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Serotonin Deficiency: The Great Brain Robbery
Is Nearly Everyone Serotonin Deficient?
"Mental illness affects not three out of five or four out of five but one of one."--William Menninger
John Donne instructed us to "ask not for whom the bell tolls, for it tolls for thee." As we shall see, mental illness now strikes nearly all of us, although with vast differences in form and degree. And the numbers are mounting steadily. In particular, serious depression has risen astonishingly in recent years, as emphasized by the late Dr. Gerald Klerman, a leading figure in American psychiatry. He termed the hunt for the mysterious cause of this epidemic "the search for Agent Blue."
To claim that nearly everyone will suffer mental illness may seem absurd, for many of us still think of it only in its most extreme forms. But let's recast the issue. Let's ask: How many people suffer emotionally or physically from stress? Indeed, the harried, floating anxiety that accompanies stress is a type of mental illness, and most of us, even if we do not care to admit it, have experienced it to some degree. However, stress is much more than that harried feeling, which originates in the brain. Biologically, it includes almost anything that puts an extra burden on an organism. For example, extreme heat falls under the heading. Mental illness is certainly stress related, but most people find stress-related illness a far more acceptable term, for then their condition joins the respectable company of high blood pressure, ulcers, and the many other stress-causedillnesses.
Ironically, many of the people we most admire are included in this stigmatized group. A study of three hundred biographies of history's most accomplished scientists, politicians, philosophers, and artists found evidence that some three out of four had suffered serious mental illness. For example, two of Western culture's most revered leaders, Abraham Lincoln and Winston Churchill, wrote in detail of their struggle with incapacitating depression. At one point Lincoln concluded: "I am now quite certainly the most miserable man alive."
As the above study shows, the mentally ill are, overall, quite disproportionately gifted and achieving. We fear such illness probably because at some level it reminds us of our own vulnerability. That we don't understand how these conditions develop has made them seem even more frightening. Fortunately, the more we learn about the causes of mental illness and how to treat it, the less stigma is attached to it.
We now know that many mental disorders are actually biological in origin, which puts them on the same plane as angina or arthritis, for example. Apart from biological factors, many psychiatric conditions are simply the result of poor learned responses to life. Fortunately, these can readily be unlearned through cognitive or behavioral therapy. There's nothing terribly mysterious or threatening about such cases.
I believe that making people aware of just how widespread these conditions are, even the most serious ones, will further lessen the stigma. When I first began looking at the puzzle of rising mental illness rates, best estimates were that about one in five people were afflicted at some time during their life. Just as the first large-scale, rigorous study of sexuality in America produced big surprises, the first such study on mental illness produced rather shocking results.
Published in 1994 in Archives of General Psychiatry, but curiously receiving little publicity, the study found that among people between the ages of eighteen and fifty-four, nearly half had already met the formal diagnostic criteria for at least one of fourteen serious psychiatric illnesses. These people did not merely feel bad for the occasional few days; nearly one-third of them had had a disorder lasting over a year. The elderly, who were not included in the study, are also at risk for psychiatric conditions. Thus, over a lifetime, clearly a majority of us will undergo serious mental illness.
Mental illness is certainly stress related but genetics plays a role, as it does with stress-related physical illness. However, a recent study found that stress played the greater role in causing depression.
I cannot emphasize strongly enough that all stress-related conditions are similar, whether manifested as psychiatric or as general medical problems. Indeed, a majority of primary care physician visits concern stress-related illness. This mental-physical overlap is further demonstrated in that roughly two-thirds of those who suffer depression also suffer at least one of the following: hypertension, arthritis, advanced coronary artery disease, diabetes, gastrointestinal disorders, chronic back pain, chronic lung problems, and angina. Insomnia falls somewhere in the netherland between psychiatry and general medicine. The National Commission on Sleep Disorders Research estimates that occasional "tossing and turning" troubles more than 90 percent of the U.S. population, with more than 30 percent reporting the problem as serious and chronic.
Certainly, stress-induced mental illness is no more deserving of shame, fear, or prejudice than are similarly induced medical conditions.
"Generation X," the group of people born between about 1960 and 1970, has a particularly high depression rate--but so do generations "X - 1" and "X + 1." Most alarmingly, since World War II, depression and suicide among adolescents has more than tripled. Over all ages depression has been increasing steadily across international, cultural, and ethnic boundaries. A national collaborative group recently evaluated these trends in various countries, including Germany, Italy, France, Lebanon, and Taiwan. Some of the studies found that depression in men born after World War II continues to rise, while women's rates have flattened, although twice as many women suffer from depression as men.
According to Paul Greenberg and others, the economic burden that depression inflicts on the United States reaches over $44 billion annually. While other psychiatric conditions have not been studied to the extent that depression has, we see that most other forms of mental illness are certainly increasing. Some, such as anorexia and bulimia, were virtually unknown until recently.
A recent study headed by Dr. Louis Judd, former director of the National Institute of Mental Health, found that many people who do not meet the current diagnostic criteria for depression nonetheless suffer real impairment due to one or more symptoms of the illness. This milder depression, which Judd has labeled "subsyndromal symptomatic depression," befalls four times the number who meet the full definition of depression.
Just how bad is this lesser depression? A recent study found that surprisingly the impairment associated with minor depression often exceeded that caused by medical conditions such as heart disease, diabetes, and arthritis. Further, people with minor depression may use even more psychiatric and other medical services than do those who suffer the full condition. The mildly depressed also take a greater economic toll on society in lost workdays than do their formally diagnosed counterparts.
Curiously, people with minor depression sometimes lack the symptom of depressed mood. (The three most common symptoms reported are sleep disturbances, fatigue, and thoughts of death.) Perhaps even more curious, those who do not experience lowered mood account for twice the number of disability days than those who do have the symptom.
To understand this, we must first realize that depression often arrives without noticeably lowering one's mood. In order to qualify for the diagnosis of major depression, one need have only five symptoms, and depressed mood need not be among them.
I developed the following mnemonic as a diagnostic aid and use it when I lecture on depression.
A:Appetite and/or weight (e.g., 5 percent in a month) reduction or increase
P:Psychomotor retardation or agitation
E:Energy reduction (fatigue)
S:Sleep reduction or increase
S:Suicidal ideas or thoughts of death
W:Worthlessness or feelings of excessive/inappropriate guilt
I:Interest or pleasure-marked diminution in most activities
M:Mental ability diminution (difficulty thinking, concentrating, or deciding)
The Diagnostic Statistical Manual IV diagnosis of a major depressive episode in adults requires either loss of interest or depressed mood plus four other of the above symptoms to bepresent nearly every day during the same two-week period, and that these symptoms represent a change from previous functioning (suicidal ideation need not meet the nearly-every-day requirement).