Episode 59: All About Anxiety and Depression Part 2

Dr. Robert Rountree:

This is the Thorne Podcast, the show that navigates the complex world of wellness and explores the latest science behind diet supplements and lifestyle approaches to good health. I'm Dr. Robert Rountree, Chief Medical Advisor at Thorne and functional medicine doctor.

Dr. Frank Lipman:

And I'm Dr. Frank Lipman, New York Times bestseller and functional medicine doctor. As a reminder, the recommendations made in this podcast are the recommendations of the individuals who express them and not the recommendations of Thorne. Statements in this podcast have not been evaluated by the Food and Drug Administration.

Dr. Robert Rountree:

Any products mentioned are not intended to diagnose, treat, cure, or prevent any disease.

Dr. Frank Lipman:

Hi everyone and welcome to the Thorne Podcast. We're glad you're here and excited to talk about a fascinating topic for you today. This week is part two of our two-part episode on anxiety and depression and we'll be talking about depression. These are obviously topics that are relatable to a lot of you listening. We've got a lot of questions for you, and we're going to do our best to give some really good advice. So this week we're going to start focusing on depression, but first, Bob how you doing?

Dr. Robert Rountree:

I'm doing pretty well. I'm dealing with that kind of age- old issue of how to get enough balance in life. It seems like there's always more work that needs to be done than there is time to do it. And yet, it's beautiful outside. So, I'm always asking the question how much time do I need to take for myself, because if I don't do that I won't stay healthy enough to do my job correctly. There's always more to do than there's time to do. How do you do that? It's kind of an age-old question.

Dr. Frank Lipman:

Yeah, and I think that fits right into our topic for today. I think spending time on yourself, doing things you enjoy, getting away from work and getting time in nature, doing things apart from work, are very important to prevent anxiety and depression. So, we talked about anxiety in the last podcast, so let's start talking about depression. Give us some Bob wisdom on depression.

Dr. Robert Rountree:

Well, again where I start where somebody... Let's put a box around this, which is when does something become a big enough problem that they go in to see a doctor like you or me. Generally, that means that it's more than just being a little bit depressed about the state of affairs in the world. It generally means that they're having difficulty getting through their day or a person will tell me they're crying a lot, or in the quiet moments when they're not super busy, they stop and they just feel unhappy. And I emphasize that word feel. What is that? The feeling often that a person will describe is they have a kind of sense of heaviness that everything takes effort, it's difficult to get out of bed in the morning, they're not motivated to move forward with their day.

Dr. Robert Rountree:

Now, in traditional psychiatry they talk about melancholy, which melancholy is kind of again a feeling that life is not worth living. They just can't move forward. Now, that tends to be more on the severe end. What about the person who they're doing their thing, but they just don't have any joy? That's all part of this same scenario. So what I try to do, first of all, is assess whether this is something that's really deep-seated or it's situational. We talked about that with anxiety, as well. Is the person having anxiety because of a situation and once the situation has improved, is it going to go away?

Dr. Robert Rountree:

And the same thing's true for depression. Is it situational? So if a person comes in and says, "I'm depressed," then the first question I ask is, "About what? What's depressing you?" Because if someone tells me, "I'm depressed," then I think, "Well, that means you've identified with it. I thought you were John Smith. I didn't think you were depressed. I think of you as a person that's going through an experience." And so how do we circumscribe that? How do we kind of pull you out of it so that we can try to define what it is that's going on and what the causes might be?

Dr. Frank Lipman:

And I think that's really important because my experience has been too many people do think that way, and that's partly a cultural thing and partly I blame it on our medical system where we are too quick to give antidepressants. Now, I'm not saying there's not a place for antidepressants. Absolutely. I mean, I've seen them help a lot of people, especially for severe depression, but I think in our culture, and it's partly from psychiatrists or even regular doctors, and partly by patients asking or demanding that they get antidepressants because of the way we think of depression in our culture.

Dr. Frank Lipman:

And I think we've got to be very careful because I've seen too many people now over the years that have been on antidepressants for too long and just get used to that feeling, that's numbing or whatever that antidepressant does, and it can be very difficult to get off antidepressants, in particular SSRI's. I mean, I've seen people really struggle to get off the SSRI's. So I think that's very important what you said because the rush to antidepressants is a problem, and then the difficulty getting off them is another problem. And I think we've got a major epidemic of people on antidepressants who probably don't really need to be on them. That sounds a bit strange me saying that without even knowing someone, but I do think as a general rule, antidepressants are given out too easily and I just see more and more people who come to me and they want to get off their antidepressants and it's very, very difficult.

Dr. Robert Rountree:

I think the published research is pretty clear that for severe depression, the person in the melancholic state that I mentioned that can't function, that's laying in bed crying all the time.

Dr. Frank Lipman:

Yeah.

Dr. Robert Rountree:

I've seen that happen. Somebody loses a spouse or a parent or a close friend and they just can't go on. And the data, I think, shows that these prescription antidepressants can be helpful to get people through that. The problem that you're pointing out is that depression per se is not an antidepressant deficiency. Just because somebody is depressed or feeling depressed, doesn't mean they've got a Prozac deficiency.

Dr. Frank Lipman:

Exactly.

Dr. Robert Rountree:

So if we hand this stuff out like candy without realizing their consequences and that people go on the Prozac. What the studies show is that the Prozac makes them feel different. It doesn't necessarily change their mood, they just feel different. They feel the side effects and they think, "Well, I must be getting better because I feel different." But it doesn't necessarily mean that you've changed their brain chemistry in a way that's going to be beneficial in the long run, and these drugs do reprogram brain chemistry.

Dr. Frank Lipman:

Yep. And I think that's important for people to realize. They're not benign drugs. And as you point out, there's absolutely a place for these antidepressant drugs. I'm not denying that at all. But I do think they are overused and people are too quick to go on them and then it's a struggle to get off them, because when you stop them, as you said, it changes the brain chemistry, and you stop them and you have these weird feelings and sensations and you think, "Well, what the hell is going on? Let me go back on my Prozac."

Dr. Robert Rountree:

The drug industry basically, the pharmaceutical companies, have convinced us that the cause of depression is a deficiency of neurotransmitters in the brain. And so neurotransmitters are chemicals that our nerve cells use to talk to each other. And so there's this whole model of mood disorders that says they're related to problems with those specific chemicals. If we pull back our lens and look at the big picture, you have to ask the question, "Well, what else is going on in the brain?" One issue that's been brought up is that inflammation can create the same symptoms as a deficiency of neurotransmitters, and by that I'm specifically talking about something that's been called cytokine sickness.

Dr. Robert Rountree:

So cytokines, as you know Frank, are little small protein molecules that cells use to talk to each other, mainly immune cells. And it was discovered years ago that if you give interferon, which is a type of cytokine, to somebody with viral hepatitis, that used to be the treatment, you give them an injection of interferon, they feel depressed. And I think a light bulb went off for some people who said, "Wait a minute, these normal chemicals made by our immune cells, if they're in excess, they can make you feel depressed." And what's a scenario where you can have a lot of excessive cytokines? Dysbiosis.

Dr. Frank Lipman:

Exactly.

Dr. Robert Rountree:

You know, an imbalance of gut bacteria can cause inflammation in the gut and then the immune cells make cytokines that then go to the brain and make you feel all the things we talked about, lethargy, dysphoria, difficulty getting out of bed, difficulty having joy in your life, all of that can come about from an abnormal mix of gut bacteria.

Dr. Frank Lipman:

And as we talked about in anxiety, I think in depression it's even more of an issue. I think there is a major connection between the gut and depression. And as you point out, it very well could be related to these metabolites of these bacteria that trigger these neurochemicals. But the way I explain it to a lot of people is, there's more serotonin, because we have this idea in our culture that depression is a serotonin deficiency, and it's obviously much, much more complicated than that. But, using that cultural belief system, I tell people there's more serotonin made in your gut than is made in your brain, so if we can correct your gut, there's a good chance you're going to increase your serotonin and your depression will get better. I know that's very simplistic, but that's the way people understand it and sort of can take it in. So sort of a way of emphasizing how important gut health is to your moods and that obviously is very simplistic, but people say, "Wow, that's interesting."

Dr. Frank Lipman:

And when people believe something, when people believe what you have to sell, I think that's very important in the healing, especially when it comes to something like depression. I do think the gut is an area that needs to be treated when someone is depressed.

Dr. Robert Rountree:

Yep. It's always the first place that I start. And again, I pull the lens back. The person comes in and they're all focused on their mood and, "Should I do something for this," and I pull back and say, "Well, tell me how your gut feels. What's your digestion like? What are your stools like? How often do you go? Do you have cramping or discomfort?" And they're going, "I came to you because I wanted some Prozac and you're asking me about my poop patterns." And people are a little taken aback, but when you explain what you just explained, then it's much easier to get them on board. And I also tell them, "Hey, there are animal studies... They can't ask the rat are you depressed, but you can look at their behaviors. You watch them and they clearly are not being enthusiastic about getting on their little wheel and spinning all day. There's something wrong with this animal. And you can change their gut bacteria and their behavior changes.

Dr. Frank Lipman:

Yep. And there are more and more studies showing this, and actually they are more and more psychiatrists that actually believe this. You know, I've had some talks with some psychiatrists who've actually called me. I mean, they're obviously a little bit more hip than maybe a regular psychiatrist, but they are very aware of this gut-brain connection, depression, and ask me about, "Can I help this patient correct their gut," because they are also starting to realize that correcting gut imbalances may be the first line of therapy for depression, which is very interesting.

Dr. Robert Rountree:

And it does make you wonder if you use something like 5-HTP, 5-hydroxytryptophan, which is a precursor to serotonin, I've seen it work. And the question is, is it working because it's correcting a serotonin deficiency in the brain or is it doing something in the gut? Is it actually changing something in the gut that then affects the gut-brain connection?

Dr. Frank Lipman:

The studies show that exercise is just as effective or even more effective for mild-to-moderate depression. Is that right?

Dr. Robert Rountree:

Yeah, absolutely, and those studies have been around for decades now. They used to say it's because of endorphins, you get a runner's high, but the downside of that is then if I tell somebody, "Oh, you're depressed. You need to take up marathon running." They get intimidated. "Well, I'm not going to run a marathon." "Okay, if you don't run a marathon, you should run sprints. Go down to your local track and go all out." Again, if you make it an extreme kind of challenge, then a lot of people are not going to do it, so it's got to be practical.

Dr. Frank Lipman:

Yeah, practical and something that you like doing, because you know like meditation, you've got to keep doing it. It's not something you can do once in a while, or once a week. You have got to exercise regularly to have that antidepressant effect. I know that's, once again, simplistic, but the constant or the regularity of the exercise is really important. Yeah.

Dr. Robert Rountree:

And it's again the challenge of somebody saying, "Well, it's hard for me to get out of bed in the morning. I just get up and I do my work and then I maybe eat and go back to bed, and that's all I've got energy for in my life." And then you say, "Well, you've got to exercise." Then the person it as a task.

Dr. Frank Lipman:

Yep.

Dr. Robert Rountree:

And so the challenge is to convince them that if you do this, everything else will get easier.

Dr. Frank Lipman:

Right, and I think most people understand or know that exercise boosts their mood, so that is sort of an easier explanation as opposed to something like meditation, which is harder for people to understand or realize because they haven't experienced the effects of it. Most people know that when they exercise, they feel much better. So it's sort of something easier to convince people to do.

Dr. Robert Rountree:

The other thing that I'm a big fan of is what's called learned optimism. Dr. Seligman, who I think used to be at University of Pennsylvania, did a lot of research on that. And the notion is that sometimes the optimists bend the truth a little bit. If you've got a glass that's like 40% full, the pessimist is more accurate. They'll say, "Well, the glass is only 40% full. What's the point in going on?" The optimist will say, "I'm arguing with you. I think the glass is a little bit more than half full and that somebody misread the reading." So Seligman would say the optimist basically maybe lies a little bit, maybe bends the truth, and the odd thing is, according to Seligman, that leads to success.

Dr. Frank Lipman:

I agree. I've seen that clinically. I do see people who are more optimistic actually do much better or are less depressed. I think he's spot on.

Dr. Robert Rountree:

You know, he's saying the facts are one thing, what you do with the facts are the most important thing. If a person comes in and says, "Well, all these things have gone wrong in my life and I just can't go on because of that," you know it's a cliche, but there's always a silver lining. To get to learned optimism, there's got to be one thing that works for you, one thing that you've got going and how do we take that one thing and seize on it and amplify it?

Dr. Frank Lipman:

Right. I agree. I think perception or the lenses we use to see life are really important. Okay, so now we're going to take a short break and when we get back, we'll take some questions from our listeners.

Dr. Robert Rountree:

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Dr. Frank Lipman:

Okay folks, we're back now. Now it's time to answer some questions from our community and we have some interesting questions. So Bob, our first question this week comes from a listener who asks, "Please touch on postpartum depression and anxiety and what nutrients may be deficient causing it."

Dr. Robert Rountree:

Well, I think that you can make a pretty good case for postpartum depression being a biochemical/inflammatory issue. I mean, there's so many changes that go on in the body, especially after the baby has been delivered. One of the things that happens is that you have all this excitement about having a baby for nine months, all this anticipation, and then boom, you have a baby and that's great, but now you've got to take care of the baby and for many women, that means being at home alone with the baby.

Dr. Robert Rountree:

So there's a cabin fever that sets in. I've actually talked to a number of women about this. You've got to address the cabin fever issue. Your life is not just about being the mother to that baby. You still are a person. You still have needs, and you got to address those needs. So, that's the platform, but then you got to say have you been eating. As part of addressing your needs, are you eating properly? Are you eating whole foods, plant-oriented diet? You don't have to be vegetarian, et cetera, but that diet should include deep sea fish. And what's a deep sea fish that's so important is DHA, Docosahexaenoic acid, a very important long-chain polyunsaturated fatty acid that has been shown in studies to affect mood, and those levels can drop sometimes precipitously.

Dr. Robert Rountree:

A lot of it's going into breast milk. So, if the mom is breastfeeding, that's going to also have an impact on this. So, that's the first nutrient that I go after. And if you don't feel like eating wild caught salmon several times a week, or you can't get it, then I think taking fish oil that's got a lot of DHA in it is important.

Dr. Robert Rountree:

How much do you need? At least 500 milligrams a day. Some studies say up to 2000 milligrams a day. So, it's not that the EPA isn't beneficial, but that's one time in a person's life where the DHA is clearly more important than the EPA. So, I go with that and I go with magnesium, and then my third nutrient is either choline or phosphatidyl choline. So, I would make sure that all those bases are covered.

Dr. Robert Rountree:

I actually want to make sure that during pregnancy the woman is taking supplements with all of those, but if she's gotten through pregnancy without doing it, that's the time to add them in. So these are not fancy nutrients or esoteric nutrients. They're basic things, but you might need higher than normal levels of them. You may need 500 milligrams of magnesium. I prefer to use magnesium glycinate because that's also calming and good for the mood because of the glycine in it. So again, DHA, magnesium glycinate, and either choline or phosphatidyl choline.

Dr. Robert Rountree:

So Frank, what other deficiencies and we've kind of started talking about that, in general what deficiencies would you say can cause depression?

Dr. Frank Lipman:

Right, so you mentioned three of them. I always look at B12. I look at vitamin D, even iron deficiency could be there. I generally, when someone is depressed, will do a nutrient panel. Some of the B's, B6 in particular, can do it. So, I look at general nutrient levels. I do think it's not as simple as one nutrient, but sometimes I even give amino acids. I think sometimes there's an imbalance in amino acids that giving amino acids can be helpful too.

Dr. Robert Rountree:

Like tyrosine you mean?

Dr. Frank Lipman:

Yeah, but I do think deficiencies can and often affect depression, so I think that all needs to be checked out and ruled out. I do think that's a real issue with depression, I think, and correcting those nutrient deficiencies can absolutely be helpful.

Dr. Robert Rountree:

I remember years ago they did a study of people who were chronically depressed and took Prozac and the Prozac helped, but then stopped working. And in this particular study, they gave them Prozac and folic acid and they gave them pretty high doses of folic acid, I think five milligrams, sometimes even more than five milligrams. And they showed an "augmenting effect of folic acid on the Prozac."

Dr. Frank Lipman:

Interesting.

Dr. Robert Rountree:

And I would say that has continued to be a recommendation to psychiatrists, and a lot of psychiatrists will say that, "Oh, the SSRI you're on has stopped working or is not as effective, so we'll add a high dose of folic acid." But the question is, why not just give the folic acid by itself? You know, they actually didn't do that study, at least initially, but it begs the question if the Prozac wasn't working, why didn't you just stop it and take folic acid by itself?

Dr. Robert Rountree:

Now, is this correcting a deficiency, in which case a milligram would be okay, or is it actually pushing biochemical pathways in a certain direction? I tend to think that that's what's going on.

Dr. Frank Lipman:

Yeah, I agree.

Dr. Robert Rountree:

It's changing methylation patterns in the brain. I don't think we fully know what's going on there, but it appears to be safe and I've seen it work.

Dr. Frank Lipman:

Okay, so here is a question we sort of discussed, but let's maybe discuss it a bit more because I think it's very, very important and it's, "How is gut health and depression linked?"

Dr. Robert Rountree:

So, I've already mentioned this and we've talked about it a little bit in terms of the cytokine effect, that if there's inflammation in the gut, then that inflammation can spill over into the bloodstream and then that can affect the brain, so that's part of it.

Dr. Robert Rountree:

Also, we know that microbes in the gut make neurotransmitters, or they influence the cells that line the gut that make the neurotransmitters. I think they're called EC cells or enterochromaffin cells, that actually make serotonin and other neurotransmitters. So the mix of gut bacteria is important, the level of inflammation is important, the presence of leaky gut can be a big issue. If there's leaky gut going on, and that's a real thing, leaky gut, there's no doubt about it, but it's microscopic. So you have a microscopic change in the permeability of the gut wall, and that can allow certain fragments of foods or microbes to get in the bloodstream. When that happens, that can cause not just inflammation in the gut itself, but inflammation throughout the body. And the inflammation again, can make the person feel cranky, tired, irritable, lose their motivation, et cetera.

Dr. Robert Rountree:

So, many different ways that these two things are linked and there's actually some pretty good books on it. Our friend, David Perlmutter, wrote a book on how the gut microbiome can affect mood. And that was a great book. I can't remember the name of that particular book. It was his second or third book, and he did a great job of reviewing some of that research. So Frank, do medications for depression and anxiety affect the gut, and if so, do they do that in the long run or not?

Dr. Frank Lipman:

Yeah, I think that's a great question because I actually think they do affect the gut. That's definitely been my clinical experience. And what's interesting is there are some GI doctors, and I'm not saying they should, starting to use antidepressants to help their patients with gut problems. So yes, I do think they affect the gut in the long run and I don't think they affect them positively in the long run. I would definitely not encourage someone to take an SSRI for gut problems, which some people are doing, and I do think people who have been on these Prozacs, these SSRIs, for long-time periods, they actually do affect the gut. I mean, that's just definitely been my experience.

Dr. Robert Rountree:

Yeah. I agree. I mean 90% of the serotonin in your body is made in the gut, at least 90%. Some studies show it's even more than that. What's going on if you take a drug that increases serotonin? Is it increasing the serotonin in your brain or is it increasing in your gut? And you know, if you've got a happy gut, then maybe you've got a happier brain, but if that's the case, then why not use something like 5-HTP?

Dr. Frank Lipman:

Right, exactly. So Bob, another good question, "How necessary is it for me to see a psychologist or psychiatrist if I feel depressed?"

Dr. Robert Rountree:

Well, it really depends on how deep-seated the issues are. I mentioned this earlier. If the person just can't function, they can't get out of bed, if they're really in bad shape, and especially if they've got a long, long history of depression and they've tried different medicines and had mixed responses to the medicine, if it's a more complicated case, then I would send a person to a psychiatrist. You know, I will often send people to someone who specializes in trauma. It's the rare person that hasn't had some kind of trauma in their upbringing or maybe trans-generational trauma, but I'm talking about the person that had some kind of traumatic event and that's continuing to create problems for them. Then someone who specializes in somatic psychology, which means how do you deal with the way that traumas show up in the body, or craniosacral therapy combined with somatic psychology, I've found tremendously useful for people.

Dr. Robert Rountree:

So, I'm probably more prone to sending somebody to that kind of practitioner, again a somatic-trained psychologist than I am to a psychiatrist. Nothing against psychiatrists, but I tend to think, psychiatry if you really need fine tuning for drugs, psychology if you've got some kind of deep-seated trauma that's going to take a lot of working through.

Dr. Robert Rountree:

So Frank, is depression even a thing that can be cured or is it something that you have to live with?

Dr. Frank Lipman:

Yeah, I think for a lot of people it absolutely can be cured. If you're dealing with the underlying issues, I think it can be cured. I mean, you may be prone to depression, but I do think lifestyle changes, dietary changes, supplements, seeing a therapist, in many ways one can cure. Yeah, I do see, not for everyone, but I think for most people, I do think depression can be cured. I mean, we don't really believe that in our culture or think that way in our culture, but I'm actually a strong believer that it can be cured per se. What do you think?

Dr. Robert Rountree:

Well, years ago I read this book, I think it was called the Eden Express by Mark Vonnegut, and he was Kurt Vonnegut's son. Remember Kurt Vonnegut? Just an amazing writer, science fiction, et cetera, and so Mark, this really bright guy and I think it was back during the 60s he ran off and joined a commune and started doing all kinds of psychedelic drugs, et cetera, and had a psychotic break. And he was told, "You're going to have to be on these anti-psychotic meds the rest of your life. You're schizophrenic," et cetera.

Dr. Robert Rountree:

And he got really involved in orthomolecular medicine, which is a branch of medicine that uses nutrients to treat psychological disorders and was able to cure himself, and he writes about this. So, he was able to reverse the problem without using the medications and eventually became a doctor, went to medical school, became a gynecologist, very successful. So to me, that kind of held up an example of saying the brain is malleable. There's this thing called neuroplasticity and if you deal with it correctly and almost aggressively, it's not just a simple matter of taking a little St. John's wort and boom, everything goes away, but it's a combination of the learned optimism, of the exercise, eating healthy, lifestyle, maybe acupuncture, it's a complete program. I do think the chemistry of the brain can change and I think the wiring of the brain can change. We're not just bumping up the serotonin or the norepinephrine, we're changing the whole way the brain is work.

Dr. Robert Rountree:

Now that's the road less traveled. It's not for everyone because there's work involved, but for people that are willing to do the work, I think this is a reversible condition.

Dr. Frank Lipman:

Yeah. I agree 100%. Well said. So, last question Bob, is "What does America need to do to be better at handling mental health issues?"

Dr. Robert Rountree:

Boy, that's a really tough one. I mean, having done a lot of training in community psychiatry, I think the main thing is that, I hate to say this, but police need more training in how to deal with somebody who's acutely suicidal or depressed or even psychotically depressed. They need really basic training. If somebody is threatening to jump off a bridge, et cetera, you need someone who's got the right kind of training that knows how to talk to that person. And so, I think the way we get better at handling this is just to get that training out there so that it's not just for psychiatrists or social workers, the person's got to make an appointment and go to an office and get that training, but there's a lot of people out there that are not getting the help they need and that's been especially true during this pandemic.

Dr. Robert Rountree:

A lot of people are quietly suffering at home and I feel for them, and then maybe they get over the break and then they want to go out and do harm to themselves in public. And we need to have a trained task force that can go out and talk to these people and they can deal with them. We also need to make sure that mental health coverage is included in any insurance plan. Why would we say this insurance plan will pay to treat your diabetes, but if you're depressed or you're anxious, we're not going to pay for that because you need to just buck up and deal with it? Well no, it's a real problem as we've said in these last two episodes. These are neuro-physiologic things that are going on and we can deal with them in really comprehensive ways. So I would like to see more coverage from insurance companies. More training and more coverage.

Dr. Frank Lipman:

Remember folks, there's a national suicide prevention lifeline at 1-800-273-8255, which is free and really helpful, especially if you feel really depressed, suicidal, please call that number. 1-800-273-8255. So all right folks, that's all the time we have this week. Remember to subscribe and if you feel like leaving a comment, we'd really appreciate it. Thanks for listening and thanks Bob, once again, for all your wisdom and doing this podcast with me. It's always an absolute pleasure.

Dr. Robert Rountree:

You bet. Take care.

Dr. Frank Lipman:

Thanks for listening to the Thorne Podcast. Make sure to never miss an episode by subscribing to the show on your podcast app of choice.

Dr. Robert Rountree:

If you've got a health or wellness question you'd like answered, simply follow our Instagram and shoot a message to @thornehealth. You can also learn more about the topics we discussed by visiting thorne.com and checking out the latest news, videos, and stories on Thorne's Take Five daily blog.

Dr. Frank Lipman:

Once again, thanks for tuning in and don't forget to join us next time for another episode of the Thorne Podcast.