 healthy controls, by measuring their fatty acid levels and cortisol levels. They then gave the depressed patients 20mg of an SSRI daily for 6 weeks, and in those who did not respond to the SSRIs the dose was gradually increased up to 50mg/day. Fatty acid and cortisol levels were measured during the trial.
They found that the MDD patients who didn't respond to the SSRI also tended to have abnormal fatty acid metabolism, so they checked the dietary habits of all those taking part in the trial. Fatty fish is rich in fatty acids, such as the well-known Omega-3 DHA. So the researchers looked at the amount of fatty fish in the diet of all involved in the trial. They categorised the patients into 4 groups, according to their fatty fish intake, and they found that those who took the least fish tended to respond badly to anti-depressants, whereas those who had most fish in the diet responded best to anti-depressants. Those who ate fatty fish at least once a week had a 75% chance of responding to antidepressants, whereas those who never ate fatty fish had only a 23% chance of responding to antidepressants.

There were a couple of problems with this study. For one thing the study was on the small side and should be replicated with a larger one. A second problem is that the researchers appeared to know the fatty acid status of the depressed patients so they might have subconsciously altered the depression scores in order for their hypothesis to be proven correct. How the depression scores were measured is unclear from the article.

Andrew Stoll was one the first researchers to notice the antidepressant effect of fish oil. He theorized that fish oil might effect the composition of nerve cell membranes and consequently neurotransmission. Barry Sears, author of " The Zone", was another researcher who mentioned that stress could effect the type of fatty acids. They both probably inspired this study. I did not read the original article so if you are curious you will have to pay for the article through ECNP.

Evolutionary Origins of the Depression Epidemic

I recently read a book called "The Depth: The Evolutionary Origins of the Depression Epidemic". Here is a summary of the book from Amazon:

Why are we losing the fight against depression? In this groundbreaking work, psychologist Jonathan Rottenberg explains that despite advances in pharmaceutical science, progress has been hampered by our fundamental misunderstanding of depression as a psychological or chemical defect. Instead, Rottenberg introduces a surprising alternative: that depression is a particularly severe outgrowth of our natural capacity for emotion; it is a low mood gone haywire. Drawing on recent developments in the science of mood—and his own harrowing depressive experience as a young adult—Rottenberg explains depression in evolutionary terms, showing how its dark pull arises from adaptations that evolved to help our ancestors ensure their survival.

For a good part of the book the author tried to make a case that mild depression is the same as major depression and  if mild depression( reactive depression) is the same as major depression( endogenous depression) then neither is a disease. According to him they both have the same causes, similar symptomatology, and respond to similar treatments, therefore they are the same. This didn't seem like an air tight argument to me since there are some things that have similar causes, similar symptomatology, respond to similar treatments and yet are different. For example Subictal Mood Disorders (epilepsy) and Bipolar disorder are exacerbated by stress and can display similar symptomology( mood changes) but yet could have different pathology.

Additionally, one person has argued that the term major depression includes too many people who might not necessarily have endogenous depression. What the author should have possibly been comparing is mild depression to melancholic depression in order to make his case. Melancholic is considered by many to be more endogenous in nature than major depression which might include more of the neurotic/reactive variety.

Another argument that he makes is that depression could be evolutionarily favorable. He makes a better argument here except severe depression doesn't seem to be for the most part evolutionarily favorable. He specifically mentions an experiment where severely depressed people were a better judge of character than controls however this was just one experiment.

The author argues that depression is evolutionarily favorable since it causes people to stop pursuing impossible goals which are causing unnecessary stress. This seems plausible for mild depression which appears to make people more realistic but not so much for severely depressed people since they often have a distorted view of reality.

In conclusion his evolutionary theory in relation to mild depression was quite interesting  and gives depression a more positive image but the inclusion of severe depression needs a stronger argument.

Meditation regulates genes involved with inflammation

Dr. Khalsa and a group out of UCLA have shown that KKM resulted in different patterns of brain metabolism compared to other general relaxation methods. Using PET scanning, they saw that KKM resulted in 19 genes being up-regulated and 49 genes being down-regulated, resulting in the production of fewer inflammatory mediators, and increased telomerase activity by almost 50%. Why do we care about telomeres? Well, for starters, the Nobel Prize in Medicine was recently awarded to another research group, which found a connection between increased telomerase activity and greater longevity. Finally, the group taught KKM also had higher scores of mental health and lower depression.

KKM is a type of meditation. Inflammation is thought to be involved in depression and telomere activity is relevant  since depression is thought to accelerate the aging process. Due to the small number of people in research studies, more research is necessary.

Personally I find that meditation immediately helps with my fatigue, irritability and ability to focus. I'm not so sure about the long term effects.

Habits of miserable people

English: Abraham Lincoln, the sixteenth President of the United States. Latviešu: Abrahams Linkolns, sešpadsmitais ASV prezidents. Српски / Srpski: Абрахам Линколн, шеснаести председник Сједињених Америчких Држава. (Photo credit: Wikipedia)

Yesterday I came across an article regarding habits of miserable people. while I know some people like this who are chronically mildly depressed I'm afraid this person would extend it to  the severely depressed. Here are a few quotes that summarize the authors thinking.

• When you’re miserable, people feel sorry for you. Not only that, they often feel obscurely guilty, as if your misery might somehow be their fault. This is good! There’s power in making other people feel guilty. The people who love you and those who depend on you will walk on eggshells to make sure that they don’t say or do anything that will increase your misery.

• When you’re miserable, since you have no hopes and expect nothing good to happen, you can’t be disappointed or disillusioned.

• Being miserable can give the impression that you’re a wise and worldly person, especially if you’re miserable not just about your life, but about society in general. You can project an aura of someone burdened by a form of profound, tragic, existential knowledge that happy, shallow people can’t possibly appreciate.

There are a couple of problems with this article if one extends her thinking to all types of depression. First of all Madanes could be accused of " mind reading" by CBT therapists. She thinks she knows how all depressed people think. Ironically she has the same overly negative perception of depressed people that she is accusing them of. There are some depressed people who gain from being "depressed" however this isn't necessarily true of most of them.(over generalizing) I personally have been treated quite negatively when depressed. Additionally she lumps all "depressed" people together when their depression could differ with regard to degree and source, some more biological and some more environmental.

There are many great people who are depressed, Churchill, Dostevsky and Lincoln. Lincoln was one outstanding example of a person who contributed much to society despite being quite miserable. I wonder how his life would have been different if he hadn't been depressed.

Diet could affect mood via bacteria in gut

Lord of Ayurveda,Dhanvantari (Photo credit: Wikipedia)

I have tried a number of diets in order to improve my mood and one that seemed to help the most was the Pitta diet of Ayurveda. This diet consists mainly of food that has the flowing qualities: bitter, astringent,  and sweet. Additionally the diet specifies eating little to no meat,no eggs, and avoiding certain oils. The Pitta dosha is associated with inflammation in Ayurveda.

Recently I read in NPR that a diet consisting of just meat, eggs and cheese increases a type of bacteria your gut that could lead to inflammation and inflammation has in turn been associated with depression. A vegetarian diet on the other hand increased other types of bacteria which haven't been associated with inflammation.

Scientists are just beginning to learn about how our decisions at the dinner table — or the drive-through — tweak our microbiome, that is, the communities of bacteria living in our bodies. But one thing is becoming clear: The critters hanging out in our intestine influence many aspects of our health, including weight, immunity and perhaps even behavior.
"The relative abundance of various bacteria species looked like it shifted within a day after the food hit the gut," David says. After the volunteers had spent about three days on each diet, the bacteria in the gut even started to change their behavior. "The kind of genes turned on in the microbes changed in both diets," he says.

Presence of 'activation syndrome' suggests bipolarity

When younger(in my twenties) I noticed that SSRIs initially gave me panic attacks and akathisia. I always had a suspicion that my depression had a degree of bipolarity about it and this study confirms it a little. Activation syndrome is more common among bipolar patients and it consists of the following symptoms:

The components of activation syndrome, as stated by the US Food and Drug Administration, are anxiety, agitation, panic attack, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and mania/hypomania. The syndrome is believed to flag suicidality risk in patients taking antidepressants.

If an individual has these symptoms it increases the chance of being bipolar by 3.27 fold.

On multivariate analysis, a bipolar diagnosis was one of only two variables independently associated with activation syndrome, increasing the likelihood 3.27-fold.

The other variable was experiencing a mixed depressed state which like a bipolar diagnosis, increases suicidality. In the past another mood researcher Benazzi, a proponent of 'mixed depression', believed that individuals with a few hypomanic traits such as irritability, insomnia and agitation while depressed were more likely to have bipolar disorder.

The other significant variable was being in a depressive mixed state, which raised the likelihood for activation syndrome 4.13-fold. The researchers note that a depressive mixed state is reportedly almost as common in patients with MDD who attempt suicide while on antidepressive treatment as it is in patients with bipolar disorder.

Given the small size of the study and the naturalistic/retrospective nature, further studies are needed to confirm the connection between activation syndrome and bipolarity.

Not all Fish oil Supplements Created Equal

I have been taking a variety of fish oil supplements( Twinlab, Now) since 2003 and I believe, for the most part, that they were helpful, however I couldn't say for certain. Recently I came across some information that is new to me. A website PsychEducation mentioned that if you purchase fish oil the amount of EPA should be 60 percent of the total amount of Omega-3 fatty acids per/pill.  A fish oil pill with less than that percentage acts more or less like a placebo. I found it difficult to discern this from some of the brands since some don't give you much detail.

a big review of all these studies and more suggests that the ratio of EPA to DHA (the two omega-3 fatty acids) really matters. Their analysis shows that of these two omega-3's in each pill, at least 60%  must be EPA. Less than that and it does not work better than a placebo; in fact in several studies, less than 60% EPA was worse than a placebo.