Beyond Blue

Beyond Blue

The Murky Politics of Mind-Body: “Depression Is a Brain Disease” 101

According to yesterday’s comprehensive article in the “New York Times” by Sarah Kershaw, this month the House has passed a bill that would require insurance companies to provide mental health insurance parity.
Writes Kershaw:

It was the first time it has approved a proposal so substantial.
The bill would ban insurance companies from setting lower limits on treatment for mental health problems than on treatment for physical problems, including doctor visits and hospital stays. It would also disallow higher co-payments. The insurance industry is up in arms, as are others who envision sharply higher premiums and a free-for-all over claims for coverage of things like jet lag and caffeine addiction.
Parity raises all sorts of tricky questions. Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?


I suppose I might be a tad more excited about this than the average person because Eric and I spent $30,000 in mental-health fees during the fiscal year of 2006: two hospital stays that were supposed to be covered but weren’t, thousands of dollars in therapy because after eight sessions I hadn’t been cured, medication, and of course our $12,000 premiums for a year, since Eric works for a small firm, where he is one of the youngest architects and (surprise!) some of them aren’t in perfect health.

I’m pumped by this bill, not because I’m expecting my next counseling session to be covered. But because more than a few people might actually BELIEVE me when I say that I suffer from a brain disease commonly known as bipolar disorder.
After reading many of the comments on the combox of my post, “J.K. Rowling’s Suicidal Days,” I was convinced that day would never come, or if it did, it would be a century after scientists solved the whole global warming crisis and pollution problem.
Take a peak at those comments and you’ll see that we haven’t come all that far in our perception of mental illness. Most of the country—unlike Scandinavian countries where people treat mental illnesses as medical diseases—still says (or definitely THINKS) things like, “yikes, one of those pathetic sad cases who can’t get over her childhood crap”; the average American (in my circles, anyway) tells a person who accurately names her bipolar disorder as a brain disease that she is buying into the very flawed “disease model,” that by saying she “suffers from depression” she is cursing herself with a term renowned medical intuitive Caroline Myss calls “woundology”: defining ourselves by our wounds, and in so doing burdening and losing our physical and spiritual energy, opening ourselves to the risk of illness.
Yep, folks. That’s what we’re up against. And also these people, explains Kershaw:


Critics of parity say that anything that would not turn up in an autopsy, as in depression or agoraphobia, cannot be equated with physical illness, either in the pages of a medical text or on an insurance claim. These critics also say that because the mental abnormality research is so new, it should still be considered theory rather than an established basis for equal payment and treatment. “Schizophrenia and depression refer to behavior, not to cellular abnormalities,” said Jeffrey A. Schaler, a psychologist and an assistant professor of justice, law and society at American University in Washington. “So what constitutes medicine? Is it what anybody says is medicine? Is it acupuncture? Is it homeopathy?”
The Bush administration and other opponents say the list of disorders is far too broad. That leads from parity to another, parallel morass in the fields of psychiatry and pharmacology. Both fields are accused of over-diagnosis and of seizing on fashionable diagnoses — bipolar disorder or post-traumatic stress disorder, for example — for financial gain or through highly subjective assessments.
“It’s the phone-book approach of possible conditions,” said Karen Ignagni, president of America’s Health Insurance Plans, an industry group representing insurance companies that cover 200 million Americans. “And this comes at a time when advocates have made a very persuasive case about the importance of covering behavioral health.”


I’m wondering if any of Karen’s siblings have taken their own lives, or been so crippled by depression that they’ve had to drop out of school. My guess is no. Here’s the defense, thank God:

“Insurance companies balk at this, but there are striking similarities between mental and physical diseases,” said George Graham, the A.C. Reid professor of philosophy at Wake Forest University. “There is suffering, there is a lacking of skills, a quality of life tragically reduced, the need for help. You have to develop a conception of mental health that focuses on the similarities, respects the differences but does not allow the differences to produce radically disparate and inequitable forms of treatment.”
Attitudes about mental illnesses and addiction have changed significantly in the decades since advocates for the mentally ill — and for parity — first tried to include broad coverage of mental illnesses in the nation’s insurance plans. Pop culture has normalized and even glamorized rehab and even suicide attempts, chipping away slowly at social stigmas and lending strength to the idea that the sufferer of a mental illness or addiction may be a victim, rather than a perpetrator. Still, a cancer patient generally remains a far more sympathetic figure than a cocaine addict or a schizophrenic.
But scientific advances may go a long way to help the parity cause. The biological and neurological connection lends strength to the notion that mental illnesses are as real and as urgent as physical illnesses and that there may, at long last, even be a cure in this lifetime, or the next.
“The more research that is done, the more the science convinces us that there is simply no reason to separate mental disorders from any other medical disorder,” said Thomas R. Insel, director of the National Institute of Mental Health, which has conducted a series of studies on the connection between depression and brain circuitry and on Thursday released an important study showing a connection between genetics and the ability to predict the risk for schizophrenia.


Ever since I signed the contract to write Beyond Blue, I’ve buried my head in research that asserts the biological cause of depression because I have so many people tell me that I’m making all of it up. I don’t think any statistics that I share with some of them will convince them that mental disorders really aren’t imaginary friends, the kind we play with in the bath tub. I’ll always be part of what Caroline Myss calls the “wounded,” licking my sores and delighting in the taste of them. HOWEVER, for those who might try to open their minds to view depression and all mental illness with the same legitimacy as diabetes, cancer, and arthritis, here is my summary of my research, a piece I call “Depression Is a Brain Disease” 101:


Depression and bipolar disorder are more than imbalances of neurotransmitters (serotonin, norepinephrine, and dopamine), chemicals that bridge the synaptic clefts and pass messages to each other. These diseases are the result of organic changes in specific areas of the brain, especially in the limbic system, a ring of structures that form the brain’s emotional center, including the cerebral cortex, thalamus, hypothalamus, and hippocampus.
In his book Against Depression, Dr. Peter D. Kramer, Professor of Psychiatry at Brown University, provides an overview of research studies that sketch out the effect of stress hormones in the prefrontal cortex of the brain. Based on a survey of cutting-edge medical research, he believes that it’s the devastation in the amygdala and hippocampus regions–the significant cell death and shrinkage, and the diminished capacity for nerve generation–that contributes to fragile moods. “The longer the episode [of depression],” he writes, “the greater the anatomical disorder. To work with depression is to combat a disease that harms patients’ nerve pathways day by day.”
Kramer is trying to use his synthesis of research to change attitudes among psychiatrists and patients.
“Psychiatrists have learned that depression is progressive, and there is widespread agreement that we need to interrupt it very promptly and decisively to prevent further deterioration,” he writes. From a public health perspective, he believes that “depression is the most devastating disease known to mankind.”
There are psychiatrists and neurologists like Helen S. Mayberg, M.D., Professor of Psychiatry and Neurology at Emory University School of Medicine in Atlanta, Georgia, who are using brain-mapping techniques to view brain activity and how those functions affect our emotions.
“Thanks to refinements in brain-imaging technologies (higher resolution in PET scans and MRIs), scientists now know that there are regional patterns of brain activity–differences in specific circuits of the brain–that distinguish depressed people from non-depressed people,” she writes in an in-depth report in the October 2006 issue of The Johns Hopkins Depression and Anxiety Bulletin.
Mayberg sees this neurological perspective–focusing on specific brain circuits–as a new way of understanding depression, which coupled with a biochemical approach, can lead to more targeted treatments.
The research into the genetics of mood disorders continues to pinpoint the genes that may predispose individuals and families to depression and bipolar disorder. There has been remarkable success in locating and identifying genes associated with schizophrenia, and, more recently, with obsessive-compulsive disorder (the “transporter” gene SLC1A1). Researchers have confirmed a role for the gene G72/G30, located on chromosome 13q, in some families with bipolar disorder, and also evidence for genes on chromosome 18q.
Most recently, with genetic studies on families with major depression disorder, psychiatric geneticists like James Potash, M.D. have been able to mark a narrow area on chromosome 15 as having a tie to depression. In an interview with “BrainWise” the newsletter of Johns Hopkins Department of Psychiatry and Behavioral Sciences, Potash says this:


Of nine genes in that vicinity that we analyzed, one, NTRK3, piqued our interest. We’ve just launched a study about 2,000 times more powerful than the last to make the suspect genes far more obvious, one that should clarify what NTRK3 and others are doing. For the first time, we have the potential to understand the truth about what sets depression in motion.

Moreover, researchers are beginning to see what a genetic predisposition to depression actually looks like. For example, the National Institute of Mental Health conducted a compelling study involving a gene known as the “serotonin transporter gene.” Further studies will point to biochemical pathways of disease and could lead to development of new medications to alter those pathways.
But even as all the genetic and structural information is interesting and helpful, the far more convincing data for the biological basis of mental illness, according to my psychiatrist and other doctors, is the natural history of these diseases.
“It didn’t take us finding the cellular basis of HIV or cancer or tuberculosis to convince us that these were diseases,” Dr. Smith explained to me recently. “It was the stereotypical nature of their symptoms and natural history.” So why should it take fancy science to convince people that mental illnesses are biological diseases?
Interestingly enough, 100 years ago tuberculosis was perceived similarly to depression today. It was an illness that “signified refinement,” Peter Kramer explains, containing a “measure of erotic appeal.” But that diminished as science helped identify the origins of the illness and as treatment became possible and then routine. “Depression may follow the same path,” writes Kramer. “As it does, we may find that heroic melancholy is no more.”
Even if depressives aren’t as fascinated by the biological basis of their condition, as I am, they should know this: Depression is an organic brain disorder. As Kramer succinctly states, “Depression is not a perspective. It is a disease.” End of story.

  • Cindy

    I was in this situation for a long time and nobody had actually diagnosed me until i had some testing done and that is where i found out that i have depression and it has gotten under control with medications and i dont like the idea on being on meds all of my life. I am happy that i found out what my illness is now and not wait until it was to late. I am a advocate and a mentor for the disabled and going back to school and going on to be a social worker if i can actually make it as time will tell but now i am taking just the basic classes now and decide what to pursue after i have some testing done to see where i would actually fit in. Thank you for having this topic as i am also doing a project on depression in one of my classes so this had helped me to know where i can actually start and feel confident and not be scared.

  • Barbara formerly Babs

    I am perplexed by many of the comments to which you refer. Over the time you have written Beyond Blue, you have made it abundantly clear that you employ a variety of approaches to managing your disorder. Never have you advocated medication alone, to the exclusion of other therapies. Some of the “hit and run” crowd seem to be determined to ignore what I believe is a very balanced, very sound approach to maintaining mental health, and construct a straw man argument, or attack you personally, (you whiny white woman!).
    For anyone who takes the problem of depression and its attendent issues seriously, these people add nothing to the discussion. They accuse you as a shill for the drug companies, but it is clear to any frequent reader of this blog, that THEY have some sort of ax to grind.
    I find it personally offensive to read the personal attacks to which you are subjected, and the misrepresentation of your position. The only comfort I think you can take in it all, is that you are speaking for those who don’t have the same facility with the language as you do, or a forum with which to present the issues as you see them. As such you are a lightning rod for those who won’t have a conversation that is civil and thoughtful.
    Thank God for all those like you and Peter Kramer, who are willing to put themselves and their reputation on the line in the persuit of truth.

  • Barbara formerly Babs

    Correction: In the first line, I meant “disease” as opposed to disorder. It was a slip o’ the brain.

  • Larry Parker

    I thought the comments on the J.K. Rowling box were generally disgusting.
    (And in that, I include my first comment about Harry Potter’s wizard. I realized I had been far too hard on her and tried to be more nuanced in my second comment — but nuance seemed to be lacking on that comment box, for some reason …)

  • Marla Gamble

    Felt that disregarding or discounting J.K. Rowling’s life experience as “not being genuine depression” or “unauthentic” because it is connected to Divorce is a mistake. Families and marriages who experience Divorce consistantly report that “experiencing Divorce is parallel to experiencing a death”. I am a therapist and hear this everyday in my practice and believe it to be true and genuine. Yes, it may be situational but that does not mean because something is situaltional it is not depression. I also have suffered from Depression and was on prescription medication for almost 14 years, this was even during the time to which I was in graduate school…etc. and did receive therapy to work through some issues in order to be more self-aware and prepared to facilitate change in those I serve and realistically I only touched the tip of the iceberg during that time. I believe with all my heart that Depression is a “thought disorder”. I have been prescription free for over 4 years now. For years, I experienced suicidal ideations, O self esteem, lacked a healthy self identity, had diffiuclty concentrating, making decisions etc. etc…..continued to believe the cure was in prescription medication…was so depressed I lost faith and beleived that life was all one rendom act after another and that their was “no god force, or creater, or connection among people”. This all changed once I began to take responsibility for myself and my life, for my choices…and to self examine my cognitive thought patterns. Yep, Cognitive Behavior Therapy learned and then applied to self…..saved my life. I also read a book by Louise Hay called “You Can Heal Your Life”, and several books by “Marianne Williamson” These two authors along with the insightful Dr. Dyer (who writes and communicates from a cognitive perspective….gave me new life. Louise Hay spells the word disease like dis-ease. Being a victim, lacking insight, and avoiding working through our unresolved issues….will allow dis-ease (wether its a thought disorder such as depression or back pain to manifest itself physiologically over and over). If you begin to identify your negative inner dialogue, and when and why you consistantly allow yourself to partake in the negative inner dialogue, then turn it around and began to discipline yourself to change that. It will allow you to form new neuropathways and change your receptors and your depression will begin to lift. Many times I find that my patients are addicted to negative thoughts and negative feelings and sometimes will continue to stick with “what they know because it feels comfortable…like an old pair of shoes”…..I have been there. The challenge here is to “honor and value each others experiences as genuine” and then “challenge ourselves to create a new way of being”…..If a person suffering from depression is on medication it is important to not stop taking that medication. But a person can set a goal to seek professional help (start therapy) and articulate your intention to change the way you think and once you have been stable and you know in your heart that you’re thinking and reality has shifted and the weight has lifted ….. work with your prescriber to lower the dose in increments through out (like every three to six months) and stay on a low dose, or eventually go off or maybe cut a few meds and stay on one low dose of medication. At one point in my life my Dr. had me one Nine Medications and I am Medication free now….for four years. Through surrendering….and taking responsibility etc….I not only was liberated from my chronic depression, but I found my source and creator again.

  • Anonymous

    I was diagnosed with Bipolar 10 years ago, although I suffered terribly from depression, most of my life before that, I did not know it at the time, I just thought, that was “life”. And, even though I have gone to therapy on and off for the last 14 years (and, it has helped my tremdously), I continue to struggle with life in gereral. I can’t seem to move forward. I am 38! years old now. What in the world, should I do for myself, that I obviously haven’t. I want so desparately to love and appreciate my life, at least MOST OF THE TIME. Something doesn’t seem right! I’m a mom of 3 wonderful children, that I love dearly, I’m active in my church (although when I get hit with the blues, I’m nowhere to be found, but in bed of course), oh yeah, I almost forgot to mention, I’m also a wife, when I make myself be, my friend and family love me very much, and my faith in, God has increased, dramatically (in the last 3 years). What else could anybody want. I just feel so stuck. Is this it or can I do more to help myself (and, what)???
    By the way, I love reading your articles and the info that you give. And, I really love this website. Thank you, for dedicating yourself to doing this. I, too, am intrigued with learning about mental illness, it facinates me!

  • Tania L. Finch

    I forgot to enter my name and email to a previous comment I posted a few minutes ago.
    Melbourne, FL.

  • Sweet P Hood, RN

    Yes, yes, all well and good. I do at times, find some entertainment, with the stigmatic opinions of those that really believe mental llness is “all in our heads” but I am mostly saddened, by the shallow depths the modern american mind swims in. We are the poorest, third world country in are ideals with death, mental illness, and our isolated, drug-ingestd homeless We live in a poverty stricken society of denial.
    I know why, they havn’t been living with or loving someeone withmental illness Mental health is opinions and conclusions of others, about how they have supposedly won by their own personal battle, by conquering their minds and emotions, how they have mastered their weaknesses, with some positive thinking, increased prayer and a new excercise move. In some pretty diary they write their feelngs, they suddenly saw the truth and the light, which brought them the ultimate inner peace, which made them free to live each day to its fullest. How they snapped back into reality, mastered their life/work balance, and of course, with some positive thinking, we too, could find “the answers” to life’s “tough questions”. If we would just followed the rules, or tried a little harder, and get a better atttitude, and stop feeling sorry for ourselves.
    with some easy how-to’s and being able to be one’s self, one with nature. All it really takes is some good old fashioned self-control, bringing us back into normal behavior, to attain positive and productive living through dicipline, self control, the mind-over matter, mantra. That healing takes place by a special little prayer, and some good-old, god-given, common sense, you will get back in the saddle, and live successfully, againsuccessful advice, coerce others to believe they truly know and have mastered the weaknesses of mankind, and if only those other, misguided, low self-esteem, weak-minded people, you know the ones, that won’t pull their boot straps up, or the selfish, introspective wound licker,cop-outs, would just try to believe that this life can completely be understood, and there is a logical answer to all things manknd must face. That we are in controll of our destiny, even dodging death, even when we deny (try)
    hard enough. I love how our priorities in million dollar athletes, american idols, are real to us, but people that are pretending to be sick n the head is unreal and all made up. It feels good when people whisper and snicker, I love the attention. Respect and care is for our plasma, hdtv, our new corian, granite, Dooney & Bourke & we need more juicey, and wang. but don’t waste tax dollars on special projects for the homeless, they choose to live that lifestyle being high, and drunk, what pain. Mental illness is when the mind is consistantly being inconsistant. To study how gas becomes exhaust, to study cellular respiration, to watch zygotes become bald headed babies, can you write sexual attraction as a mathematical equatio?
    These are common daily occurrences, normal patterns that are happening, within, around and to us, non stop, do we control them, understand the process, can they be completely described and explained easily, if there is any small change, interuption , or factor added or taken away what will the outcome be? Our brain is more intricate and complex than these above normal everyday occurances. How dare we say anything regarding the mind and how or not how it functions. Lets take a scenerio. If you were standing on home plate and you were in between a baseball and the swinging bat of Barry Bonds explain the pathophysiology of a head injury and the contol of your actions after the injury has accurred. Why is it your thoughts can’t be controlled by you? Your brain is affected, but your thoughts are not organs like your heart, or liver or your skin they cannot felt or hit with the bat, they should not be affected, why would you act differently than someone else with the same exact injury?. To rush and judge human behavior and dysfuncton is to fully understand these terms. Look these words up in Tabors Medical Dictonary once you research them, write ther function, and how they are interrelated to each other n a normal and an abnormal brain Find a PET scan picture see the color of the normal brain vs. abnormal why it a diferent what makes it different
    show your work. Neuro-glial pathway, synapse, dendrite, gray matter.
    maybe with some good old homework on the brain and maybe the next time you see a crazy person, they might not look the same.
    mental illness looks better than ignorance, and yes, I am mentally ill
    with a dash of manic and a spoonful of anger to balance it all out.

  • Jim Willimas

    There are two important issues in your comments. The primary one is the recognition of the medical reality of diseases the symptoms of which are behavioral. I commend all efforts to inform and educate about this. The second is the recognition that health insurance is primarily for the treatment of disease symptoms. There are precious few mechanisms of support for the maintenance of health in the health insurance industry. Make no mistake about it, health insurance, is one of the biggest oxymorons in the English language.
    Having spewed all this I also take a deep breath and ask myself “What role does belief play in health and disease?”

  • Tony Mancuso

    I have BiPolar and need a wholistic Doctor. Can any one help me. 1-321-914-3250 Melbourne Florida Cell 1-321-266-0405

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