An Expensive Illness
Depression costs. It’s generally ranked among the top three illnesses in the world in cumulative economic carnage. Depressed people don’t work well and often get physically sick—while their illness frequently wrecks careers, marriages, and families. Perhaps 30 percent of Americans will become clinically depressed in their lifetimes—a proportion that is rising. Public efforts to prevent clinical depression are virtually nonexistent. Treatment, to put it bluntly, stinks. For an illness so expensive and prevalent, “considerable” improvement by most research protocols is achieved only for a minority. Yet researchers fight out which is “better”—psychotherapy or antidepressants—in ways reminiscent of deciding whether Thai boxing is superior to kung fu.
It’s time for a different approach, one that looks not to ghettoized medical care options but to actual health—the physical, mental, social, and spiritual well-being of the population. A healthy economy requires a healthy population. Depression is a big black mark on the American and global economy. Treatments should ideally be complementary, useful, and cheap. Here are a few candidates. They may not attract a lot of research dollars or insurance payments, but they might help a lot of people.
1. Physical Activity. Physical health improves mental health. Many depressed patients do not want to move at all—but feel much better when they do. Many are physically able to walk for 30 minutes. Gym equipment can be as uncomplicated as putting an obsolete textbook on the floor and stepping on it—left foot then right—while watching TV. Anecdotal reports also include people “miraculously” improving with high levels of physical activity. Present day interval training—with perhaps 10 to 20 percent of total exercise time spent “flat out”—certainly turns on different genes than moderate exercise. It also deserves a workout for checking its use in treating depression as well as preventing it. For those refusing to move, see below on social support.
2. Light. With a quarter to half of the northern population experiencing winter mood drops, you would expect therapeutic light boxes in millions of American homes. But as Anna Wirz Justice showed in unsunny Basel, you can get plenty of people undepressed by walking or biking under dank, grey skies—the sun is still out there. Dan Kripke at UCSD has argued long and well that light—sustained or used in the morning—can treat depression. Sunlight can provide more than solar energy—it can electrify people who feel half dead.
3. Nature. Lots of British work argues people feel better in natural settings, especially graced by water. The Dutch treat severe depression by putting people on farms. Getting people out in nature—which usually includes walking and sunlight—may be preventive of depression, as well as complementary and perhaps as effective as “standard” treatments. It’s also cheap.
4. Relentless Problem Solving. One of the useful facets of cognitive-behavioral treatment, so underutilized in many physical illnesses, is to look forcefully at solutions instead of problems. A relentless focus on solutions helps many depressed patients. Large, publically supported clinical trials of Internet cognitive-behavioral programs appear indicated.
5. Social Support. Many depressed patients want to hide and socially isolate. This generally makes them worse—often much worse. Depression is an illness that creates more of itself. Just as AA utilizes social support to fight addiction, family and social engagement often help treat depression. They can also help get depressed patients to exercise, obtain light, and follow standard psychotherapeutic and medical treatments. Mobilizing family, friends, and communities is extraordinarily underused in clinical treatments of depression.
6. Work. Many depressed people lose their jobs – worsening their lives as they may then go on to lose money, income, health benefits, and not infrequently spouses. Keeping people on the job and getting depressed people “work” equivalents—including volunteer and family/house projects—lets people get stuff done, move their bodies, socially connect, and retain elements of self worth.
Fighting the Cartels
There are many cartels in medical care. The cartels around drugs and psychotherapy are vigorous. Because most studies argue combining medication with psychotherapy gets the best results, this is a tragedy.
Yet that is where the research money goes, or to no longer “new” treatments like transcranial magnetic stimulation or ketamine. Worthy of support? Certainly. Our first priority? No.
A healthy economy requires a healthy population. Health may be cheaply obtained combining four components: physical health (like exercise), mental health (including a relentless focus on problem solving), social health (family and social engagement and support), and spiritual health (meaning and purpose, connecting with something larger than one self.) All four forms of health increase the effectiveness of the others.
Health—combined with physical, mental, social, and spiritual health—is the ultimate goal. We might start with cheap, complimentary treatments for a real scourge—depression. Depression costs way too much physically, financially, fiscally, and globally. It’s time for a rethink in how we treat and prevent it.
